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Hyperbaric oxygen therapy for acute coronary syndrome
Michael H Bennett, Jan P Lehm, Nigel Jepson
[[mailto:m.bennett@unsw.edu.au | m.bennett@unsw.edu.au]].

Editorial group: Cochrane Heart Group.
Publication status and date: Edited (no change to conclusions), published in Issue 7, 2015.

===Citation:===
Bennett MH, Lehm JP, Jepson N. Hyperbaric oxygen therapy for acute coronary syndrome. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD004818. DOI: 10.1002/14651858.CD004818.pub4.

===Background===
Acute coronary syndrome (ACS), includes acute myocardial infarction and unstable angina, is common and may prove fatal. Hyperbaric oxygen therapy (HBOT) will improve oxygen supply to the threatened heart and may reduce the volume of heart muscle that perishes. The addition of HBOT to standard treatment may reduce death rate and other major adverse outcomes.
This an update of a review previously published in May 2004 and June 2010.
===Objectives===
The aim of this review was to assess the evidence for the effects of adjunctive HBOT in the treatment of ACS. We compared treatment regimens including adjunctive HBOT against similar regimens excluding HBOT. Where regimens differed significantly between studies this is clearly stated and the implications discussed. All comparisons were made using an intention to treat analysis where this was possible. Efficacy was estimated from randomised trial comparisons but no attempt was made to evaluate the likely effectiveness that might be achieved in routine clinical practice. Specifically, we addressed:
Does the adjunctive administration of HBOT to people with acute coronary syndrome (unstable angina or infarction) result in a reduction in the risk of death?
Does the adjunctive administration of HBOT to people with acute coronary syndrome result in a reduction in the risk of major adverse cardiac events (MACE), that is: cardiac death, myocardial infarction, and target vessel revascularization by operative or percutaneous intervention?
Is the administration of HBOT safe in both the short and long term?
===Search methods===
We updated the search of the following sources in September 2014, but found no additional relevant citations since the previous search in June 2010 (CENTRAL), MEDLINE, EMBASE, CINAHL and DORCTHIM. Relevant journals were handsearched and researchers in the field contacted. We applied no language restrictions.
===Selection criteria===
Randomised studies comparing the effect on ACS of regimens that include HBOT with those that exclude HBOT.
===Data collection and analysis===
Three authors independently evaluated the quality of trials using the guidelines of the Cochrane Handbook and extracted data from included trials. Binary outcomes were analysed using risk ratios (RR) and continuous outcomes using the mean difference (MD) and both are presented with 95% confidence intervals. We assessed the quality of the evidence using the GRADE approach.
===Main results===
No new trials were located in our most recent search in September 2014. Six trials with 665 participants contributed to this review. These trials were small and subject to potential bias. Only two reported randomisation procedures in detail and in only one trial was allocation concealed. While only modest numbers of participants were lost to follow-up, in general there is little information on the longer-term outcome for participants. Patients with acute coronary syndrome allocated to HBOT were associated with a reduction in the risk of death by around 42% (RR: 0.58, (95% CI 0.36 to 0.92), 5 trials, 614 participants; low quality evidence).
In general, HBOT was well-tolerated. No patients were reported as suffering neurological oxygen toxicity and only a single patient was reported to have significant barotrauma to the tympanic membrane. One trial suggested a significant incidence of claustrophobia in single occupancy chambers of 15% (RR of claustrophobia with HBOT 31.6, 95% CI 1.92 to 521).
===Authors' conclusions===
For people with ACS, there is some evidence from small trials to suggest that HBOT is associated with a reduction in the risk of death, the volume of damaged muscle, the risk of MACE and time to relief from ischaemic pain. In view of the modest number of patients, methodological shortcomings and poor reporting, this result should be interpreted cautiously, and an appropriately powered trial of high methodological rigour is justified to define those patients (if any) who can be expected to derive most benefit from HBOT. The routine application of HBOT to these patients cannot be justified from this review.


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[[Acute ischaemia | BACK]]

@@ Line 1: / Line 1: @@
-<span style="line-height:normal">'''<span style="font-size:18.0pt"><span style="font-family:" times="" new="" roman",serif"="">Hyperbaric oxygen therapy for acute coronary syndrome</span></span>'''</span>
+<span style="line-height:normal">'''<span style="font-size:18.0pt"><span style="font-family:">Hyperbaric oxygen therapy for acute coronary syndrome</span></span>'''</span>
-<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"="">Citation:</span></span>'''<span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"="">Bennett MH, Lehm JP, Jepson N. Hyperbaric oxygen therapy for acute coronary syndrome. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD004818. DOI: 10.1002/14651858.CD004818.pub4.</span></span></span>
+<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:">Citation:</span></span>'''<span style="font-size:12.0pt"><span style="font-family:">Bennett MH, Lehm JP, Jepson N. Hyperbaric oxygen therapy for acute coronary syndrome. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD004818. DOI: 10.1002/14651858.CD004818.pub4.</span></span></span>
-<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"=""><span style="color:black">Background</span></span></span>'''</span>
+<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:"><span style="color:black">Background</span></span></span>'''</span>
-<span style="line-height:normal"><span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"="">Acute coronary syndrome (ACS), includes acute myocardial infarction and unstable angina, is common and may prove fatal. Hyperbaric oxygen therapy (HBOT) will improve oxygen supply to the threatened heart and may reduce the volume of heart muscle that perishes. The addition of HBOT to standard treatment may reduce death rate and other major adverse outcomes. This an update of a review previously published in May 2004 and June 2010.</span></span></span>
+<span style="line-height:normal"><span style="font-size:12.0pt"><span style="font-family:">Acute coronary syndrome (ACS), includes acute myocardial infarction and unstable angina, is common and may prove fatal. Hyperbaric oxygen therapy (HBOT) will improve oxygen supply to the threatened heart and may reduce the volume of heart muscle that perishes. The addition of HBOT to standard treatment may reduce death rate and other major adverse outcomes. This an update of a review previously published in May 2004 and June 2010.</span></span></span>
-<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"=""><span style="color:black">Objectives</span></span></span>'''</span>
+<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:"><span style="color:black">Objectives</span></span></span>'''</span>
-<span style="line-height:normal"><span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"="">The aim of this review was to assess the evidence for the effects of adjunctive HBOT in the treatment of ACS. We compared treatment regimens including adjunctive HBOT against similar regimens excluding HBOT. Where regimens differed significantly between studies this is clearly stated and the implications discussed. All comparisons were made using an intention to treat analysis where this was possible. Efficacy was estimated from randomised trial comparisons but no attempt was made to evaluate the likely effectiveness that might be achieved in routine clinical practice. Specifically, we addressed: Does the adjunctive administration of HBOT to people with acute coronary syndrome (unstable angina or infarction) result in a reduction in the risk of death? Does the adjunctive administration of HBOT to people with acute coronary syndrome result in a reduction in the risk of major adverse cardiac events (MACE), that is: cardiac death, myocardial infarction, and target vessel revascularization by operative or percutaneous intervention? Is the administration of HBOT safe in both the short and long term?</span></span></span>
+<span style="line-height:normal"><span style="font-size:12.0pt"><span style="font-family:">The aim of this review was to assess the evidence for the effects of adjunctive HBOT in the treatment of ACS. We compared treatment regimens including adjunctive HBOT against similar regimens excluding HBOT. Where regimens differed significantly between studies this is clearly stated and the implications discussed. All comparisons were made using an intention to treat analysis where this was possible. Efficacy was estimated from randomised trial comparisons but no attempt was made to evaluate the likely effectiveness that might be achieved in routine clinical practice. Specifically, we addressed: Does the adjunctive administration of HBOT to people with acute coronary syndrome (unstable angina or infarction) result in a reduction in the risk of death? Does the adjunctive administration of HBOT to people with acute coronary syndrome result in a reduction in the risk of major adverse cardiac events (MACE), that is: cardiac death, myocardial infarction, and target vessel revascularization by operative or percutaneous intervention? Is the administration of HBOT safe in both the short and long term?</span></span></span>
-<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"=""><span style="color:black">Search methods</span></span></span>'''</span>
+<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:"><span style="color:black">Search methods</span></span></span>'''</span>
-<span style="line-height:normal"><span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"="">We updated the search of the following sources in September 2014, but found no additional relevant citations since the previous search in June 2010 (CENTRAL), MEDLINE, EMBASE, CINAHL and DORCTHIM. Relevant journals were handsearched and researchers in the field contacted. We applied no language restrictions.</span></span></span>
+<span style="line-height:normal"><span style="font-size:12.0pt"><span style="font-family:">We updated the search of the following sources in September 2014, but found no additional relevant citations since the previous search in June 2010 (CENTRAL), MEDLINE, EMBASE, CINAHL and DORCTHIM. Relevant journals were handsearched and researchers in the field contacted. We applied no language restrictions.</span></span></span>
-<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"=""><span style="color:black">Selection criteria</span></span></span>'''</span>
+<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:"><span style="color:black">Selection criteria</span></span></span>'''</span>
-<span style="line-height:normal"><span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"="">Randomised studies comparing the effect on ACS of regimens that include HBOT with those that exclude HBOT.</span></span></span>
+<span style="line-height:normal"><span style="font-size:12.0pt"><span style="font-family:">Randomised studies comparing the effect on ACS of regimens that include HBOT with those that exclude HBOT.</span></span></span>
-<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"=""><span style="color:black">Data collection and analysis</span></span></span>'''</span>
+<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:"><span style="color:black">Data collection and analysis</span></span></span>'''</span>
-<span style="line-height:normal"><span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"="">Three authors independently evaluated the quality of trials using the guidelines of the Cochrane Handbook and extracted data from included trials. Binary outcomes were analysed using risk ratios (RR) and continuous outcomes using the mean difference (MD) and both are presented with 95% confidence intervals. We assessed the quality of the evidence using the GRADE approach.</span></span></span>
+<span style="line-height:normal"><span style="font-size:12.0pt"><span style="font-family:">Three authors independently evaluated the quality of trials using the guidelines of the Cochrane Handbook and extracted data from included trials. Binary outcomes were analysed using risk ratios (RR) and continuous outcomes using the mean difference (MD) and both are presented with 95% confidence intervals. We assessed the quality of the evidence using the GRADE approach.</span></span></span>
-<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"=""><span style="color:black">Main results</span></span></span>'''</span>
+<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:"><span style="color:black">Main results</span></span></span>'''</span>
-<span style="line-height:normal"><span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"="">No new trials were located in our most recent search in September 2014. Six trials with 665 participants contributed to this review. These trials were small and subject to potential bias. Only two reported randomisation procedures in detail and in only one trial was allocation concealed. While only modest numbers of participants were lost to follow-up, in general there is little information on the longer-term outcome for participants. Patients with acute coronary syndrome allocated to HBOT were associated with a reduction in the risk of death by around 42% (RR: 0.58, (95% CI 0.36 to 0.92), 5 trials, 614 participants; low quality evidence). In general, HBOT was well-tolerated. No patients were reported as suffering neurological oxygen toxicity and only a single patient was reported to have significant barotrauma to the tympanic membrane. One trial suggested a significant incidence of claustrophobia in single occupancy chambers of 15% (RR of claustrophobia with HBOT 31.6, 95% CI 1.92 to 521).</span></span></span>
+<span style="line-height:normal"><span style="font-size:12.0pt"><span style="font-family:">No new trials were located in our most recent search in September 2014. Six trials with 665 participants contributed to this review. These trials were small and subject to potential bias. Only two reported randomisation procedures in detail and in only one trial was allocation concealed. While only modest numbers of participants were lost to follow-up, in general there is little information on the longer-term outcome for participants. Patients with acute coronary syndrome allocated to HBOT were associated with a reduction in the risk of death by around 42% (RR: 0.58, (95% CI 0.36 to 0.92), 5 trials, 614 participants; low quality evidence). In general, HBOT was well-tolerated. No patients were reported as suffering neurological oxygen toxicity and only a single patient was reported to have significant barotrauma to the tympanic membrane. One trial suggested a significant incidence of claustrophobia in single occupancy chambers of 15% (RR of claustrophobia with HBOT 31.6, 95% CI 1.92 to 521).</span></span></span>
-<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:" times="" new="" roman",serif"=""><span style="color:black">Authors' conclusions</span></span></span>'''</span>
+<span style="line-height:normal">'''<span style="font-size:12.0pt"><span style="font-family:"><span style="color:black">Authors' conclusions</span></span></span>'''</span>
-<span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:" times="" new="" roman",serif"="">For people with ACS, there is some evidence from small trials to suggest that HBOT is associated with a reduction in the risk of death, the volume of damaged muscle, the risk of MACE and time to relief from ischaemic pain. In view of the modest number of patients, methodological shortcomings and poor reporting, this result should be interpreted cautiously, and an appropriately powered trial of high methodological rigour is justified to define those patients (if any) who can be expected to derive most benefit from HBOT. The routine application of HBOT to these patients cannot be justified from this review.</span></span></span>
+<span style="font-size:12.0pt"><span style="line-height:107%"><span style="font-family:">For people with ACS, there is some evidence from small trials to suggest that HBOT is associated with a reduction in the risk of death, the volume of damaged muscle, the risk of MACE and time to relief from ischaemic pain. In view of the modest number of patients, methodological shortcomings and poor reporting, this result should be interpreted cautiously, and an appropriately powered trial of high methodological rigour is justified to define those patients (if any) who can be expected to derive most benefit from HBOT. The routine application of HBOT to these patients cannot be justified from this review.</span></span></span>
-[[File:Sumhorsa.gif|center|sumhorsa.gif]] <span style="display: block; text-align: center;"><span style="color: #7c00ff; font-size: 230%;">[[Acute_ischaemia|BACK]]</span></span>
+[[File:Sumhorsa.gif|center|sumhorsa.gif]] <span style="display: block; text-align: center;"><span style="color: #7c00ff; font-size: 230%;">[[Myocardial_ischaemia|BACK]]</span></span>

@@ Line 1: / Line 1: @@
 <span style="font-size: 30pt;">Hyperbaric oxygen therapy for acute coronary syndrome</span>
-<span style="font-size: 150%;">Editorial group: Cochrane Heart Group.</span>
+<span style="font-size: 150%;">Michael H Bennett, Jan P Lehm, Nigel Jepson</span>&nbsp;
 <span style="font-size: 150%;">Publication status and date: Edited (no change to conclusions), published in Issue 7, 2015.</span>
 <span style="font-size: 160%;">Bennett MH, Lehm JP, Jepson N. Hyperbaric oxygen therapy for acute coronary syndrome. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD004818. DOI: 10.1002/14651858.CD004818.pub4.</span>
-===<span style="color: #000000; font-size: 1.9em; vertical-align: baseline;">Background</span>===
+=== <span style="color: #000000; font-size: 1.9em; vertical-align: baseline;">Background</span> ===
 <span style="font-size: 1.6em; vertical-align: baseline;">Acute coronary syndrome (ACS), includes acute myocardial infarction and unstable angina, is common and may prove fatal. Hyperbaric oxygen therapy (HBOT) will improve oxygen supply to the threatened heart and may reduce the volume of heart muscle that perishes. The addition of HBOT to standard treatment may reduce death rate and other major adverse outcomes.</span>
-<span style="font-size: 1.6em; vertical-align: baseline;">This an update of a review previously published in May 2004 and June 2010.</span>
+<span style="font-size: 1.6em; vertical-align: baseline;">Acute coronary syndrome (ACS), includes acute myocardial infarction and unstable angina, is common and may prove fatal. Hyperbaric oxygen therapy (HBOT) will improve oxygen supply to the threatened heart and may reduce the volume of heart muscle that perishes. The addition of HBOT to standard treatment may reduce death rate and other major adverse outcomes.</span> <span style="font-size: 1.6em; vertical-align: baseline;">This an update of a review previously published in May 2004 and June 2010.</span>
 ===<span style="color: #000000; font-size: 1.9em; vertical-align: baseline;">Objectives</span>===
-<span style="font-size: 1.6em; vertical-align: baseline;">The aim of this review was to assess the evidence for the effects of adjunctive HBOT in the treatment of ACS. We compared treatment regimens including adjunctive HBOT against similar regimens excluding HBOT. Where regimens differed significantly between studies this is clearly stated and the implications discussed. All comparisons were made using an intention to treat analysis where this was possible. Efficacy was estimated from randomised trial comparisons but no attempt was made to evaluate the likely effectiveness that might be achieved in routine clinical practice. Specifically, we addressed:</span>
+=== <span style="color: #000000; font-size: 1.9em; vertical-align: baseline;">Objectives</span> ===
 <span style="font-size: 1.6em; vertical-align: baseline;">Does the adjunctive administration of HBOT to people with acute coronary syndrome (unstable angina or infarction) result in a reduction in the risk of death?</span>
-<span style="font-size: 1.6em; vertical-align: baseline;">Does the adjunctive administration of HBOT to people with acute coronary syndrome result in a reduction in the risk of major adverse cardiac events (MACE), that is: cardiac death, myocardial infarction, and target vessel revascularization by operative or percutaneous intervention?</span>
+<span style="font-size: 1.6em; vertical-align: baseline;">The aim of this review was to assess the evidence for the effects of adjunctive HBOT in the treatment of ACS. We compared treatment regimens including adjunctive HBOT against similar regimens excluding HBOT. Where regimens differed significantly between studies this is clearly stated and the implications discussed. All comparisons were made using an intention to treat analysis where this was possible. Efficacy was estimated from randomised trial comparisons but no attempt was made to evaluate the likely effectiveness that might be achieved in routine clinical practice. Specifically, we addressed:</span> <span style="font-size: 1.6em; vertical-align: baseline;">Does the adjunctive administration of HBOT to people with acute coronary syndrome (unstable angina or infarction) result in a reduction in the risk of death?</span> <span style="font-size: 1.6em; vertical-align: baseline;">Does the adjunctive administration of HBOT to people with acute coronary syndrome result in a reduction in the risk of major adverse cardiac events (MACE), that is: cardiac death, myocardial infarction, and target vessel revascularization by operative or percutaneous intervention?</span> <span style="font-size: 1.6em; vertical-align: baseline;">Is the administration of HBOT safe in both the short and long term?</span>
 <span style="font-size: 1.6em; vertical-align: baseline;">Is the administration of HBOT safe in both the short and long term?</span>
-===<span style="color: #000000; font-size: 1.9em; vertical-align: baseline;">Search methods</span>===
+=== <span style="color: #000000; font-size: 1.9em; vertical-align: baseline;">Search methods</span> ===
 <span style="font-size: 1.6em; vertical-align: baseline;">We updated the search of the following sources in September 2014, but found no additional relevant citations since the previous search in June 2010 (CENTRAL), MEDLINE, EMBASE, CINAHL and DORCTHIM. Relevant journals were handsearched and researchers in the field contacted. We applied no language restrictions.</span>
 ===<span style="color: #000000; font-size: 1.9em; vertical-align: baseline;">Selection criteria</span>===
 <span style="font-size: 1.6em; vertical-align: baseline;">Randomised studies comparing the effect on ACS of regimens that include HBOT with those that exclude HBOT.</span>
 ===<span style="color: #000000; font-size: 1.9em; vertical-align: baseline;">Data collection and analysis</span>===
 <span style="font-size: 1.6em; vertical-align: baseline;">Three authors independently evaluated the quality of trials using the guidelines of the Cochrane Handbook and extracted data from included trials. Binary outcomes were analysed using risk ratios (RR) and continuous outcomes using the mean difference (MD) and both are presented with 95% confidence intervals. We assessed the quality of the evidence using the GRADE approach.</span>
 ===<span style="color: #000000; font-size: 1.9em; vertical-align: baseline;">Main results</span>===
-<span style="font-size: 1.6em; vertical-align: baseline;">No new trials were located in our most recent search in September 2014. Six trials with 665 participants contributed to this review. These trials were small and subject to potential bias. Only two reported randomisation procedures in detail and in only one trial was allocation concealed. While only modest numbers of participants were lost to follow-up, in general there is little information on the longer-term outcome for participants. Patients with acute coronary syndrome allocated to HBOT were associated with a reduction in the risk of death by around 42% (RR: 0.58, (95% CI 0.36 to 0.92), 5 trials, 614 participants; low quality evidence).</span>
+=== <span style="color: #000000; font-size: 1.9em; vertical-align: baseline;">Main results</span> ===
 <span style="font-size: 1.6em; vertical-align: baseline;">In general, HBOT was well-tolerated. No patients were reported as suffering neurological oxygen toxicity and only a single patient was reported to have significant barotrauma to the tympanic membrane. One trial suggested a significant incidence of claustrophobia in single occupancy chambers of 15% (RR of claustrophobia with HBOT 31.6, 95% CI 1.92 to 521).</span>
-===<span style="color: #000000; font-size: 1.9em; vertical-align: baseline;">Authors' conclusions</span>===
+<span style="font-size: 1.6em; vertical-align: baseline;">No new trials were located in our most recent search in September 2014. Six trials with 665 participants contributed to this review. These trials were small and subject to potential bias. Only two reported randomisation procedures in detail and in only one trial was allocation concealed. While only modest numbers of participants were lost to follow-up, in general there is little information on the longer-term outcome for participants. Patients with acute coronary syndrome allocated to HBOT were associated with a reduction in the risk of death by around 42% (RR: 0.58, (95% CI 0.36 to 0.92), 5 trials, 614 participants; low quality evidence).</span> <span style="font-size: 1.6em; vertical-align: baseline;">In general, HBOT was well-tolerated. No patients were reported as suffering neurological oxygen toxicity and only a single patient was reported to have significant barotrauma to the tympanic membrane. One trial suggested a significant incidence of claustrophobia in single occupancy chambers of 15% (RR of claustrophobia with HBOT 31.6, 95% CI 1.92 to 521).</span>
 <span style="font-size: 1.6em; vertical-align: baseline;">For people with ACS, there is some evidence from small trials to suggest that HBOT is associated with a reduction in the risk of death, the volume of damaged muscle, the risk of MACE and time to relief from ischaemic pain. In view of the modest number of patients, methodological shortcomings and poor reporting, this result should be interpreted cautiously, and an appropriately powered trial of high methodological rigour is justified to define those patients (if any) who can be expected to derive most benefit from HBOT. The routine application of HBOT to these patients cannot be justified from this review.</span>
-<span style="display: block; text-align: center;">
-</span>
+[[File:Sumhorsa.gif|center|sumhorsa.gif]] <span style="background-color: #ffffff; display: block; text-align: center;"></span><span style="background-color: #ffffff; display: block; text-align: center;"></span> <span style="display: block; text-align: center;"><span style="color: #7c00ff; font-size: 230%;">[[Acute_ischaemia|BACK]]</span></span>