BackgroundRecently, high-sensitive troponin (hsTrop) assays consistent with professional societies’ recommendations became available. We aimed to summarize the evidence on the diagnostic accuracy of hsTrop on presentation.MethodsWe searched electronic databases for studies evaluating the diagnostic accuracy of hsTrop in suspected acute coronary syndrome (ACS) patients. Random effect meta-analyses and meta-regression were performed. Primary and secondary analyses were restricted to studies using conventional Trop and hsTrop in the reference standard, respectively.ResultsFifteen studies with a total of 8,628 patients met the inclusion criteria for the primary analysis. hsTrop T (Hoffman-La Roche Ltd) and hsTrop I (Siemens) had sensitivities of 0.89 (95% confidence interval [CI]: 0.86–0.91) and 0.90 (95% CI: 0.87–0.92) and specificities of 0.79 (95% CI: 0.77–0.80) and 0.89 (95% CI: 0.87–0.90), respectively. There was no statistically significant difference in the area under the curve between hsTrop (95% CI: 0.920) and conventional Trop (95% CI: 0.929) at the 99th percentile (P=0.62). hsTrop at the level of detection had a sensitivity of 0.97 (95% CI: 0.96–0.98) and a specificity of 0.41 (95% CI: 0.40–0.42). The studies using a cut-off at coefficient of variance <10% as opposed to the 99th percentile for the conventional assay used for diagnosis reported higher diagnostic accuracy (relative diagnostic odds ratio =2.13, P=0.02). Five studies were included in the secondary analysis; hsTrop T (Hoffman-La Roche Ltd) had a sensitivity of 0.91 (95% CI: 0.89–0.93) and a specificity of 0.67 (95% CI: 0.63–0.70). There was significant heterogeneity among the studies.ConclusionhsTrop have excellent diagnostic accuracy for myocardial infarction on presentation, but may not outperform conventional Trop assays. The variation among the studies can be explained, in part, by the cut-off used for conventional Trop assays.
Background— In-stent restenosis (ISR) remains a difficult problem in interventional cardiology. The relative efficacy and safety of available interventions is not clear. We aimed to perform a network meta-analysis using both direct evidence and indirect evidence to compare all available interventions. Methods and Results— We systematically searched electronic databases for randomized trials comparing ≥2 treatments for ISR. A network meta-analysis was performed using a Bayesian approach. Eleven treatments were compared in 31 studies with 8157 patient-years follow-up. Compared with balloon angioplasty, everolimus-eluting stent (hazard ratio [95% credibility interval], 0.13 [0.048–0.35]), paclitaxel-eluting balloon (0.32 [0.20–0.49]), paclitaxel-eluting cutting balloon (0.054 [0.0017–0.5]), paclitaxel-eluting stent (0.39 [0.24–0.62]), and sirolimus-eluting stent (0.32 [0.18–0.50]) are associated with lower target vessel revascularization. Balloon angioplasty is not different from cutting balloon (0.73 [0.31–1.5]), excimer laser (0.89 [0.29–2.7]), rotational atherectomy (0.96 [0.53–1.7]), and vascular brachytherapy (0.60 [0.35–1.0]). In drug-eluting stent ISR, balloon angioplasty was inferior to everolimus-eluting stent (0.19 [0.049–0.76]), paclitaxel-eluting balloon (0.43 [0.18–0.80]), paclitaxel-eluting stent (0.35 [0.13–0.76]), and sirolimus-eluting stent (0.36 [0.11–0.86]) for target vessel revascularization. There was no difference between treatments in probable or definitive stent thrombosis. The results of binary restenosis and target lesion revascularization were similar. Paclitaxel-eluting cutting balloon, everolimus-eluting stent, and paclitaxel-eluting balloon have the highest probability of being in the top 3 treatments based on low target lesion revascularization, but there was no statistical significant difference between them. Conclusions— Balloon angioplasty is inferior to all drug-eluting treatments for ISR, including drug-eluting stent ISR. Drug-eluting stent, particularly everolimus-eluting stent, or paclitaxel-eluting cutting balloon and paclitaxel-eluting balloon should be preferred for treating ISR.
Cardiovascular disease, particularly ischemic heart disease, is one of the most common causes of morbidity and mortality in the United States. Atherosclerosis, the root cause of ischemic heart disease, is promoted by risk factors like elevated plasma low-density lipoprotein, low plasma high-density lipoprotein, smoking, hypertension, and diabetes mellitus. Even 66 years after a relation between triglycerides (TG) and cardiovascular disease was first suspected, TGs still continue to be a controversial risk factor and target for therapy. Some previous studies did not show any significant positive relationship between TG and cardiovascular mortality; however, recent meta-analyses found otherwise. The role of elevated TG in patients with low low-density lipoprotein and interventions to lower TG to reduce cardiovascular mortality and morbidity is an area of active research.
Systemic lupus erythematosus is an autoimmune disease with diffuse organ involvement. The cardiac complications include pericarditis, myocarditis, pulmonary hypertension, coronary vasculitis, and Libman-Sacks endocarditis. Symptomatic lupus myocarditis presenting with left ventricular dysfunction, acute heart failure, and pulmonary edema, although rare, is a life-threatening complication. We report the occurrence of acute lupus myocarditis in a 38-year-old postpartum female who had a cesarean section a week before presentation for preeclampsia. Initially she was managed for pneumonia but later found to have acute pericarditis and myocarditis related to systemic lupus erythematosus. She had a complicated hospital course including acute respiratory failure and cardiogenic shock. She was started on pulse dose steroids besides the treatment for heart failure and had a dramatic improvement within days.
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