CANCARE RESEARCH
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An automated research-discovery feed. Summaries are based on published abstracts and are not clinical recommendations.
The Cost-Effectiveness and Health Equity of Prehospital Treatment Strategies for Out-of-Hospital Cardiac Arrest Patients: A Systematic Review.
Clinical takeaway These findings may inform resuscitation-system economic discussions, particularly around prehospital ECPR. They do not establish a survival advantage, and heterogeneous comparisons limit confidence in applying the estimates across settings.
Summary & abstract
Study summary
This systematic review included ten economic evaluations of prehospital out-of-hospital cardiac arrest strategies, mostly cost-utility analyses, with six using Markov models. Prehospital ECPR was reported as more cost-effective than in-hospital ECPR, with incremental cost-effectiveness ratios ranging from AUD $27,323 to $44,000 per quality-adjusted life-year gained. Survival and neurological outcomes influenced cost-effectiveness estimates, while almost all studies reported fewer than 40% of assessed equity criteria. The authors concluded that many strategies enabling earlier advanced care were cost-effective, but heterogeneous comparators and sparse equity reporting limited evidence certainty.
Study limitation: The evidence primarily comprised economic evaluations, often using Markov models, with heterogeneous comparators and sparse equity reporting.
Published abstract
OBJECTIVES: Out-of-hospital cardiac arrest (OHCA) remains a major public health challenge, associated with substantial mortality and significant costs for health care system. This systematic review aimed to (i) synthesize economic evaluations of prehospital treatment strategies for OHCA from ambulance attendance through to hospital discharge; (ii) assess the methodological quality and reporting of the included studies; and (iii) evaluate the reporting of health equity-relevant data. METHODS: We searched Medline, Embase, Scopus, EconLit, and CINAHL databases for records from database inception to 12 June 2026. The QHES and CHEERS checklists were used to assess the quality and reporting standards of included studies, and the review was reported according to the PRISMA checklist. The completeness of reporting health equity outcomes was reviewed using the PROGRESS (Place of residence, Race, Occupation, Gender, Religion, Education, Socioeconomic status and Social capital) - Plus framework. RESULTS: Ten economic evaluations met eligibility criteria. Most studies were cost-utility analyses (n = 8, 80%) and used Markov models (n = 6, 60%). Most evaluations were 'very good quality' (≥80%) (n = 6, 60%). Early defibrillation and advanced life support (ALS) delivered by trained emergency medical technicians were cost-effective compared with no intervention, emergency physician-led ALS, standard emergency medical services or paramedic care (ICER range from £11,407 to USD $56,700 per QALY gained). Prehospital extracorporeal cardiopulmonary resuscitation (ECPR) was more cost-effective than in-hospital ECPR strategies (ICER range from AUD $27,323 to $44,000 per QALY gained). Termination-of-resuscitation (TOR) strategies were cost-effective compared with no TOR or other TOR strategies, including basic life support and ALS TOR, with estimates of $110,554 saved per QALY lost and USD $23,851 per QALY gained. Survival rate and neurological outcomes influenced cost-effectiveness results. Equity reporting was limited: almost all included studies addressed less than 40% of the PROGRESS-Plus equity criteria. CONCLUSIONS: Most strategies that increased prehospital treatment intensity, avoided futile transport, or enabled earlier advanced care were cost-effective; however, the certainty of evidence, particularly for sub-groups, was limited by heterogeneous comparators and sparse equity reporting.
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Mechanical versus manual bag-valve ventilation during cardiopulmonary resuscitation in adults with cardiac arrest: A systematic review and Bayesian meta-analysis.
Clinical takeaway Mechanical ventilation during CPR was associated with higher ROSC, but a survival or neurological benefit remains uncertain. These findings do not establish superiority for patient-centred outcomes.
Summary & abstract
Study summary
This Bayesian meta-analysis included eight studies involving 6,847 adults with cardiac arrest, comparing mechanical ventilation during CPR with manual bag-valve ventilation alone. Mechanical ventilation was associated with more ROSC (pooled RR 1.20; 95% credible interval 1.04–1.42), with a 99% posterior probability of benefit. Posterior probabilities favoring mechanical ventilation were 92.3% for survival to admission, 93.6% for survival to discharge, and 92.2% for favorable neurological outcome. Despite these directional signals, evidence for improved survival and neurological outcomes remained imprecise and inconclusive.
Study limitation: Classification as mechanical ventilation required any use during CPR, so this group could also have received manual ventilation.
Published abstract
BACKGROUND/OBJECTIVE: Optimal ventilation delivery during cardiopulmonary resuscitation (CPR) remains uncertain. Current resuscitation guidelines do not recommend mechanical ventilation (MV) over manual bag-valve ventilation (BV). We evaluated the association between MV use during CPR and clinical outcomes in adults with cardiac arrest compared with manual BV. METHODS: We searched 6 bibliographic databases from inception through May 31, 2026. Included studies compared MV and BV ventilation CPR in adult cardiac arrest patients. Patients receiving MV at any moment during CPR were classified as the MV group; those receiving only BV comprised the BV group. Primary outcomes included return of spontaneous circulation (ROSC), survival to hospital admission, survival to hospital discharge, and good neurological outcome. Secondary outcomes included physiologic variables and pneumothorax. We calculated pooled risk ratios (RRs) and mean differences with 95% credible intervals (CrIs) using Bayesian random-effects meta-analyses. RESULTS: Eight studies involving 6,847 patients were included. For the primary outcome, MV use during CPR was associated with a higher rate of ROSC than BV use (pooled RR, 1.20; 95% CrI, 1.04 to 1.42), with a 99% posterior probability of benefit. Posterior probabilities favoring MV for survival to admission, survival to discharge, and favorable neurological outcome were 92.3%, 93.6%, and 92.2%, respectively. Pneumothorax incidence was similar between groups. CONCLUSION: In adult cardiac arrest, MV use during CPR was associated with higher ROSC compared with manual BV. Evidence for improved survival and neurological outcomes remains imprecise and inconclusive.
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Catheter-Directed Thrombolysis Plus Anticoagulation versus Anticoagulation Alone for Acute Intermediate-Risk Pulmonary Embolism: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Clinical takeaway The pooled trials suggest less early deterioration with catheter-directed thrombolysis, but no mortality difference was demonstrated. Increased bleeding and access-site complications temper the early efficacy findings.
Summary & abstract
Study summary
This meta-analysis included six randomized trials involving 886 patients with acute intermediate-risk pulmonary embolism. Compared with anticoagulation alone, adding catheter-directed thrombolysis reduced the RV/LV ratio (mean difference −0.11, 95% CI −0.21 to −0.00) and early cardiorespiratory deterioration (risk ratio 0.36, 95% CI 0.19–0.68). Mortality did not differ between groups. Major bleeding was not significantly different, but its estimate remained imprecise (risk ratio 1.52, 95% CI 0.71–3.24). Any bleeding and vascular access-site complications or hematomas were significantly more frequent with catheter-directed thrombolysis, highlighting a trade-off between early improvement and procedural harms.
Study limitation: The major-bleeding confidence interval permits substantial harm; larger trials with longer follow-up are needed to clarify sustained clinical outcomes.
Published abstract
Systemic anticoagulation is the standard initial therapy for intermediate-risk pulmonary embolism (PE) but fails to reverse right ventricular (RV) overload rapidly. While full-dose systemic thrombolysis accelerates RV recovery, it carries an unacceptable risk of major hemorrhage. Catheter-directed thrombolysis (CDT) offers a targeted, low-dose alternative to improve hemodynamics safely. A comprehensive search of PubMed, Web of Science, CENTRAL, Scopus, and Embase was conducted up to May 2026. Mean differences (MD) and risk ratios (RR) were pooled using a random-effects model. PROSPERO ID: CRD420261402147. Six RCTs involving 886 patients were included. CDT was associated with a significantly greater reduction in the RV/LV ratio than anticoagulation alone (MD: -0.11, 95% CI: [-0.21, -0.00]; P < 0.05). Also, CDT significantly reduced the risk of early cardiorespiratory deterioration (RR: 0.36, 95% CI [0.19, 0.68]; P < 0.001). There was no significant increase in major bleeding (RR: 1.52, 95% CI [0.71, 3.24]; P = 0.28) or intracranial hemorrhage. However, CDT significantly increased the risk of any bleeding ( P = 0.02) and vascular access-site complications/hematomas ( P = 0.02). Mortality did not differ between the two groups. Adding CDT to standard systemic anticoagulation led to a statistically significant reduction in the RV/LV ratio compared with anticoagulation alone, with a significantly lower risk of early hemodynamic and cardiorespiratory deterioration, without increasing the risk of major bleeding or intracranial hemorrhage in patients with acute intermediate-risk PE. However, larger RCTs with longer follow-up are required to provide a clearer picture of its sustained effects on hard clinical outcomes.
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Temporary Right Ventricular Mechanical Circulatory Support Devices in Acute Right Ventricular Failure and Cardiogenic Shock: A Cross-Device Systematic Review and Single-Arm Meta-Analysis.
Clinical takeaway These pooled estimates describe outcomes and complication burden in selected patients receiving temporary RV support. They cannot establish benefit over alternative care or identify a superior device.
Summary & abstract
Study summary
This single-arm meta-analysis included 106 studies and 4653 adults receiving temporary mechanical support for acute right ventricular failure or RV-predominant cardiogenic shock. Pooled survival to discharge was 60.4% (95% CI 56.0–64.7), with a wide prediction interval of 34.4%–81.6%; separately pooled 30-day mortality was 30.1% (95% CI 24.1–36.9). Pooled bleeding, renal complications, and stroke rates were 36.5%, 46.6%, and 14.5%, respectively. Concurrent left-sided support was reported in 85.8% of patients with available data, limiting applicability to isolated primary RV shock; these descriptive findings do not establish treatment benefit or comparative device effectiveness.
Study limitation: Heterogeneous treated cohorts, frequent concurrent left-sided support, and inclusion of 57 conference-abstract studies limit certainty and generalizability.
Published abstract
BACKGROUND: Evidence for temporary right ventricular assist devices (tRVADs) is fragmented. We characterized outcomes among adults receiving temporary support for acute right ventricular (RV) failure or RV-predominant cardiogenic shock. METHODS: MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov were searched from inception to June 2026. Arm-level outcome proportions were pooled on the logit scale using three-level random-effects models, with arms nested within studies. Device-stratified estimates, meta-regression, and sensitivity analyses were examined. RESULTS: We included 106 studies (119 device arms; 4653 patients), including 57 conference-abstract studies (53.8%). Concurrent left-sided support was reported in 85.8% of patients with available data; post-LVAD RV failure predominated in 47.5% of arms. Separately pooled survival to discharge was 60.4% (95% CI 56.0-64.7; 63 arms), successful weaning 60.6% (54.8-66.2; 68 arms), and 30-day mortality 30.1% (24.1-36.9; 31 arms). The survival prediction interval was wide (34.4%-81.6%). Pooled bleeding, renal complications (acute kidney injury and/or renal replacement therapy, as reported), and stroke were 36.5%, 46.6%, and 14.5%, respectively. Device-stratified estimates were vulnerable to confounding. No meta-regression association remained significant after multiplicity correction. CONCLUSIONS: These descriptive estimates characterize selected, heterogeneous treated cohorts, predominantly receiving left-sided or biventricular support; they do not establish treatment benefit or comparative device effectiveness. Complication rates were high. Applicability to isolated primary RV shock is limited. Standardized prospective data are needed to inform patient selection, timing, and device strategy. TRIAL REGISTRATION: PROSPERO registration number: CRD420261406088.
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Automated external defibrillators for in-hospital cardiac arrest: a systematic review.
Clinical takeaway The review does not establish a patient-centred outcome benefit from routine ward-level AED deployment. Heterogeneous observational evidence leaves the balance between earlier defibrillation and possible compression interruptions uncertain.
Summary & abstract
Study summary
This systematic review compared AED use with manual defibrillation for in-hospital cardiac arrest outside specialized areas, synthesizing six reports from five observational cohorts descriptively. Neurologically favorable survival findings were inconsistent, with improvement reported after a combined AED-and-training intervention in one study. The largest multicentre cohort found no significant difference in neurological disability among survivors (adjusted relative risk 1.01, 95% CI 0.93–1.09). ROSC and survival to discharge were not consistently improved. Evidence was insufficient to determine whether routine ward-level AED deployment improves outcomes.
Study limitation: Included studies were observational and heterogeneous, with incomplete characterization of CPR quality and training.
Published abstract
BACKGROUND: Automated external defibrillators (AEDs) improve survival after out-of-hospital cardiac arrest, but their role in in-hospital cardiac arrest (IHCA) remains uncertain. This systematic review evaluates whether ward-accessible AED capability prior to code blue team arrival improves survival and neurologic outcomes compared with standard resuscitation systems. METHODS: Six databases were searched. Eligible studies compared AED use to manual defibrillation in IHCA outside specialized areas. Primary outcome was survival with favorable neurological status (CPC 1-2, mRS 0-3, or no deterioration from baseline). Secondary outcomes included ROSC, survival at 24 h, survival to discharge, 30-day survival, CPR quality, and timing metrics. Three independent reviewers performed study selection, data extraction, and risk-of-bias assessment. Due to substantial heterogeneity, results were synthesized descriptively. RESULTS: Six reports from five unique study cohorts met inclusion criteria (total screened = 5510). Neurologically favorable survival was inconsistent. One study reported improved outcomes following a combined AED-and-training intervention, whereas the largest multicentre cohort found no significant difference in neurological disability among survivors (adjusted relative risk 1.01, 95% CI 0.93-1.09). ROSC and survival to discharge were not consistently improved. Only one study directly quantified AED-associated compression pauses, and effects on time to defibrillation varied by setting. CONCLUSION: Available evidence is insufficient to determine whether routine ward-level AED deployment improves IHCA outcomes. Included studies were observational and heterogeneous and CPR quality and training were incompletely characterized. Potential benefit from earlier defibrillation in shockable rhythms must be weighed against possible compression interruptions. Contemporary comparative studies are needed.
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Bivalirudin Versus Heparin and Protamine in Adult Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis.
Clinical takeaway The pooled trials did not establish a difference in major postoperative outcomes. The wide confidence interval for reexploration leaves substantial uncertainty and does not establish equivalence or safety.
Summary & abstract
Study summary
This systematic review pooled three randomized trials involving 407 adults undergoing cardiac surgery, comparing bivalirudin with unfractionated heparin for anticoagulation. Reexploration for hemorrhage, the primary outcome, did not differ significantly between groups (risk ratio 1.38, 95% confidence interval 0.42–4.48). No observable differences were reported in thromboembolic events, mortality, or postoperative transfusion requirements. All included trials had some concern for risk of bias, although interstudy heterogeneity was low across comparisons. The review also identified variability in bivalirudin dosing and therapeutic monitoring as limitations.
Study limitation: Only 407 patients were pooled, with risk-of-bias concerns and variable bivalirudin dosing and monitoring.
Published abstract
OBJECTIVES: To summarize the evidence on the morbidity, mortality, and transfusion requirements of adult patients undergoing cardiac surgery using bivalirudin for anticoagulation compared to unfractionated heparin (UFH). MEASUREMENTS AND MAIN RESULTS: A total of 407 patients in three randomized controlled trial (RCTs) were included for pooled analysis. There was no significant difference in the primary outcome; reexploration for hemorrhage between groups (risk ratio: 1.38, 95% confidence interval: 0.42 to 4.48). There were no observable differences in any of the secondary outcomes; thromboembolic events (myocardial infarction, stroke, pulmonary embolism), mortality, or postoperative transfusion requirements (packed red cells (PRC), platelets, cryoprecipitate, fresh frozen plasma (FFP)). All studies included were assessed to have some concern for risk of bias. Interstudy heterogeneity was low across all comparisons. CONCLUSION: Bivalirudin has not been shown to have any significant difference to UFH on clinical outcomes in patients undergoing cardiac surgery, and as per current international guidelines, can be considered for safe use in those patients for whom UFH is contraindicated. The study is limited by the bias of the included studies and the variability of bivalirudin drug dosage and its therapeutic monitoring; further, well-powered RCTs are required.
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Efficacy and safety of nafamostat mesilate for anticoagulation during ECMO/CRRT: insight from the integrated meta-analysis and FAERS pharmacovigilance study.
Clinical takeaway The pooled bleeding association is relevant to extracorporeal-support care, but does not establish an ECMO-specific benefit. Nonsignificant filter-lifespan findings do not demonstrate equivalence.
Summary & abstract
Study summary
This meta-analysis included 17 studies involving 1,893 patients, comparing nafamostat with sodium citrate, unfractionated heparin, or no anticoagulation during ECMO/CRRT. Nafamostat was associated with fewer bleeding events (odds ratio 0.61; 95% confidence interval 0.43–0.86). Filter lifespan did not differ significantly between groups (mean difference 1.29 hours; 95% confidence interval −1.09 to 3.66). A separate FAERS analysis included 24,238 reports across the three anticoagulants and identified nafamostat reporting signals for disseminated intravascular coagulation, gastrointestinal hemorrhage, and decreased platelet count; these are reporting signals rather than comparative clinical risks.
Study limitation: The abstract does not separate ECMO from CRRT results or report mortality findings, limiting cardiac ICU interpretation.
Published abstract
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) require a balance between maintaining circuit patency and minimizing bleeding risk. Nafamostat mesilate (NM) is a short-acting anticoagulant with distinctive pharmacokinetic properties, including rapid metabolism and a short half-life, which may reduce prolonged systemic anticoagulant exposure. These characteristics make NM a potential alternative to conventional anticoagulation strategies, particularly for patients at high risk of bleeding. This study aimed to systematically evaluate the efficacy and safety of NM as an anticoagulant for ECMO/CRRT. METHODS: PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, and Wanfang Data were systematically searched for randomized controlled trials and cohort studies comparing NM with sodium citrate, unfractionated heparin (UFH), or no anticoagulation. A meta-analysis was conducted to evaluate filter lifespan, bleeding events, thromboembolic events, and 28-day/intensive care unit (ICU) mortality. Reporting characteristics and potential safety signals for the three anticoagulants were also compared using data from the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS). RESULTS: The meta-analysis included 17 studies involving 1,893 patients. Filter lifespan did not differ significantly between the NM and control groups (mean difference [MD] = 1.29 h; 95% confidence interval [CI], -1.09-3.66), whereas the risk of bleeding events was significantly lower in the NM group (odds ratio [OR] = 0.61; 95% CI, 0.43-0.86). Subgroup analyses showed that NM was associated with a significantly lower risk of bleeding than sodium citrate (OR = 0.53; 95% CI, 0.31-0.90) and no anticoagulation (OR = 0.41; 95% CI, 0.19-0.90); sensitivity analyses supported the robustness of this finding. The FAERS analysis included 24,238 reports, comprising 233 for NM, 1,612 for sodium citrate, and 22,393 for UFH, with distinct reporting profiles observed among the three anticoagulants. Representative signals for NM included disseminated intravascular coagulation (n = 17; ROR = 112.68, 95% CI: 69.69-182.19), gastrointestinal hemorrhage (n = 12; ROR = 15.44, 95% CI: 8.74-27.29), and decreased platelet count (n = 13; ROR = 7.52, 95% CI: 4.35-13.00). CONCLUSION: NM may reduce bleeding risk while maintaining a filter lifespan comparable to that achieved with other anticoagulation strategies, potentially providing an individualized anticoagulation option for patients at high risk of bleeding. In clinical practice, coagulation abnormalities, changes in platelet counts, and bleeding-related events should be closely monitored.
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Oxidative Stress and Postoperative Atrial Fibrillation: A Systematic Review and Meta-Analysis.
Clinical takeaway Oxidative stress biomarkers show sampling-site-dependent associations with POAF, with stronger signals in atrial tissue than blood. These findings do not establish a clinically useful prediction strategy.
Summary & abstract
Study summary
This systematic review included 31 studies involving 4,983 adults undergoing cardiac surgery and examined oxidative stress biomarkers associated with postoperative atrial fibrillation (POAF). Pooled POAF incidence was 30.4% (95% CI 27.4–33.5). Atrial oxidative stress biomarkers were higher among patients developing POAF (Hedges g 0.89, 95% CI 0.45–1.32), whereas corresponding blood measurements showed no statistically significant difference (g 0.13, 95% CI −0.04–0.30). The between-compartment difference was 0.76 (p=0.005), highlighting the importance of sampling site. Most included studies were at high risk of bias, and clinical utility remains unvalidated.
Study limitation: Most studies had high risk of bias, and heterogeneous sampling sites and timing limit interpretation and clinical applicability.
Published abstract
Postoperative atrial fibrillation (POAF) is the most common arrhythmia after cardiac surgery and is linked to higher mortality and hospitalizations. Oxidative injury may contribute to its development; therefore, we aimed to systematically evaluate the relationship between oxidative stress biomarkers and POAF. MEDLINE, Embase, and the Cochrane Library were searched from inception to August 2026 for studies reporting oxidative stress biomarkers and POAF in adults undergoing cardiac surgery. Altogether, 31 studies (4,983 patients) were included; most were at high risk of bias by QUIPS assessment. We pooled similar studies using random-effects meta-analysis, compared associations between atrial and circulating measurements using a three-level model with cluster-robust inference, and summarized the remaining studies by effect direction. Pooled POAF incidence was 30.4% (95% CI 27.4 to 33.5). Atrial oxidative stress biomarkers were higher in patients who developed POAF (Hedges g 0.89, 95% CI 0.45 to 1.32), but blood levels of the same biomarker showed no statistical significance (g 0.13, 95% CI -0.04 to 0.30; between-compartment difference of 0.76, p = 0.005). Among individual markers, preoperative malondialdehyde differed only modestly between groups, while circulating markers increased postoperatively. Atrial oxidase and pericardial myeloperoxidase activity showed the largest adjusted associations with POAF. Oxidative-stress associations with POAF depend on sampling site and timing. Atrial tissue measures show stronger associations than preoperative blood biomarkers, while early postoperative pericardial and circulating markers may reflect reperfusion injury. Because the evidence is heterogeneous, standardized prospective studies are needed to validate these biomarkers and determine their clinical utility.
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Associated factors for in-hospital mortality in patients with fulminant myocarditis: a systematic review and meta-analysis.
Clinical takeaway These findings identify potential prognostic markers in fulminant myocarditis, but do not establish causality or treatment benefit. The immunoglobulin association is particularly fragile.
Summary & abstract
Study summary
This systematic review pooled 26 retrospective cohorts involving 4,890 patients with fulminant myocarditis to examine associations with all-cause in-hospital mortality. Cardiac arrest or CPR was associated with higher mortality odds (OR 2.57, 95% CI 1.49–4.44), while LVEF was inversely associated (OR 0.94, 95% CI 0.90–0.97). Age, lactate and cTnI also showed positive associations, while intravenous immunoglobulin therapy showed an inverse association. Evidence certainty was low for age and cTnI and very low for the other significant factors; lactate and immunoglobulin estimates were unstable in sensitivity analyses.
Study limitation: All included cohorts were retrospective, and most significant associations had very-low-certainty evidence.
Published abstract
BACKGROUND: Fulminant myocarditis (FM) progresses rapidly and carries high all-cause in-hospital mortality. Patients in the early phase often develop cardiogenic shock and malignant ventricular arrhythmias, with widely varying mortality rates reported across studies. Existing single-center cohorts yield conflicting prognostic findings with marked cross-cohort heterogeneity, and no standardized meta-analysis with GRADE certainty grading has been published to guide risk stratification. This meta-analysis pooled prognostic associations of all-cause in-hospital mortality in FM to inform acute risk evaluation and personalized care. METHODS: Eleven Chinese and English electronic databases were searched from database establishment through June 2025. Eligible studies were observational cohorts reporting prognostic associations of all-cause in-hospital mortality among FM patients. Two independent reviewers completed screening, data extraction and quality assessment separately. The Newcastle-Ottawa Scale (NOS) and AHRQ checklist were adopted to evaluate methodological quality. Pooled analyses were performed via the statsmodels package in Python, and the GRADE framework was applied to rate the certainty of evidence. RESULTS: 26 retrospective cohort studies with 4,890 FM patients were enrolled. Ten potential factors were meta-analyzed, of which six showed statistically significant associations with in-hospital mortality (P < 0.05), including age (OR = 1.03, 95% CI: 1.02-1.04), cardiac arrest or CPR (OR = 2.57, 95% CI: 1.49-4.44), lactate (OR = 1.08, 95% CI: 1.00-1.16), cTnI (OR = 1.04, 95% CI: 1.01-1.07), LVEF (OR 0.94, 95% CI 0.90-0.97), and intravenous immunoglobulin therapy (OR = 0.12, 95% CI: 0.02-0.86). CK-MB, serum creatinine, total bilirubin, and VT/VF showed no statistically significant association (all P > 0.05). GRADE evidence ratings indicated low-certainty evidence for age and cTnI, and very-low-certainty evidence for the remaining significant factors. Sensitivity analyses indicated unstable pooled estimates for lactate and intravenous immunoglobulin therapy. CONCLUSIONS: Four factors showed positive associations with elevated all-cause in-hospital mortality. LVEF was inversely associated with mortality, whereas the inverse association for IVIG represents a fragile treatment-related signal. These findings may inform acute risk screening, but most associations were supported by low or very low certainty evidence and should not be interpreted as causal. All included data were derived from retrospective cohorts. Standardized multicenter prospective studies are required to verify these prognostic associations. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261399446, identifier CRD420261399446.
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Intra-arrest strategies to treat cardiac arrest due to a non-opioid toxicological causes in adults and children: a systematic review.
Clinical takeaway Evidence for toxicology-specific modifications during cardiac arrest remains highly uncertain. The sodium bicarbonate finding is observational and does not establish that bicarbonate caused lower survival.
Summary & abstract
Study summary
This systematic review assessed modifications to advanced life support during presumed toxicological cardiac arrest, excluding studies focused specifically on opioid toxicity. Four observational studies examined nine interventions; none specifically focused on children, and three enrolled fewer than 100 patients. The primary outcome was 30-day survival. In the largest study (1,545 patients), sodium bicarbonate use during out-of-hospital arrest following suspected drug overdose was associated with lower survival to hospital discharge (adjusted odds ratio 0.16, 95% confidence interval 0.08–0.31). All studies had critical risk of bias, and intervention effect estimates were generally very imprecise.
Study limitation: Only four observational studies were available, all at critical risk of bias; none specifically focused on children.
Published abstract
OBJECTIVE: To summarise evidence on the effectiveness of specific alterations to standard advanced life support during ongoing cardiopulmonary resuscitation in adults and children with cardiac arrest due to a presumed toxicological cause. METHODS: We searched MEDLINE (OVID platform), Embase (OVID platform), and Cochrane CENTRAL from inception to 22nd July 2026 for relevant observational and interventional studies with a control group. We excluded studies focussed specifically on opioid toxicity. Two authors independently screened studies for inclusion. Our primary outcome was 30-day survival. We assessed risk of bias using the Cochrane recommended tools and certainty of evidence using the GRADE system. RESULTS: We identified four observational studies, of which none specifically focused on children and three included fewer than 100 patients. Studies examined general toxicological causes (n = 2), smoke inhalation and cyanide poisoning (n = 1), and beta-blocker and calcium-channel blocker overdose (n = 1). All studies were at critical risk of bias.Across the four studies, nine interventions were reported. Whilst some interventions were associated with either benefit or harm, estimates of effect were very imprecise and challenging to interpret. The largest study (1545 patients) reported that sodium bicarbonate use in out-of-hospital cardiac arrest due to suspected drug overdose was associated with lower survival to hospital discharge (adjusted odds ratio 0.16, 95% confidence interval 0.08-0.31). CONCLUSION: Current evidence does not support the modification of standard advanced life support during cardiac arrest due to a presumed toxicological cause in adults or children.Registration: PROSPERO CRD420251149412.
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Corticosteroid therapy in cardiogenic shock: A systematic review and meta-analysis.
Clinical takeaway The available evidence does not establish whether corticosteroids affect acute mortality in cardiogenic shock. Potential adverse-outcome signals also remain highly uncertain.
Summary & abstract
Study summary
This systematic review compared corticosteroids with placebo or usual care in adults with cardiogenic shock. Eight studies were included, but the primary analysis comprised three observational studies of clearly defined cardiogenic shock. Unadjusted acute mortality showed no clear effect (risk ratio 1.05, 95% confidence interval 0.98–1.13), with high residual-confounding risk and very low evidence certainty. Weak evidence suggested increased hyperglycaemia and hospital-acquired infection, but definitions varied and certainty was very low. The authors concluded that evidence was insufficient to determine corticosteroids’ effect on acute mortality.
Study limitation: The primary analysis relied on three observational studies, with substantial clinical heterogeneity and high risk of residual confounding.
Published abstract
INTRODUCTION: Relative adrenal insufficiency and inflammation are associated with increased mortality in cardiogenic shock. In other shock states such as sepsis, guidelines recommend the administration of corticosteroids. METHODS: We conducted a pre-registered (CRD420251042819) systematic review and meta-analysis, searching MEDLINE, Embase and Cochrane Central on 21 June 2025. We included randomised controlled trials and observational studies of adult patients with cardiogenic shock which compared corticosteroids to placebo or usual care. The primary outcome was acute mortality. RESULTS: Of 3242 studies screened, eight studies (four randomised controlled trials and four observational cohort studies) were included with three observational studies of clearly-defined cardiogenic shock included in the primary analysis. There was substantial clinical heterogeneity across included studies of populations, interventions and observed mortality. Observational studies suggested between 7% and 29% of patients with cardiogenic shock received systemic corticosteroids. There was no evidence of an effect on acute mortality in unadjusted analysis (Risk Ratio = 1.05, 95% CI 0.98-1.13, p = 0.17), but there was high risk of residual confounding and a very low certainty of evidence. There was weak evidence of increased rates of hyperglycaemia and hospital-acquired infection, but this was defined heterogeneously and the certainty of evidence was very low. CONCLUSION: Our conclusions are limited by low study numbers, heterogeneity and uncertainty. There is insufficient evidence to determine the effect of corticosteroid use on acute mortality in cardiogenic shock. Further high-quality research is needed to assess the effect of corticosteroids on mortality in patients with cardiogenic shock.
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The effect of near-infrared spectroscopy guided intraoperative care on neurocognitive and functional outcomes after cardiac surgery: a systematic review and meta-analysis of randomised controlled trials.
Clinical takeaway NIRS-guided intraoperative care may reduce early cognitive decline after on-pump cardiac surgery, but benefits for mortality, stroke, delirium, and longer-term recovery remain unestablished.
Summary & abstract
Study summary
This meta-analysis included 17 randomized trials involving 2288 adults undergoing on-pump cardiac surgery, comparing intraoperative NIRS-guided management with usual care. NIRS guidance probably reduced early postoperative cognitive decline (RR 0.65, 95% CI 0.42–0.99; moderate-certainty evidence). Effects on stroke (RR 0.89, 95% CI 0.42–1.91), mortality (RR 0.84, 95% CI 0.47–1.52), and delirium (RR 0.78, 95% CI 0.56–1.09) remained uncertain, with low-certainty evidence. Trials were predominantly small and single-centre, with heterogeneous thresholds and intervention algorithms. Few assessed outcomes beyond 30 days; none assessed validated quality-of-life or functional measures.
Study limitation: Predominantly small, single-centre trials used heterogeneous NIRS protocols, and evidence on longer-term patient-centred outcomes was sparse.
Published abstract
BACKGROUND: Adverse neurocognitive and functional outcomes are common after cardiac surgery. Cerebral near-infrared spectroscopy (NIRS) monitors regional cerebral oxygen saturation, allowing clinicians to detect and reverse cerebral desaturation. We conducted a systematic review and meta-analysis of RCTs to evaluate whether intraoperative NIRS monitoring improves neurocognitive outcomes after cardiac surgery. METHODS: We searched CENTRAL, CINAHL, Embase, MEDLINE, PsycINFO, and Web of Science for RCTs comparing NIRS-guided intraoperative management with usual care in adults undergoing on-pump cardiac surgery, assessing the outcomes of postoperative cognitive decline, delirium, stroke, mortality, and functional recovery. We pooled data using random-effects meta-analysis and assessed certainty of evidence using GRADE methodology. RESULTS: We included 17 RCTs (N=2288). NIRS-guided management probably reduces early postoperative cognitive decline (risk ratio [RR] 0.65, 95% CI 0.42-0.99; I2=65%, moderate certainty), may have little or no effect on stroke (RR 0.89, 95% CI 0.42-1.91; low certainty) or mortality (RR 0.84, 95% CI 0.47-1.52; low certainty), and may have no effect on delirium (RR 0.78, 95% CI 0.56-1.09; I2=32%, low certainty). Findings were primarily derived from small, single-centre trials with heterogenous NIRS thresholds and intervention algorithms. Few studies evaluated outcomes beyond 30 days, and none evaluated validated measures of quality of life or function. CONCLUSIONS: Although NIRS-guided intraoperative care shows promise for reducing early postoperative cognitive decline after cardiac surgery, evidence of benefit for other neurocognitive or clinical outcomes remains limited. Large multicentre studies are needed to confirm its utility, refine intervention thresholds, and determine its impact on long-term cognition, function, and quality of life. Systematic review protocol. PROSPERO (CRD42022336468).
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