David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses

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Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field,1,2 and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research,3 and some health care journals are moving in this direction.4 As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews.

Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in 4 leading medical journals in 1985 and 1986 and found that none met all 8 explicit scientific criteria, such as a quality assessment of included studies.5 In 1987, Sacks and colleagues6 evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in 6 domains. Reporting was generally poor; between 1 and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement.7

In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials.8 In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1).



Box 1

Conceptual issues in the evolution from QUOROM to PRISMA

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA Statement.

Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement

Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement [in Spanish]

Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.

Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement—a reporting guideline published in 1999—there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.

The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site (http://www.prisma-statement.org/) should be helpful resources to improve reporting of systematic reviews and meta-analyses.

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The PRISMA Statement for Reporting Systematic Reviews and Meta-Analyses of Studies That Evaluate Health Care Interventions: Explanation and Elaboration

The radial artery is a safe and feasible access site to perform cardiac catheterization and percutaneous coronary intervention (PCI) in stable and unstable settings. Recent evidence suggests potential nephroprotective benefits of the radial approach over the femoral route toward both short- and long-term kidney injury preventions. Acute kidney injury (AKI) after cardiac catheterization remains a major issue in hospitalized patients and is associated with worse clinical outcomes. Patients with chronic kidney disease (CKD) are more prone to AKI after cardiac catheterization, requiring careful management to prevent further decline in renal function. The transradial approach (TRA) provides several advantages for renal safety compared to the transfemoral approach (TFA) which include less access site-related bleeding and the avoidance of manipulation of the atheromatous aorta, thus limiting renal atheroembolic events. On the other hand, the extensive use of TRA in patients with advanced CKD has been questioned, raising concerns about the use of previously cannulated radial arteries for the creation of future autogenous radial-cephalic fistulae for hemodialysis access. Several studies have reported conflicting data regarding the use of contrast-associated AKI with TRA, possibly counterbalancing the potential benefits of this approach. In this chapter, we discuss benefits and limits of the transradial strategy in patients undergoing cardiac catheterization, with emphasis on patients with CKD and data on renal safety with this approach.

Therapeutic Considerations with Revascularization in Chronic Kidney Disease: Radial Versus Femoral Arterial Access

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Complete myocardial revascularization: Between myth and reality [5] (multiple letters)

Femoral and radial accesses are the most commonly used approaches in interventional cardiology. Femoral access-site has been implemented for many years in percutaneous coronary intervention and still today is the most used approach in several countries. Radial access, more recently introduced, guarantees a less invasive procedure and a reduced incidence of vascular access site complications.

Radial and Femoral Access in Percutaneous Intervention


 
 
 Type of funding sources: None.
 
 
 
 ST segment elevated myocardial infarction (STEMI) is associated with a systemic inflammatory response. In animal model of STEMI, a sustained inflammatory response has also been described in the non-infarcted myocardium (NIM) with potential detrimental consequences for the left ventricular (LV) remodelling.
 
 
 
 to characterize inflammation of the NIM in relation with infarct size (IS) and other inflammatory markers and its prognostic role after STEMI.
 
 
 
 171 consecutive patients with STEMI who underwent CMR after primary angioplasty were analysed in terms of standard infarct characteristics. Inflammation of the NIM was assessed based on T2 mapping. The primary endpoint was major adverse cardiac events (MACE), defined as deaths, myocardial infarction (MI), unplanned non-infarct-related artery revascularization or re-hospitalization for heart failure at follow-up.
 
 
 
 NIM T2 values were directly correlated with IS (r=0.610; p<0.001), area at risk (r = 0.503, p <0.001) and inversely correlated with LVEF (−0.397, p <0.001). T2 values of NIM followed a bimodal distribution with a mean and median values of 45 ms. A total of 78 patients (46%) presented high, defined as above the median, T2 values. Patients with high, compared with non-high NIM T2 values, had lower LVEF (46.04±12.29% vs 54.63±10.99%, p < 0.001), larger IS (median value: 19.9 vs 9.0 gr p value < 0.001), greater AAR (median value: 25.00 vs 18.61 gr, p-value < 0.001), higher T2 values in the infarcted area (64.31±7.18 vs 61.53±5.44 ms, p 0.028), and more frequent MVO (60.3% vs 32.3%, p < 0.001). At logistic multivariable analyses, IS (OR 1.116, 95%CI 1.080 – 1.258, p < 0.001) and T2 values in the infarcted area (OR 1.102, 95%CI 1.007 – 1.206, p = 0.035), were the only independent predictors of high NIM T2 values. At median follow-up of 30 [27–34] months, patients with high (>45 ms) T2 values in the non-infarcted area incurred greater MACE risk (21.5% vs 7.7% for T2 values <45 ms, p <0.001). Multivariable Cox regression analysis showed that elevated NIM T2 values (HR 2.768, 95%CI 1.262 – 6.073, p = 0.011), LVEF<50% % (HR 2.182, 95%CI 1.058–4.497, p = 0.035) and larger IS (HR 2.830, 95%CI 1.303–6.149, p = 0.009) were independently associated with MACE occurrence (HR 2.126, 95%CI 1.023 – 4.417, p = 0.043) and myocardial re-infarction (HR 10.928, 95%CI 1.441 – 83.686, p = 0.021) after correction for the main CMR parameters.
 
 
 
 High NIM T2 values after STEMI are independently associated with worse outcomes, mainly owing to higher MI risk. Importantly, the prognostic information of NIM T2 values was incremental in addition to established CMR outcome markers, including IS. Additional studies are needed to validate weather therapeutic interventions that influence remote zone native T2 improve event-free survival after revascularized STEMI or not.


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Non-infarcted myocardium inflammation predicts outcomes after myocardial infarction

Background: Evaluation of the right ventricle (RV) in patients with acute myocarditis (MY) remains challenging with both 2D transthoracic echocardiography (TTE) and cardiovascular magnetic resonance (CMR). We examined the incremental diagnostic value of CMR feature tracking (FT) to evaluate RV involvement in patients with myocarditis. Methods: We enrolled 54 patients with myocarditis and preserved left ventricle (LV) ejection fraction (EF). The CMR protocol included T2-weighted images for edema detection and late gadolinium enhancement (LGE) images. Global longitudinal strain (GLS) of the left ventricle (LV) and RV free wall strain (CMR-FWS) were obtained with CMR-FT. We identified 34 patients (62%) with inferior and lateral segment (IL-MY) involvement and 20 (38%) noIL-MY in case of any other myocardial segment involved. Here, 20 individuals who underwent CMR for suspected cardiac disease, which was not confirmed thereafter, were considered as the control population. Results: TTE and CMR showed normal RV function in all patients without visible RV involvement at the LGE or T2-weighted sequences. At CMR, LV-GLS values were significantly lower in patients with MY compared to the control group (median −19.0% vs. −21.0%, p = 0.029). Overall, CMR RV-FWS was no different between MY patients and controls (median −21.2% vs. −23.2 %, p = 0.201) while a significant difference was found between RV FWS in IL-MY and noIL-MY (median −18.17% vs. −24.2%, p = 0.004). Conclusions: CMR-FT has the potential to unravel subclinical RV involvement in patients with acute myocarditis, specifically in those with inferior and lateral injuries that exhibit lower RV-FWS values. In this setting, RV deformation analysis at CMR may be effectively implemented for a comprehensive functional assessment.

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Multimodality Imaging Evaluation to Detect Subtle Right Ventricular Involvement in Patients with Acute Myocarditis and Preserved Left Ventricular Ejection Fraction

Marco Valgimigli

Papers

Therapeutic Considerations with Revascularization in Chronic Kidney Disease: Radial Versus Femoral Arterial Access

Complete myocardial revascularization: Between myth and reality [5] (multiple letters)

Radial and Femoral Access in Percutaneous Intervention

Non-infarcted myocardium inflammation predicts outcomes after myocardial infarction

Multimodality Imaging Evaluation to Detect Subtle Right Ventricular Involvement in Patients with Acute Myocarditis and Preserved Left Ventricular Ejection Fraction