RESUMEN
Key Clinical Message: The key takeaway from this clinical scenario is to choose the most appropriate and reasonable treatment plan when dealing with a patient who has atrial septal defect (ASD) and concurrent atrial and mediastinal masses. In such cases, a heart-oncology team should make the therapeutic decision. Abstract: Right atrial masses are not pretty rare and might be a diagnostic challenge. Thrombosis, tumors, and vegetations are primary differential diagnoses. Workup for these masses usually includes multimodality imaging and biopsy in selected cases. We report a case of a 37-year-old lady who presented with cough, dyspnea, and head and neck swelling after a cesarean section. Echocardiography revealed a right atrial mass accompanied by a secundum type atrial septal defect (ASD). Pulmonary CT Angiography was performed, in which a lobulated mass in the anterior mediastinum was detected, and a heart-oncology team made the therapeutic decision. The patient was scheduled for surgical ASD closure and concomitant tissue biopsy. The pathology results were in favor of poorly differentiated germ cell tumors, and chemotherapy was started following the surgery. After two sessions of chemotherapy, the tumor did not respond to the primary regimen. Thus, an updated regimen was initiated. Compliance with the updated regimen was acceptable, and the patient is currently under treatment and follow-up.
RESUMEN
BACKGROUND: We aimed to investigate the effectiveness of fixed-dose combination therapy (polypill) for primary and secondary prevention of major cardiovascular diseases in a typical rural setting. METHODS: The PolyPars Study is a two-arm pragmatic cluster-randomised trial nested within the PARS cohort study, including all residents aged over 50 years in the entire district in southern Iran. The 91 villages underwent random allocation into two arms: the control arm, encompassing 45 clusters, was subjected to non-pharmacological intervention (educational training on healthy lifestyle), whereas the intervention arm, comprising 46 clusters, received the non-pharmacological interventions in conjunction with a once-daily polypill tablet. This tablet comprised two antihypertensive agents, a statin and aspirin. The primary outcome was the first occurrence of major cardiovascular events defined as a composite of hospitalisation for acute coronary syndrome (non-fatal myocardial infarction and unstable angina), fatal myocardial infarction, non-fatal and fatal stroke, sudden death and heart failure. The Cox regression model, with shared frailty, was used to account for clustering effect. RESULTS: During December 2015-December 2016, a total of 4415 participants aged 50-75 years were recruited (2200 participants in the intervention arm and 2215 participants in the control arm). The overall median of follow-up duration was 4.6 years (interquartile interval 4.4-4.9). The achieved adherence rate to polypill in intervention arm was 86%. In the control group, 176 (8.0%) of 2215 participants developed primary outcome, compared with 88 (4.0%) of 2200 participants in the polypill group. We found substantial reduction in risk of primary outcome both in relative and absolute scales (HR 0.50, 95% CI 0.38 to 0.65; absolute risk reduction 4.0%, 95% CI 2.5% to 5.3%). No difference in serious adverse events was observed between the two groups. CONCLUSIONS: The fixed-dose combination therapy using polypill can safely halve the risk of major cardiovascular diseases at the population level. TRIAL REGISTRATION NUMBER: NCT03459560.