The Relationship between Using Renin-Angiotensin System Inhibitors with Mortality of Atrial Fibrillation: A Systematic Review and Meta-Analysis.

BACKGROUND: Atrial fibrillation (AFib) is a highly prevalent cardiac arrhythmia associated with increased mortality in affected persons. Renin-angiotensin system inhibitors (RASIs) have been suggested as potential therapeutic agents for cardiovascular and renal diseases. OBJECTIVES: However, the relationship between RASIs and mortality in AFib patients remains uncertain. Therefore, the present study was designed and implemented for this purpose. METHODS: We searched PubMed/MEDLINE, Embase, Web of Science (WOS), Cochrane Library, and Scopus databases for studies published until 12 February 2024 with relevant keywords. We included studies that reported mortality outcomes in AFib patients treated with RASIs and non-users. The data extraction and quality assessment processes were conducted, and subgroup analyses and sensitivity analyses were done. The data were analyzed by Stata 15 using statistical tests, such as Chi-square and I2 tests. RESULTS: A total of 15 studies (2007-2024; n=2,178,565 patients) examined the association between RASI drugs and mortality of patients with AFib. The results indicated that compared to the control group, the odds of AFib mortality in the group receiving RASIs were equal to 0.81(95% CI: 0.71-0.92; P-value ≤0.001). The study results did not indicate publication bias (Pvalue= 0.733). During the meta-regression analysis, none of the study variables demonstrated a significant relationship with the observed heterogeneity (P-value > 0.20). Cumulative OR results showed that from 2022 onwards, there was enough evidence to confirm the relationship using RASIs with mortality of patients with AFib. CONCLUSION: Therefore, this meta-analysis suggests that the use of RASI drugs is associated with reduced AFib mortality. However, the authors emphasize the need for further high-quality studies and large-scale randomized clinical trials to validate these findings.

Recurrence of valvular involvement in Libman-Sacks endocarditis associated with antiphospholipid syndrome: A case report.

Key Clinical Message: Recurrence of valvular involvement may occur after Libman-Sacks endocarditis surgery, emphasizing the need for frequent multivalvular evaluations with echocardiography or more sensitive methods to optimize surgical outcomes. Abstract: This report presented a 32-year-old woman, complaining of recurrent fever and chills. Physical examination revealed the presence of a third heart sound (S3), a pan-systolic murmur (III/VI) at mitral and tricuspid foci, tachycardia, and fine pulmonary crackles. Transesophageal echocardiography (TEE) revealed severe mitral regurgitation (MR) and moderate tricuspid regurgitation (TR) with vegetations on the mitral valve. Initially, intravenous antibiotic therapy was started simultaneously with diagnostic studies. Despite a positive TEE, negative blood cultures on three separate occasions precluded meeting the diagnostic criteria outlined in the modified Duke criteria. Moreover, the patient's condition continued to deteriorate after antibiotic therapy, leading to the diagnosis of Libman-Sacks endocarditis. The patient was considered a candidate for mitral valve surgery. All vegetations were completely debrided and then the mitral valve was reconstructed. Follow-up post-surgery echocardiography revealed the absence of MR and mitral stenosis (MS). Four months later, the patient presented again complaining of fatigue, dyspnea, lower extremity edema, and ascites with evidence of pulmonary hypertension and right heart failure on physical examination. TEE was performed, which revealed severe MR, severe TR, detached artificial chordae, and blood leak from the perforated pericardial patch. Therefore, she was necessitated for valvular surgery and underwent mitral and tricuspid valve surgery. The mitral ring and perforated pericardial patch were removed, and a mitral prosthetic valve was implanted. In addition, the tricuspid valve was repaired. Follow-up post-surgery echocardiography revealed the absence of MR and TR. To our knowledge, this is the first case of LSE recurrence with multi-valvular involvement.

Association Between Gallstone Disease and Risk of Mortality of Cardiovascular Disease and Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: Gallstone disease (GD) is increasing in the world and has various complications. OBJECTIVE: This study aims to examine the relationship between GD and the risk of mortality from cardiovascular disease (CVD) and cancer using a systematic review and meta-analysis approach. METHODS: A comprehensive and systematic search was done in various databases, such as Web of Science (WOS), Scopus, MEDLINE/PubMed, Cochrane, and Embase. The search included studies published from 1980 to December 2023. Heterogeneity was assessed using Chi-square, I2, and forest plots, while publication bias was evaluated through Begg's and Egger's tests. All analyses were performed using Stata 15, with statistical significance set at p <0.05. RESULTS: A pooled analysis of five studies involving 161,671 participants demonstrated that individuals with GD had a significantly higher risk of mortality from CVD (RR 1.29, 95% CI: 1.11-1.50, p <0.001). Importantly, no evidence of publication bias was found based on the results of Begg's test (p =0.806) and Egger's test (p =0.138). Furthermore, the pooled analysis of seven studies, encompassing a total of 562,625 participants, indicated an increased risk of cancer mortality among individuals with GD (RR 1.45, 95% CI: 1.16-1.82, p <0.001). Similarly, no publication bias was detected through Begg's test (p =0.133) and Egger's test (p =0.089). CONCLUSION: In this study, the evidence of a significant association between GD and an elevated risk of mortality from CVD and canceris provided. These findings suggest that implementing targeted interventions for individuals with gallstone disease could reduce mortality rates among these patients.

Challenging in pulmonary thromboembolism diagnosis in patients with disproportionate pulmonary hypertension and severe mitral stenosis: Report of two cases.

Key Clinical Message: Before valvular interventions, echocardiography, especially the TEE or the ventilation/perfusion scan, should be performed to detect silent PTE and set a more accurate treatment and surgical plan. Abstract: Pulmonary hypertension (PH) is a progressive and critical disease that can be caused by mitral stenosis (MS). Some of these patients present with disproportionate PH, which is an uncommon phenomenon and is considered a challenging diagnostic and treatment process. In these patients, other causes may also play a role in developing PH. This report presented two cases with disproportionate PH and severe MS who were scheduled for percutaneous mitral valvuloplasty (PMV). The pre-procedural echocardiography revealed systolic pulmonary artery pressure (sPAP) of 90 and 120 mmHg, mitral valve area of 0.80 and 0.55 cm2 by three-dimensional (3D) planimetry, and diastolic pressure gradient (DPG) of 13 and 18.8 mmHg, respectively. Furthermore, in the first patient, 3D transesophageal echocardiography (TEE) revealed multiple saddle-type organized thrombi in the proximal parts of the right and left pulmonary arteries, extending to the distal branches. In the second patient, 3D TEE revealed a large, relatively fresh, flow-limiting thrombosis in the proximal part of the right pulmonary artery. The diagnosis of pulmonary thromboembolism (PTE) in both patients was confirmed by CT angiography. In both patients, the valves were surgically repaired, while all thrombi were removed from the cardiac chambers and pulmonary vessels during surgery. In addition, patients underwent warfarin therapy orally. They were followed up 6 months after the intervention, and their clinical symptoms had improved significantly.

SGLT2 inhibitors and AMPK: The road to cellular housekeeping?

Sodium-glucose co-transporter-2 (SGLT2) inhibitors, known as Gliflozins, are a class of Glucose-lowering drugs in adults with type 2 diabetes (T2D) that induce glucosuria by blocking SGLT2 co-transporters in the proximal tubules. Several lines of evidence suggest that SGLT2 inhibitors regulate multiple mechanisms associated with the regulation of varying cellular pathways. The 5'-adenosine monophosphate-activated protein kinase (AMPK) pathway plays an important role in metabolic homeostasis by influencing cellular processes. Recently, it has been shown that SGLT2 inhibitors can affect the AMPK pathway in differing physiological and pathological ways, resulting in kidney, intestinal, cardiovascular, and liver protective effects. Additionally, they have therapeutic effects on nonalcoholic fatty liver disease and diabetes mellitus-associated complications. In this review, we summarize the results of studies of AMPK-associated therapeutic effects of SGLT2 inhibitors in different organelle functions.

Dual Left Anterior Descending Artery: Clinical Overview and Interventional Management.

Congenital coronary artery anomalies are relatively rare, occurring in approximately 0.6%-1.3% of cases undergoing coronary angiography. Among these anomalies, a unique cardiac abnormality known as a dual left anterior descending artery (LAD) stands out. A dual LAD is characterized by the presence of 2 LADs in the anterior interventricular sulcus. This structural deviation consists of a shorter LAD that terminates high in the anterior interventricular sulcus and a longer LAD that extends to the distal sulcus, supplying blood to the cardiac apex. Percutaneous procedures on dual LADs are even less frequent. We describe a 53-year-old woman with typical burning chest pain, ST-elevation in leads I and aVL, and positive troponin I enzyme. Coronary angiography revealed a thrombotic lesion with 99% stenosis at the proximal part of the LAD. The main LAD originated properly from the left coronary cusp, and the remainder of its course was supplied by a second branch originating from the right coronary cusp. Computed tomography angiography and echocardiography were performed for the LAD course. The patient was discharged after an uneventful 1-week hospital stay. Our case is particularly noteworthy for several reasons. Firstly, this dual LAD anomaly is uncommon, and patients with dual LADs less frequently have a ramus artery. Secondly, there have been only a few documented cases of percutaneous transluminal coronary angioplasty performed on short LADs. The key takeaway from this scintillating case study is the significance of identifying the artery responsible for blood supply to the cardiac apex.

Biatrial Myxoma with a Shared Stalk: A Case Report.

Myxomas are rare cardiac neoplasms and may present as single or multiple tumors. Only a few cases of single biatrial myxomas have been reported. We report a very rare case of this condition in a middle-aged woman, presenting with exertional dyspnea and cough. The patient had a resting tachycardia of 105 beats per minute, and cardiac auscultation discovered a mid-diastolic murmur across the mitral valve, followed by a tumor plop focused on the apex and elevated levels of C-reactive protein (1+) and creatine phosphokinase in lab data. The diagnosis was made via transesophageal and transthoracic echocardiographic examinations, showing the tumor extension through a patent foramen ovale (PFO). The operation was undertaken, the myxoma was excised, and the PFO was repaired. She was discharged with no further complications. Although myxomas are rare, considering this condition before surgery is significant. The involvement of both atria via a PFO is possible.

Prevalence of Vitamin D Deficiency and Associated Risk Factors in Cerebral Palsy A study in North-West of Iran.

OBJECTIVE: This study aimed to compare the prevalence of 25-hydroxyvitamin D deficiency in cerebral palsied (CP) with healthy control children and evaluate possible correlations between 25-hydroxyvitamin D and severity of CP and motor function. MATERIALS & METHODS: In this case-control study, serum levels of 25-hydroxyvitamin D were evaluated in 65 children with CP and compared with 65 healthy children referred to Tabriz Pediatric Hospital, Tabriz, northwestern Iran in 2015. Blood samples were taken to measure levels of 25-hydroxyvitamin D, calcium, phosphorus and alkaline phosphatase. Regarding 25-hydroxyvitamin D levels, patients were classified as sufficient (≥30 ng/ml), insufficient (20-30 ng/ml) and deficient (<20 ng/ml). RESULTS: Mean 25-hydroxyvitamin D levels were 28.03±24.2 ng/ml in patients and 30±1.94 ng/ml in control group. 25-hydroxyvitamin D deficiency was seen in 44.6% of CP and 18.5% of healthy children. There was no significant difference in 25-hydroxyvitamin D levels between boys and girls, CP types and use of antiepileptics in case group. There was significant negative correlation between age and 25-hydroxyvitamin D levels (P=0.007). The correlation between 25-hydroxyvitamin D and Gross Motor Function Classification System was not significant. CONCLUSION: 25-hydroxyvitamin D deficiency is common in children with CP in comparison with healthy children. There was significant negative correlation between age and 25-hydroxyvitamin D levels. Routine measurement of 25-hydroxyvitamin D levels and its proper treatment is recommended to prevent its deficiency and subsequent consequences.