Rapid Acute Coronary Syndrome Evaluation Over One Hour With High-Sensitivity Cardiac Troponin I: A United States-Based Stepped-Wedge, Randomized Trial.

STUDY OBJECTIVE: The real-world effectiveness and safety of a 0/1-hour accelerated protocol using high-sensitivity cardiac troponin (hs-cTn) to exclude myocardial infarction (MI) compared to routine care in the United States is uncertain. The objective was to compare a 0/1-hour accelerated protocol for evaluation of MI to a 0/3-hour standard care protocol. METHODS: The RACE-IT trial was a stepped-wedge, randomized trial across 9 emergency departments (EDs) that enrolled 32,609 patients evaluated for possible MI from July 2020 through April 2021. Patients undergoing high-sensitivity cardiac troponin I testing with concentrations less than or equal to 99th percentile were included. Patients who had MI excluded by the 0/1-hour protocol could be discharged from the ED. Patients in the standard care protocol had 0- and 3-hour troponin testing and application of a modified HEART score to be eligible for discharge. The primary endpoint was the proportion of patients discharged from the ED without 30-day death or MI. RESULTS: There were 13,505 and 19,104 patients evaluated in the standard care and accelerated protocol groups, respectively, of whom 19,152 (58.7%) were discharged directly from the ED. There was no significant difference in safe discharges between standard care and the accelerated protocol (59.5% vs 57.8%; adjusted odds ratio (aOR)=1.05, 95% confidence interval [CI] 0.95 to 1.16). At 30 days, there were 90 deaths or MIs with 38 (0.4%) in the standard care group and 52 (0.4%) in the accelerated protocol group (aOR=0.84, 95% CI 0.43 to 1.68). CONCLUSION: A 0/1-hour accelerated protocol using high-sensitivity cardiac troponin I did not lead to more safe ED discharges compared with standard care.

Precision Medicine and Cardiac Channelopathies: Human iPSCs Take the Lead.

Sudden cardiac death (SCD) is one of the leading causes of death worldwide, usually involving young people. SCD remains a critical public health problem accounting for 185,000-450,000 deaths annually, representing around 7%-18% of all deaths globally. As per evidence, ∼2%-54% of sudden unexpected deaths in people under the age of 35 years fail to show evidence of structural cardiac abnormalities at autopsy, making ion channelopathies the probable causes in such cases. The most generally recognized cardiac ion channelopathies with genetic testing are long QT syndrome (LQTS), Brugada syndrome (BrS), short QT syndrome (SQTS), and catecholaminergic polymorphic ventricular tachycardia (CPVT). The substantial progress in understanding the genetics of ion channelopathies in the last 2 decades has obliged the early diagnosis and prevention of SCD to a certain extent. In this review, we analyze the critical challenges and recent advancements in the identification, risk stratification, and clinical management of potentially fatal cardiac ion channel disorders. We also emphasize the application of precision medicine (PM) and artificial intelligence (AI) for comprehending the underlying genetic mechanisms, especially the role of human induced pluripotent stem cell (iPSC) based platforms to unravel the primary refractory clinical problems associated with channelopathies.

Rilonacept and Anakinra in Recurrent Pericarditis: A Systematic Review and Meta-Analysis.

Interleukin 1 (IL-1) has been indicated as a mediator of recurrent pericarditis. Rilonacept, a soluble IL-1 receptor chimeric fusion protein neutralizing interleukin 1 alpha (IL-1α) and interleukin 1 beta (IL-1ß), has demonstrated promising results in a phase II study in recurrent or refractory pericarditis. Anakinra is a recombinant inhibitor of the IL-1 receptor with a demonstrated reduction in the incidence of recurrent pericarditis. Definite pharmacological management of pericarditis is key to preventing recurrences, mostly treatment options for recurrent pericarditis refractory to conventional drugs. Here we critically discuss the existing therapy options for recurrent pericarditis, with a focus on new pharmacological approaches: rilonacept and anakinra. A systematic search was conducted across online databases such as PubMed, Cochrane, Google Scholar, ScienceDirect, CINAHL, Scopus, and Embase to obtain clinical trials that assess the effectiveness of anti-interleukin 1 therapy such as anakinra and rilonacept in the management of recurrent pericarditis. Our study concluded that anti-interleukin 1 therapy significantly improved both the quality of life and the clinical outcomes of the study population. These outcomes were most prominent with the use of rilonacept and anakinra in the trial treatment. Rilonacept and anakinra are valuable options in case of recurrent pericarditis refractory to conventional drugs.

Continuous positive airway pressure reduces the incidence of atrial fibrillation in patients with obstructive sleep apnea: A Meta-Analysis and Systematic Review.

INTRODUCTION: Obstructive sleep apnea (OSA) and atrial fibrillation (AF) are disorders that have increased in the United States during recent years. Earlier investigations have shown that underlying undiagnosed and unmanaged OSA plays a significant role in high rates and also as a trigger for newly diagnosed AF. Since the introduction of continuous positive airway pressure (CPAP) as a main therapy for OSA, more studies have evaluated the effect of CPAP on the development or recurrence of AF in OSA patients. However, sample sizes in a limited number of studies have been too small to conclude whether CPAP therapy has a significant effect on the development of AF in patients with OSA. The authors report results of their systematic review and meta-analysis summarizing what is currently known about the efficacy of CPAP for mitigating AF in patients with OSA. METHOD: The authors systematically reviewed the published reports on CPAP use and the incidence of AF from PubMed, Google Scholar, EMBASE, Web of Science, meeting abstracts, and Cochrane databases published between January 2015 and November 2021. Study data were extracted by two reviewers and a random-effects meta-analysis was performed using RevMan version 5.4. RESULTS: A total of 17 studies that met inclusion criteria were identified Studies included a total of 6,523 patients, 3,248 (49.8%) who used CPAP and 3,275 (50.2%) who did not use CPAP. In a random effects model, patients treated with CPAP showed a decrease in the incidence of AF (OR, 0.51; 95% CI; 0.27; 0.97, p = 0.04). High heterogeneity among the included studies was also observed (I2 = 97%). CONCLUSION: Our results add to the increasing evidence that CPAP therapy may reduce the incidence of development of AF in patients with OSA. Prospective future studies and clinical trials are needed to refine our understanding of the relationship between OSA and AF and how CPAP may reduce cardiovascular disease development.

A Meta-Analysis Comparing Venoarterial (VA) Extracorporeal Membrane Oxygenation (ECMO) to Impella for Acute Right Ventricle Failure.

The right ventricular complication happens when the right ventricle (RV) fails to move sufficient blood through the pulmonary circle to enable enough left ventricular pumping. A significant pulmonary embolism/right-sided myocardial infarction may cause this to develop suddenly in a previously healthy heart, but many of the patients treated in the critical care unit have gradual, compensated RV failure as a result of chronic heart and lung disease. RV failure management aims to decrease afterload and improve right-side filling pressures. Vasoactive medications have a lower effect on lowering vascular obstruction in the pulmonary circulation than in the systemic circle because the vascular tone is lower in the pulmonary circulation. Any factors that induce an elevation in pulmonary vascular tone must be addressed, and selective pulmonary vasodilators must be administered in a prescription that does not result in systemic hypotension or compromise oxygenation. The system-based systolic arterial pressure should be kept near the RV systolic pressure to ensure RV perfusion. When these efforts prove futile, judicious application of inotropic medications for better RV contractility may help ensure cardiac output. After obtaining the finest medical treatment, certain individuals may need the implantation of a mechanical circulatory support device. This meta-analysis is intended to compare the Impella and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) mechanical supports for patients with acute right ventricular failure. This comparison should demonstrate the best mechanical support between the two through thorough analysis. The analysis was begun by data collection from relevant sites; PUBMED and EMBASE were searched in collaboration with Google Scholar. Keywords were searched: Impella for acute right ventricle failure and VA ECMO for acute right ventricle failure. The results that were close to the search titles had their respective articles downloaded for further scrutiny. The search finally brought 1001 related articles that were exposed to further analysis to find more refined and closer articles within the needs of this meta-analysis. After extensive scrutiny, 23 articles were found to be the best for these analyses. The data showed that VA ECMO had better results than Impella for acute RV failure. However, the data were not statistically significant, as either the numbers of the studies were not enough or the null hypothesis was true and there was no true difference between them. More studies will be needed to confirm this.

COVID-19 Infection in Men on Testosterone Replacement Therapy.

BACKGROUND: Men who contract coronavirus disease 2019 (COVID-19) appear to have worse clinical outcomes compared with women which raises the possibility of androgen-dependent effects. AIM: We sought to determine if testosterone replacement therapy (TRT) is associated with worse clinical outcomes. METHODS: Through a retrospective chart review, we identified 32 men diagnosed with COVID-19 and on TRT. They were propensity score matched to 63 men diagnosed with COVID-19 and not on TRT. Data regarding comorbidities and endpoints such as hospital admission, intensive care unit admission, ventilator utilization, thromboembolic events, and death were extracted. Chi-square and Kruskal-Wallis tests examined differences in categorical and continuous variables, respectively. Logistic regression analysis tested the relationship between TRT status and the study endpoints. RESULTS: There were no statistically significant differences between the 2 groups, and TRT was not a predictor of any of the endpoints on multivariate analysis. CONCLUSION: These results suggest that TRT is not associated with a worse clinical outcome in men diagnosed with COVID-19. Rambhatla A, Bronkema CJ, Corsi N, et al. COVID-19 Infection in Men on Testosterone Replacement Therapy. J Sex Med 2021;18:215-218.