Tenecteplase (TNK) is a promising candidate to replace alteplase as the standard of care for acute ischemic stroke (AIS); however, the optimal dosage is still to be investigated. Therefore, we aim to evaluate the safety and efficacy of TNK versus alteplase and to investigate the optimal TNK dosage. A systematic review, pairwise, and network meta-analysis synthesizing randomized controlled trials (RCTs) from WOS, SCOPUS, EMBASE, and PubMed until July 26th, 2022. We used the risk ratio (RR) for dichotomous outcomes presented with the corresponding 95% confidence interval (CI). We registered our protocol in PROSPERO with ID: CRD42022352038. Nine RCTs with a total of 3,707 patients were included. TNK significantly led to complete recanalization (RR: 1.27 with 95% CI [1.02, 1.57], P = 0.03); however, we found no difference regarding early neurological improvement (RR: 1.07 with 95% CI [0.94, 1.21], P = 0.33) and excellent neurological recovery (RR: 1.03 with 95% CI [0.96, 1.10], P = 0.42). Also, TNK was similar to alteplase regarding mortality (RR: 0.99 with 95% CI [0.82, 1.18], P = 0.88), intracranial haemorrhage (RR: 1.00 with 95% CI [0.85, 1.18], P = 0.99), and parenchymal hematoma (RR: 1.13 with 95% CI [0.83, 1.54], P = 0.44). TNK in the dose of 0.25 mg is a viable candidate to displace alteplase as the standard of care in patients with an AIS within 4.5 h of presentation due to its better rate of early neurological recovery and non-inferiority in terms of safety outcomes. However, the evidence regarding TNK’s role in AIS presenting after 4.5 h from symptoms onset, wake-up stroke, and minor stroke/TIA is still lacking, necessitating further double-blinded pragmatic RCTs in this regard.

Patients hospitalized for acute myocardial infarction (AMI) may have concomitant positive coronavirus disease 2019 (COVID-19). We aimed to compare the risk of in-hospital mortality in patients primarily hospitalized for AMI with or without concomitant COVID-19 positive status. Using the random-effects model, we conducted a systematic review and meta-analysis of published articles from December 1, 2019, to April 1, 2022. There were eight studies with 10,128 patients, including 612 patients with COVID and 9516 patients without COVID. A total of 261 patients (42.64%) with COVID-19 positive and 612 patients (6.43%) with negative COVID-19 status died in the hospital. Pooled data showed that patients with a primary diagnosis of AMI with COVID-19 infection had more than five times increased risk of in-hospital mortality compared to patients without COVID-19 (OR: 5.06, 95% CI: 3.61, 7.09; I 2 = 35%, P < 0.001). However, pooled data from five studies with adjustment of baseline differences in patient demographics and characteristics, comorbidities, and in-hospital pharmacology revealed more than three times increased risk of in-hospital mortality compared to patients who had primary AMI without COVID-19 infection (aOR: 3.47, 95% CI: 2.21, 5.45; I 2 = 0%, P < 0.001). In subgroup analysis, ST-elevation myocardial infarction (STEMI) had lower in-hospital mortality (OR 4.23, 95% CI: 3.31, 5.40; I 2 = 0%, P < 0.001) compared to non-ST-segment elevation myocardial infarction (NSTEMI) (OR 9.97, 95% CI: 5.71, 17.41; I 2 = 0%, P < 0.001) (p-value = 0.006). Our study shows that COVID-19 infection is associated with increased in-hospital mortality in patients with index hospitalization for AMI.

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Introduction: The role of sex-based differences in the outcomes after principal percutaneous coronary intervention (PCI) in octogenarians is not well studied. Hypothesis: There are no differences in outcomes of PCI in octogenarians based on sex. Methods and Results: From 2016 to 2019, 37,147 hospitalizations (unweighted sample) for principal PCI procedures were identified. Among the principal PCI procedures performed, 44.9% (n = 16,660) were performed in females, and 55.2% (n = 20,487) in males (p < 0.001), 82.4% in Whites, 5.4% in Blacks, 6.4% in Hispanics, and 2.6% in Asians. 20,986 (56.5%) principal PCI hospitalizations had a Charlson comorbidity index (CCI) of three or higher. The mean age for Octogenarians was 83.6 ± 2.7 years. Compared to males, the females were slightly older (mean age: 83.8 vs. 83.5; p < 0.001), had higher prevalence of diabetes mellitus (20.5% vs 18%, p<0.001) and lower Charlson comorbidity index (CCI) of three or higher (53.6% vs. 58.9%, p <0.001). Females had higher incidence of cardiogenic shock (4.9% vs 4.2%, p=0.002), higher in-hospital mortality (4% vs 3%, p<0.001) and longer length of stay (LOS) (4.4 days vs 4.1 days, p<0.001). Multivariate regression analysis showed that, compared to males, females had a significantly higher odds of in-hospital mortality (aOR: 1.23; 95% CI: 1.10, 1.37; p <0.001) and cardiogenic shock (aOR: 1.17; 95% CI: 1.06, 1.30; p=0.002) after controlling for age, race, hospital region, hospital teaching status, income, insurance provider, and CCI. From 2016-2019, in octogenarians, the annual incidence of principal PCI hospitalizations increased from 127 per 100,000 hospitalizations in 2016 to 137 per 100,000 hospitalizations in 2019, p<0.001. Conclusions: The incidence of PCI done in octogenarians is rising every year. Females have an increased likelihood of in-hospital mortality, longer LOS, and cardiogenic shock.

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Introduction: Atrial fibrillation (AF) is a common arrhythmia after Coronary artery bypass graft (CABG). There is a paucity of data on the outcomes of CABG either On-pump CABG (ONCABG) or Off-pump CABG (OFCABG) in patients with underlying AF. Methods: We queried the National Inpatient Sample (NIS) from 2016-2019 to identify adult patients who underwent CABG (On and Off-pump) using ICD 10 codes. Patients were divided into two groups based on history of AF. Primary outcomes of interest were in-hospital mortality and mean length of stay. Other covariates of interest included sex, age, race, insurance, income quartile by zip code, comorbidities, hospital location, and size. We used the Charlson Comorbidity Index (CCI) categories to account for comorbidities. We ran multivariate regression models to investigate the possible association. Results: There were 100,715 unweighted index hospitalizations identified for ONCABG and 25,956 for OFCABG. Patients were predominantly male and white race with a mean age of 65.7 years. A total of 34,333 (34.1%) patients had underlying AF in ONCABG group and 8369 (32.24%) in the OFCABG group. Multivariate regression analysis showed that in ONCABG, AF gorup had significantly higher odds of in-hospital mortality (aOR: 1.22; 95% CI: 1.10, 1.36; p = <0.001) compared to those without AF. Similarly, in OFCABG group, AF group had significantly higher odds of in-hospital mortality (aOR: 1.26; 95% CI: 1.04, 1.52; p = 0.019) compared to those without AF after controlling for the covariates of interest and comorbidities. The mean LOS was higher in the AF group in both ONCABG (10.6 vs 8.59 days, p<0.001) and OFCABG (10.78 vs 8.77 days, p<0.001). The number of ONCABG performed each year increased from 24,761 in 2016 to 25,683 in 2019, however, the number of OFCABG decreased from 7008 in 2016 to 6179 in 2019. Conclusions: AF was associated with increased in-hospital mortality and mean LOS among the patients who underwent CABG. The number of ONCABG performed each year increased whereas the number for OFCABG decreased.