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Statins for acute coronary syndrome
Noah Vale, Alain J Nordmann, Gregory G Schwartz, James de Lemos, Furio Colivicchi, Frank den Hartog, Petr Ostadal, Stella M Macin, Anho H Liem, Edward J Mills, Neera Bhatnagar, Heiner C Bucher, Matthias Briel | 1 September 2014

Cochrane Clinical Answers

Topics

Topics

Study flow diagram

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Figure 1

Study flow diagram

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Forest plot of comparison: 1 Death, outcome: 1.1 Death at any time.

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Figure 2

Forest plot of comparison: 1 Death, outcome: 1.1 Death at any time.

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Comparison 1: Death, Outcome 1: Death at any time

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Analysis 1.1

Comparison 1: Death, Outcome 1: Death at any time

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Comparison 1: Death, Outcome 2: Death ‐ best case scenario

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Analysis 1.2

Comparison 1: Death, Outcome 2: Death ‐ best case scenario

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Comparison 1: Death, Outcome 3: Death ‐ worst case scenario

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Analysis 1.3

Comparison 1: Death, Outcome 3: Death ‐ worst case scenario

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Comparison 2: Major Adverse Cardiac Events, Outcome 1: Major Adverse Cardiac Events

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Analysis 2.1

Comparison 2: Major Adverse Cardiac Events, Outcome 1: Major Adverse Cardiac Events

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Comparison 2: Major Adverse Cardiac Events, Outcome 2: MACE ‐ Best case scenario

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Analysis 2.2

Comparison 2: Major Adverse Cardiac Events, Outcome 2: MACE ‐ Best case scenario

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Comparison 2: Major Adverse Cardiac Events, Outcome 3: MACE ‐ worst case scenario

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Analysis 2.3

Comparison 2: Major Adverse Cardiac Events, Outcome 3: MACE ‐ worst case scenario

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Comparison 2: Major Adverse Cardiac Events, Outcome 4: Recurrent acute myocardial infarction (AMI)

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Analysis 2.4

Comparison 2: Major Adverse Cardiac Events, Outcome 4: Recurrent acute myocardial infarction (AMI)

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Comparison 2: Major Adverse Cardiac Events, Outcome 5: Recurrent AMI ‐ best case scenario

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Analysis 2.5

Comparison 2: Major Adverse Cardiac Events, Outcome 5: Recurrent AMI ‐ best case scenario

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Comparison 2: Major Adverse Cardiac Events, Outcome 6: Recurrent AMI ‐ Worst case scenario

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Analysis 2.6

Comparison 2: Major Adverse Cardiac Events, Outcome 6: Recurrent AMI ‐ Worst case scenario

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Comparison 3: Significant dysrhythmias (complete heart block, ventricular fibrillation, asystole), Outcome 1: Overall (CHB, VF and asystole combined)

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Analysis 3.1

Comparison 3: Significant dysrhythmias (complete heart block, ventricular fibrillation, asystole), Outcome 1: Overall (CHB, VF and asystole combined)

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Comparison 3: Significant dysrhythmias (complete heart block, ventricular fibrillation, asystole), Outcome 2: Significant dysrrythmias (complete heart block, ventricular fibrillation or asystole)

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Analysis 3.2

Comparison 3: Significant dysrhythmias (complete heart block, ventricular fibrillation, asystole), Outcome 2: Significant dysrrythmias (complete heart block, ventricular fibrillation or asystole)

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Comparison 3: Significant dysrhythmias (complete heart block, ventricular fibrillation, asystole), Outcome 3: Overall best case

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Analysis 3.3

Comparison 3: Significant dysrhythmias (complete heart block, ventricular fibrillation, asystole), Outcome 3: Overall best case

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Comparison 3: Significant dysrhythmias (complete heart block, ventricular fibrillation, asystole), Outcome 4: Overall worst case

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Analysis 3.4

Comparison 3: Significant dysrhythmias (complete heart block, ventricular fibrillation, asystole), Outcome 4: Overall worst case

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Comparison 4: Time to pain relief, Outcome 1: Time to relief of pain

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Analysis 4.1

Comparison 4: Time to pain relief, Outcome 1: Time to relief of pain

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Comparison 5: Magnitude of cardiac enzyme changes, Outcome 1: 12 hour Plasma Creatine Phosphokinase

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Analysis 5.1

Comparison 5: Magnitude of cardiac enzyme changes, Outcome 1: 12 hour Plasma Creatine Phosphokinase

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Comparison 5: Magnitude of cardiac enzyme changes, Outcome 2: 24 hour Plasma Creatine Phosphate

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Analysis 5.2

Comparison 5: Magnitude of cardiac enzyme changes, Outcome 2: 24 hour Plasma Creatine Phosphate

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Comparison 5: Magnitude of cardiac enzyme changes, Outcome 3: Maximum Plasma Creatine Phosphate

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Analysis 5.3

Comparison 5: Magnitude of cardiac enzyme changes, Outcome 3: Maximum Plasma Creatine Phosphate

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Comparison 6: Improvement in left ventricular function, Outcome 1: Improved contraction in at least one segment (post‐HBOT echo)

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Analysis 6.1

Comparison 6: Improvement in left ventricular function, Outcome 1: Improved contraction in at least one segment (post‐HBOT echo)

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Comparison 6: Improvement in left ventricular function, Outcome 2: Left Ventricular Ejection Fraction‐ % (final estimate)

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Analysis 6.2

Comparison 6: Improvement in left ventricular function, Outcome 2: Left Ventricular Ejection Fraction‐ % (final estimate)

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Comparison 7: Length of Stay, Outcome 1: Overall length of stay (days)

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Analysis 7.1

Comparison 7: Length of Stay, Outcome 1: Overall length of stay (days)

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Comparison 8: Adverse events of therapy, Outcome 1: Total adverse events

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Analysis 8.1

Comparison 8: Adverse events of therapy, Outcome 1: Total adverse events

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Summary of findings 1. hyperbaric oxygen therapy for acute coronary syndrome

hyperbaric oxygen therapy for acute coronary syndrome

Patient or population: patients with acute coronary syndrome
Settings: Acute care hospital
Intervention: hyperbaric oxygen therapy

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

hyperbaric oxygen therapy

Death at any time

Study population

RR 0.58
(0.36 to 0.92)

614
(5 studies)

⊕⊕⊝⊝
low1,2

116 per 1000

67 per 1000
(42 to 107)

Medium risk population

102 per 1000

59 per 1000
(37 to 94)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Critical outcome
2 Small sample with low numbers of events

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Summary of findings 1. hyperbaric oxygen therapy for acute coronary syndrome
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Summary of findings 2. hyperbaric oxygen therapy for acute coronary syndrome

hyperbaric oxygen therapy for acute coronary syndrome

Patient or population: patients with acute coronary syndrome
Settings: acute care hospital
Intervention: hyperbaric oxygen therapy

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

hyperbaric oxygen therapy

12 hour Plasma Creatine Phosphokinase

The mean 12 hour Plasma Creatine Phosphokinase in the intervention groups was
138 lower
(843.83 lower to 567.83 higher)

84
(1 study)

⊕⊕⊕⊝
moderate1

24 hour Plasma Creatine Phosphate

The mean 24 hour Plasma Creatine Phosphate in the intervention groups was
65 lower
(530.96 lower to 400.96 higher)

72
(1 study)

⊕⊕⊕⊝
moderate1

Maximum Plasma Creatine Phosphate

The mean Maximum Plasma Creatine Phosphate in the intervention groups was
493.16 lower
(838.74 to 147.58 lower)

184
(2 studies)

⊕⊕⊕⊕
high

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Single trial only

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Summary of findings 2. hyperbaric oxygen therapy for acute coronary syndrome
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Comparison 1. Death

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1.1 Death at any time Show forest plot

5

614

Risk Ratio (M‐H, Fixed, 95% CI)

0.58 [0.36, 0.92]

1.1.1 Subjects presenting in cardiogenic shock

1

12

Risk Ratio (M‐H, Fixed, 95% CI)

0.61 [0.32, 1.18]

1.1.2 Subjects presenting without cardiogenic shock

5

602

Risk Ratio (M‐H, Fixed, 95% CI)

0.57 [0.33, 0.98]

1.2 Death ‐ best case scenario Show forest plot

5

617

Risk Ratio (M‐H, Fixed, 95% CI)

0.37 [0.23, 0.58]

1.3 Death ‐ worst case scenario Show forest plot

5

617

Risk Ratio (M‐H, Fixed, 95% CI)

1.34 [0.91, 1.96]
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Comparison 1. Death
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Comparison 2. Major Adverse Cardiac Events

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

2.1 Major Adverse Cardiac Events Show forest plot

1

61

Risk Ratio (M‐H, Fixed, 95% CI)

0.12 [0.02, 0.85]

2.2 MACE ‐ Best case scenario Show forest plot

1

69

Risk Ratio (M‐H, Fixed, 95% CI)

0.09 [0.01, 0.61]

2.3 MACE ‐ worst case scenario Show forest plot

1

69

Risk Ratio (M‐H, Fixed, 95% CI)

0.56 [0.23, 1.40]

2.4 Recurrent acute myocardial infarction (AMI) Show forest plot

1

129

Risk Ratio (M‐H, Fixed, 95% CI)

0.28 [0.08, 0.95]

2.5 Recurrent AMI ‐ best case scenario Show forest plot

1

129

Risk Ratio (M‐H, Fixed, 95% CI)

0.17 [0.05, 0.55]

2.6 Recurrent AMI ‐ Worst case scenario Show forest plot

1

129

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.42, 2.02]
Figures and Tables -
Comparison 2. Major Adverse Cardiac Events
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Comparison 3. Significant dysrhythmias (complete heart block, ventricular fibrillation, asystole)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

3.1 Overall (CHB, VF and asystole combined) Show forest plot

1

208

Risk Ratio (M‐H, Fixed, 95% CI)

0.59 [0.39, 0.89]

3.2 Significant dysrrythmias (complete heart block, ventricular fibrillation or asystole) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

3.2.1 Complete heart block

1

208

Risk Ratio (M‐H, Fixed, 95% CI)

0.32 [0.12, 0.84]

3.2.2 Ventricular fibrillation

1

208

Risk Ratio (M‐H, Fixed, 95% CI)

0.78 [0.36, 1.71]

3.2.3 Asystole

1

208

Risk Ratio (M‐H, Fixed, 95% CI)

0.73 [0.34, 1.56]

3.3 Overall best case Show forest plot

1

221

Risk Ratio (M‐H, Fixed, 95% CI)

0.51 [0.34, 0.77]

3.4 Overall worst case Show forest plot

1

221

Risk Ratio (M‐H, Fixed, 95% CI)

0.73 [0.50, 1.06]
Figures and Tables -
Comparison 3. Significant dysrhythmias (complete heart block, ventricular fibrillation, asystole)
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Comparison 4. Time to pain relief

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

4.1 Time to relief of pain Show forest plot

1

81

Mean Difference (IV, Fixed, 95% CI)

‐353.00 [‐487.55, ‐218.45]
Figures and Tables -
Comparison 4. Time to pain relief
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Comparison 5. Magnitude of cardiac enzyme changes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

5.1 12 hour Plasma Creatine Phosphokinase Show forest plot

1

84

Mean Difference (IV, Fixed, 95% CI)

‐138.00 [‐843.83, 567.83]

5.2 24 hour Plasma Creatine Phosphate Show forest plot

1

72

Mean Difference (IV, Fixed, 95% CI)

‐65.00 [‐530.96, 400.96]

5.3 Maximum Plasma Creatine Phosphate Show forest plot

2

184

Mean Difference (IV, Fixed, 95% CI)

‐493.16 [‐838.74, ‐147.58]
Figures and Tables -
Comparison 5. Magnitude of cardiac enzyme changes
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Comparison 6. Improvement in left ventricular function

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

6.1 Improved contraction in at least one segment (post‐HBOT echo) Show forest plot

1

34

Risk Ratio (M‐H, Fixed, 95% CI)

0.09 [0.01, 1.40]

6.2 Left Ventricular Ejection Fraction‐ % (final estimate) Show forest plot

2

190

Mean Difference (IV, Random, 95% CI)

5.47 [2.19, 8.75]
Figures and Tables -
Comparison 6. Improvement in left ventricular function
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Comparison 7. Length of Stay

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

7.1 Overall length of stay (days) Show forest plot

1

64

Mean Difference (IV, Fixed, 95% CI)

‐1.80 [‐3.70, 0.10]
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Comparison 7. Length of Stay
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Comparison 8. Adverse events of therapy

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

8.1 Total adverse events Show forest plot

3

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

8.1.1 Tympanic membrane rupture

2

269

Risk Ratio (M‐H, Fixed, 95% CI)

4.56 [0.19, 107.54]

8.1.2 Acute neurological oxygen toxicity

2

274

Risk Ratio (M‐H, Fixed, 95% CI)

Not estimable

8.1.3 Claustrophobia

1

208

Risk Ratio (M‐H, Fixed, 95% CI)

31.60 [1.92, 521.22]
Figures and Tables -
Comparison 8. Adverse events of therapy
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