Managing the Intricacies of Coronary Revascularization: A Close Look at the Complete Versus Culprit-Only Approach and its Implications in Elderly Patients.

Coronary heart disease is the leading cause of mortality in the United States, and data indicates that 805,000 Americans will face a new or recurrent myocardial infarction (MI) attack every year. Frailty, a conceptual syndrome categorized by a functional decline that occurs with aging, has been linked to adverse health outcomes in cardiovascular disease and all cardiac-related procedures in general. It is therefore reasonable to deliberate that more conservative medical therapy or medical management should be considered in the frail population when managing acute coronary syndrome. This course of action has, in fact, been documented in clinical practice. However, the recent Functional Assessment in Elderly MI Patients with Multivessel Disease trial, in which all subjects were 75 years of age or above, indicated that the more invasive complete revascularization approach may be favorable over incomplete or culprit-only revascularization in patients with acute MI. In this review, we will discuss coronary heart disease and review guidelines and procedures for culprit lesion identification, including electrocardiogram procedures, coronary angiography, intravascular ultrasound, fractional flow reserve, and instantaneous fractional flow reserve. We then discuss the concept of complete vs culprit-only/incomplete coronary revascularization and staging. Following this, we will delve into recent trials discussing complete vs culprit-only revascularization, emphasizing the insights gleaned from this latest trial within this special frailty cohort which warrants special consideration.

Diastolic Dysfunction and Atrial Fibrillation: Recognition, Interplay, and Management.

Diastolic dysfunction occurs when the left ventricle loses its ability to relax normally, impairing ventricular filling during diastole. This most commonly occurs as a pathological sequela of left ventricular hypertrophy and remodeling due to chronic hypertension and/or age-related sclerotic changes of the aortic valve. This can subsequently deteriorate to diastolic heart failure or heart failure with preserved ejection fraction. There is a substantive interplay between atrial fibrillation and diastolic dysfunction, as atrial fibrillation can cause, exacerbate, or be a direct result of diastolic dysfunction and vice versa. In this review, we first independently define diastolic heart failure and atrial fibrillation while discussing the diagnostic guidelines, which encompass various modalities such as medical history, electrocardiography, echocardiography, and laboratory tests. We subsequently examine their interplay and pathophysiological links drawing on recent evidence in the literature. Finally, we discuss management approaches, including pharmacological interventions targeting rate and rhythm control, diuretics, and addressing comorbidities.

SGLT-2 Inhibitors: Focus on Dapagliflozin.

Dapagliflozin (trade name FARXIGA) is a sodium-glucose cotransporter-2 (SGLT-2) inhibitor that has transcended its initial antidiabetic application to demonstrate benefits in cardiac and renal diseases. It was first approved by the food and department administration for type 2 diabetes in 2014. Since then, it has gained food and department administration approval for chronic kidney disease in 2021, heart failure with reduced ejection fraction in 2020, and heart failure with preserved ejection fraction in 2023. Thus, dapagliflozin plays a pivotal role in improving patient outcomes. By competitive binding to renal SGLT-2 cotransporters, dapagliflozin effectively prevents glucose and sodium reabsorption, leading to glucosuria. Its pharmacokinetic profile involves minimal cytochrome P450-induced metabolism, rapid absorption with an 18-hour duration of action, and stable effects. Clinical trials have revealed dapagliflozin's efficacy in glycemic control without the risk of hypoglycemia, making it an advantageous choice for patients insufficiently managed on other antidiabetic drugs. Comparative analysis with other SGLT-2 inhibitors suggests dapagliflozin's potential superiority in preventing heart failure. Compared to empagliflozin, it has more extended effects, contributing to stable sodium diuresis, reduced blood pressure fluctuations, and potentially lower cardiovascular disease risks. However, it leads to less urinary glucose excretion compared with canagliflozin. Dapagliflozin has specific contraindications, such as type 1 diabetes and end-stage chronic kidney disease. Adverse effects include an increased risk of genital infections, urinary tract infections, and Fournier's gangrene. A nuanced understanding of dapagliflozin's benefits and limitations is imperative for informed clinical decision-making in the management of diabetes and its complications.

Insulin's Legacy: A Century of Breakthroughs and Innovation.

The clinical use of insulin to treat diabetes started just over 100 years ago. The past century has witnessed remarkable innovations in insulin therapy, evolving from animal organ extracts to bioengineered human insulins with ultra-rapid onset or prolonged action. Insulin delivery systems have also progressed to current automated insulin delivery systems. In this review, we discuss the history of insulin and the pharmacology and therapeutic indications for a variety of available insulins, especially newer analog insulins. We highlight recent advances in insulin pump therapy and review evidence on the therapeutic benefits of automated insulin delivery. As with any form of progress, there have been setbacks, and insulin has recently faced an affordability crisis. We address the challenges of insulin accessibility, along with recent progress to improve insulin affordability. Finally, we mention research on glucose-responsive insulins and hepato-preferential insulins that are likely to shape the future of insulin therapy.

Hypothalamic-pituitary dysfunction in Sturge-Weber syndrome: case report and review of the literature.

OBJECTIVES: Sturge-Weber syndrome (SWS) is a rare neurocutaneous disorder that is characterized by a segmental dermatomal facial port-wine stain birthmark and is frequently accompanied by ipsilateral brain and eye abnormalities. We present a case of a patient with SWS who exhibited hypogonadotropic hypogonadism, growth hormone (GH) deficiency, and central hypothyroidism at the age of 20 despite the absence of radiographic findings in the pituitary and hypothalamus. CASE PRESENTATION: A 20-year-old male with SWS with epilepsy and Klippel-Trenaunay syndrome presents with delayed pubertal development, short stature, and obesity. Upon further examination, he was found to have biochemical and clinical evidence of hypogonadism, hypothyroidism, and GH deficiency. A pituitary MRI displayed no abnormalities of the pituitary or hypothalamus. Treatment with testosterone cypionate and levothyroxine was initiated. Despite successful pubertal induction, IGF-1 levels have remained low and treatment with recombinant human growth hormone (rhGH) is now being considered for metabolic benefits. CONCLUSIONS: This case emphasizes the importance of endocrine evaluation and treatment of hormonal deficiencies in patients with SWS despite the absence of radiographic findings.

Effects of sex, age, and apolipoprotein E genotype on hippocampal parenchymal fraction in cognitively normal older adults.

Early detection of Alzheimer's disease (AD) is important for timely interventions and developing new treatments. Hippocampus atrophy is an early biomarker of AD. The hippocampal parenchymal fraction (HPF) is a promising measure of hippocampal structural integrity computed from structural MRI. It is important to characterize the dependence of HPF on covariates such as age and sex in the normal population to enhance its utility as a disease biomarker. We measured the HPF in 4239 structural MRI scans from 340 cognitively normal (CN) subjects aged 59-89 years from the AD Neuroimaging Initiative database, and studied its dependence on age, sex, apolipoprotein E (APOE) genotype, brain hemisphere, intracranial volume (ICV), and education using a linear mixed-effects model. In this CN cohort, HPF was inversely associated with ICV; was greater on the right hemisphere compared to left in both sexes with the degree of right > left asymmetry being slightly more pronounced in men; declined quadratically with age and faster in APOE ϵ4 carriers compared to non-carriers; and was significantly associated with cognitive ability. Consideration of HPF as an AD biomarker should be in conjunction with other subject attributes that are shown in this research to influence HPF levels in CN older individuals.