Cangrelor in a challenging scenario of concomitant ischaemic stroke, pulmonary embolism, and ST-elevation myocardial infarction: a case report.

Background: Antithrombotic therapy in acute patients with both high ischaemic and bleeding risks remains challenging. Case summary: We presented a challenging case involving a 48-year-old man referred to our hospital for headache and a left superior quadrantanopia. A CT scan revealed a right inferior occipital lobe ischaemic stroke. During the hospital stay, the patients developed pulmonary embolism (PE), and ST-elevation myocardial infarction (STEMI). A triple antithrombotic therapy was indicated, but the patient presented with high bleeding (anaemia, active malignancy, ischaemic stroke) and ischaemic (ischaemic stroke, PE, and superimposed STEMI) risks. In this critical acute setting, prolonged cangrelor infusion of reduced dosage, coupled with aspirin and enoxaparin, proved an effective and safe antithrombotic approach. Discussion: Prolonged cangrelor bridging at a reduced dose of 0.75 µg/kg/min may represent an effective and safe option in acute patients requiring P2Y12 inhibition and presenting both high ischaemic and high bleeding risks.

Mitral valve transcatheter edge-to-edge repair with PASCAL Vs MitraClip: A aystematic teview and meta-analysis.

BACKGROUND: Transcatheter edge-to-edge repair (TEER) using the MitraClip (Abbott Vascular) system has emerged as a standard treatment for patients with symptomatic severe secondary or inoperable primary mitral regurgitation (MR). The relatively recent approval of the PASCAL Transcatheter Valve Repair System (Edwards Lifesciences) has expanded the options of TEER devices. However, evidence comparing PASCAL with MitraClip systems is still limited. METHODS: We conducted a systematic literature research and meta-analysis in PubMed, Medline, and EMBASE databases for studies comparing PASCAL and MitraClip systems. RESULTS: Four observational studies and 1 randomized controlled trial, involving 1315 patients total, were eligible for inclusion. All patients exhibited symptomatic (NYHA II-IV) MR grades 3+ or 4+. Baseline characteristics were comparable across all included studies. The clinical outcomes were assessed according to the Mitral Valve Academic Research Consortium consensus. The procedural success rates for the 2 devices were comparable in terms of achieving post-procedural MR grades of less than or equal to 2+ and less than or equal to 1+. Furthermore, most patients improved their clinical status, with no significant differences between patients treated with PASCAL and those treated with MitraClip. In terms of safety, both procedures exhibited low overall mortality rates and occurrence of major adverse events (MAE), without significant difference between the 2 devices. These findings remained consistent in both short- and long-term follow-up assessments. CONCLUSIONS: Our study revealed similar effectiveness and safety profiles between the PASCAL and MitraClip devices in patients experiencing significant symptomatic MR.

Procedural and clinical impact of intravascular lithotripsy for the treatment of peri-stent calcification.

BACKGROUND: Use of intravascular lithotripsy (IVL) for treating peri-stent calcification is increasing. However, this indication remains 'off-label'. We aimed to investigate the efficacy and clinical outcomes of in-stent IVL. METHODS: Patients from five European centers who underwent in-stent IVL were included between 2019 and 2023. Demographic, clinical, procedural and follow-up data were collected from electronic hospital records. Angiographic and intracoronary imaging (ICI) data were analyzed in a centralized core-laboratory. RESULTS: Of 101 patients (71.2 ± 9.2 years), 56(55 %) received in-stent IVL for late stent failure (median 109 days post-PCI) due to calcific neoatherosclerosis or extra-stent calcification(late-IVL), while 45(45 %) underwent bail-out IVL due to stent infraexpasion (immediate-IVL). Both late-IVL and immediate-IVL significantly improved angiographic %diameter stenosis (73.7[59.6-89.8]% to 16.4 [10.4-26.9]%;p < 0.0001 and 28.6[22.5-43.3]% to 14.1[10.3-29.4]%;p < 0.0001, and minimum lumen area (MLA) (3.4 ± 1.2 to 8.6 ± 2.5 mm2;p < 0.002 and 5.4 ± 1.9 to 7.3 ± 1.9;p < 0.0001).Device(98 %) and procedural success(80 %) were high. MACE rates in-hospital (2 %), 30-days (3 %),6-months(5 %) and 1-year(7 %) were low and comparable in both groups. Acute diameter gain was lower in immediate-IVL (2.1 ± 0.7 mm vs. 0.5 ± 0.4 mm;p < 0.0001). This, however, was explained by significant differences in pre-IVL angiographic and ICI parameters (%diameter stenosis 73.7[59.6-89.8] vs. 28.6[22.5-43.3]%; p < 0.0001 and MLA (3.4 ± 1.2 vs 5.4 ± 1.9 mm2; p < 0.0001), whereas post-IVL percentage diameter stenosis (16.4(10.4-26.9) vs. 14.1(10.3-29.4);p = 0.914) and MLA (8.6 ± 2.5vs. 7.4 ± 1.9 mm2;p = 0.064) in late- and immediate-IVL were comparable. CONCLUSIONS: IVL in-stent due to peri-stent calcification is an effective strategy, both late and immediately after stent implantation. Overall, MACE rates at short- and mid-term were low and comparable in both groups, although clinical findings should be taken with caution.

Hypertrophic Cardiomyopathy and Atrial Fibrillation: A Systematic Review and Meta-analysis of Anticoagulation Strategy.

BACKGROUND: Atrial fibrillation (AF) frequently complicates hypertrophic cardiomyopathy (HCM), and anticoagulation significantly decreases the risk of stroke in this population. To date, no randomized controlled trials (RCTs) have compared direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs). The present study aimed to systematically compare the two anticoagulation strategies in terms of effectiveness and safety. METHOD: We performed a systematic literature search and meta-analysis in the PubMed, MEDLINE, and EMBASE databases for studies reporting all-cause mortality, major bleeding, or thromboembolic events (TEs). Since no RCTs were available, we included observational studies only. The overall hazard ratio (HR) and 95% confidence interval (CI) for each analyzed parameter were pooled using a random-effects model. RESULTS: Five observational studies including 6919 patients were eligible for inclusion. Compared with VKAs, DOACs were associated with statistically significant lower rates of all-cause mortality (HR 0.64, 95% CI 0.35-0.54; p < 0.00001), comparable major bleeding events (HR 0.64, 95% CI 0.40-1.03; p = 0.07), and TEs (HR 0.94, 95% CI 0.73-1.22; p = 0.65). CONCLUSIONS: Compared with VKAs, a DOAC-based strategy might represent an effective and safe strategy regarding all-cause mortality, major/life-threatening bleeding complications, and TEs in HCM patients with concomitant AF. However, further prospective studies are necessary to reinforce a DOAC-based anticoagulation strategy in this population.

Role of cardiac magnetic resonance in the differential diagnosis between arrhythmogenic cardiomyopathy with left ventricular involvement and previous infectious myocarditis.

AIMS: Arrhythmogenic cardiomyopathy with left ventricular involvement (ACM-LV), particularly in case of isolated left ventricular involvement (i.e. left dominant arrhythmogenic cardiomyopathy, LDAC) and previous infectious myocarditis (pIM) may have overlapping clinical and cardiac magnetic resonance (CMR) features. To date, there are no validated CMR criteria for the differential diagnosis between these conditions. The present study aimed to identify CMR characteristics to distinguish ACM-LV from pIM. METHODS AND RESULTS: This observational, retrospective, single-centre study included 30 pIM patients and 30 ACM-LV patients. In ACM-LV patients CMR was performed at diagnosis; in patients with pIM, CMR was performed six months after acute infection. CMR analysis included quantitative assessment of left ventricle (LV) volumes, systolic function and wall thicknesses, qualitative and quantitative assessment of late gadolinium enhancement (LGE) sequences. Compared with pIM, ACM-LV patients showed slightly larger LV volumes, more frequent regional wall motion anomalies and reduced wall thicknesses. ACM-LV patients had higher amounts of LV LGE and extension. Notably, the LDAC subgroup had the highest amount of LV LGE. LV LGE amount > 15 g and a LV LGE percentage > 30% of LV mass discriminated ACM-LV from pIM with a 100% specificity. LGE segmental distribution was superimposable among the groups, except for septal segments that were more frequently involved in ACM-LV and LDAC patients. CONCLUSIONS: A great extension of LV LGE (a cut-off of LGE >15 g and a percentage above 30% of LV LGE in relation to total myocardial mass) discriminates ACM-LV from pIM with extremely high specificity.

Direct oral anticoagulants or vitamin K antagonists after TAVR: A systematic review and meta-analysis.

BACKGROUND: Several patients undergoing transcatheter aortic valve replacement (TAVR) also require oral anticoagulation (OAC) for atrial fibrillation (AF) or deep vein thromboembolism. However, the optimal type of OAC strategy (direct oral anticoagulants, DOACs, or vitamin K antagonists, VKA) is still unclear in this setting. METHOD: We performed systematic literature research and meta-analysis in PubMed, Medline, and EMBASE databases for studies reporting either all-cause mortality, major/life-threatening bleeding or stroke events. RESULTS: Ten observational studies and two randomized controlled trials (RCTs) including a total of 29,485 patients were eligible for inclusion. Compared to VKA, DOACs use after TAVR was associated with a modest but significantly lower rates of all-cause mortality (RR 0.90; 95% CI: 0.81-0.99, p-value 0.04) with results mainly driven by observational studies. Cardiovascular mortality (RR 1.03; 95% CI: 0.81-1.30; p-value 0.84), total stroke events (RR 0.97; 95% CI: 0.76-1.23, p-value 0.79), major/life-threatening bleeding (RR 0.93; 95% CI: 0.72-1.21, p-value 0.61) and minor bleeding (RR 0.96; 95% CI: 0.74-1.23; p-value 0.72) were similar between VKA and DOACs. CONCLUSION: Considering the totality of available evidence, in patients who underwent TAVR with a concomitant indication for OAC, DOACs-based strategy is an effective and safe anticoagulation strategy compared to VKA.

Statin and Postcardiac Surgery Atrial Fibrillation Prevention: A Systematic Review and Meta-Analysis.

ABSTRACT: Postoperative atrial fibrillation (POAF) is a frequently reported postcardiac surgery complication leading to increased in-hospital and long-term mortality rates. Many randomized controlled trials (RCTs) have recently suggested using statins to protect against POAF. Therefore, we performed a systematic literature search and meta-analysis in electronic databases for eligible studies published between January 2006 and January 2022. The principal inclusion criteria were as follows: RCTs' study design, statin-naive patients, total study participants ≥50 units, and statin pretreatment started no more than 21 days before cardiac surgery. In the primary analysis, statin pretreatment reduced the incidence of POAF compared with placebo. Analyzing different molecules, atorvastatin was associated with lower incidence of POAF but rosuvastatin was not. We therefore performed a sensitivity analysis excluding RCTs affected by important risk of biases. Thus, studies whose participants were ≥199 were those eligible for the secondary analysis. No statistically significant difference between statin pretreatment and placebo (OR 0.87; 95% CI: 0.71-1.07, P = 0.18) as well as for atorvastatin (OR 0.88; 95% CI: 0.61-1.28; P = 0.48; I 2 = 84%) and rosuvastatin (OR 0.87; 95% CI: 0.68-1.12, P = 0.29) was observed. To conclude, statin pretreatment before cardiac surgery is not associated with a significant reduction in POAF occurrence.

Amplatzer Patent Foramen Ovale Occluder Device-Related Complications.

Patent foramen ovale (PFO) is a standard variant that is present in 25% of the whole adult population. In a certain population, PFO can lead to cerebrovascular accidents. Mechanism of cerebrovascular accidents can be by paradoxical embolization from the right circulation or in situ thrombosis. Diagnosis of a PFO-responsible cerebrovascular accident is based on a thorough work-up to exclude other possible etiologies and detect PFO on trans-thoracic or trans-esophageal echocardiography with bubble study and/or Doppler. Over the last few years, multiple studies have supported that percutaneous PFO closure is superior to medical therapy in the secondary prevention of cerebrovascular accidents. However, numerous adverse events have been linked to PFO closure devices in general compared to medical therapy as new-onset atrial fibrillation, residual shunt, device-related thrombus, bleeding, deep vein thrombosis, pulmonary embolism, and inter-atrial septal erosions. Amplatzer device is one of the PFO occluder devices approved by the FDA. Device-related adverse events have been addressed by comparing the Amplatzer device with other PFO occluder devices. Based on the new data, we expect to see more complications related to PFO closure in the coming few years. We reviewed different studies that looked at the PFO closure-related complications and the trials comparing adverse events in the Amplatzer PFO occluder device compared to other devices. Amplatzer PFO occluder device is either superior or non-statistically different from other PFO occluder devices related to new-onset atrial fibrillation and residual shunt. More studies are needed to address the other less common adverse events. Since many of the device-related complications appear many years after device placement, a long-term follow-up is recommended.

Correction: The Role of Chlamydia Trachomatis in the Pathogenesis of Cervical Cancer.

[This corrects the article DOI: 10.7759/cureus.21331.].

The Role of Chlamydia Trachomatis in the Pathogenesis of Cervical Cancer.

Chlamydia trachomatis (CT) is an obligate intracellular, Gram-negative bacterium that causes a variety of infections in both humans and animals. It is the causative agent of one of the most common sexually transmitted infections (STIs) with sequelae such as pelvic inflammatory disease, ectopic pregnancy, and infertility. Furthermore, Chlamydia infections have been epidemiologically linked to cervical cancer (CC) in patients with human papillomavirus (HPV) coinfection. However, a molecular mechanism linking Chlamydia to CC is yet to be established, and we still do not know if more aggressive diagnosis and treatment of Chlamydia could possibly lead to lower incidences of CC and associated mortality. Since CC is a leading cause of death among women worldwide, and HPV infection alone is insufficient to cause cancer, our goal was to determine the link between Chlamydia, HPV, and CC. This literature review aimed to understand the pathologic model of CC and how Chlamydia might induce or promote carcinogenesis alone or alongside HPV. In addition, we compared multiple studies attempting to associate Chlamydial infection with CC in different populations and aimed to determine whether there is an epidemiological correlation or not.

Arrhythmic mitral valve prolapse: Diagnostic parameters for high-risk patients: A systematic review and meta-analysis.

BACKGROUND: Although frequently considered a benign condition, new evidence has shown that mitral valve prolapse (MVP) is associated with complex ventricular arrhythmias (VAs) and sudden cardiac death (SCD). Therefore, we conducted a systematic review and meta-analysis of the relevant studies to investigate the parameters that could identify MVP patients at higher risk of experiencing complex VAs. METHOD: We performed a systematic literature search of PubMed for potential studies between January 2010 and January 2021. Our meta-analysis included studies comparing MVP patients with complex VAs (A-MVP) and those without (NA-MVP). We used the fixed-effects model to obtain the odds ratio (OR), risk ratio (RR), or mean difference (MD) and 95% confidence interval (CI) for each analyzed parameter. RESULTS: Six studies with 848 individuals were included in the meta-analysis. As compared to the NA-MVP patients, A-MVP patients had a higher prevalence of inverted T-wave (OR: 2.73; 95% CI: 1.85-4.02; p < .00001) and longer QTc interval on the resting ECG (MD: 14.73; 95% CI: 9.39-20.08; p < .00001), longer anterior mitral leaflet length (MD: 2.67; 95% CI: 2.02-3.31; p < .00001), bi-leaflet prolapse (OR: 1.65; 95% CI: 1.22-2.24; p = .001), and mitral annulus disjunction (MAD) on echocardiogram (RR: 1.90; 95% CI: 1.50-2.40; p < .00001), and late gadolinium enhancement (LGE) on cardiac magnetic resonance (RR: 4.38; 95% CI: 1.77-10.86; p = .001). CONCLUSION: Our comprehensive meta-analysis suggests that risk factors related to A-MVP are T-wave inversion, longer QTc interval, bi-leaflet prolapse, longer anterior mitral valve leaflet, MAD, and LGE.

Subclinical Hypothyroidism in Geriatric Population and Its Association With Heart Failure.

Heart failure (HF) is one of the most common causes of hospitalization in the geriatric age group, above 65 years. It is associated with high morbidity, mortality, and bad prognosis. Subclinical hypothyroidism (SCH) is a common condition present in this age group that significantly affects the cardiovascular system. Thus, this review attempts to elaborate on the association between subclinical hypothyroidism and heart failure in terms of their prevalence, pathogenesis, prognosis, and possible management in a geriatric age group. Among the various published literature on this topic on PubMed, PubMed Central, and Google Scholar, 36 relevant studies were selected to correlate this association. We found that both SCH and HF can be present concurrently in this age group. Especially in the geriatric population with thyroid-stimulating hormone (TSH) higher than ten mIu/L, there is an increased incidence of heart failure and a worse prognosis with preexisting heart failure. However, randomized controlled trials will be needed to explore further whether treatment is warranted or not in this age group.

Post-Traumatic Seizures: A Deep-Dive Into Pathogenesis.

Post-traumatic seizures (PTS) have become an emerging challenge for neurologists worldwide with the rise of brain injuries. Trauma can lead to various outcomes, ranging from naive spasms to debilitating post-traumatic epilepsy (PTE). In this article, we will explore the pathogenesis of convulsions following a concussion. We will look at multiple studies to explain the various structural, metabolic, and inflammatory changes leading to seizures. Additionally, we will explore the association between severity and location of injury and PTE. PTE's pathophysiology is not entirely implicit, and we are still in the dark as to which anti-epileptic drugs will be useful in circumventing these attacks. The purpose of this narrative review is to explain the post-traumatic brain changes in detail so that such attacks can be either thwarted or treated more resourcefully in the future.

Role of Vitamin D in Colorectal Cancer: A Holistic Approach and Review of the Clinical Utility.

Vitamin D is well known for its effects on the homeostasis of calcium and phosphorus. Lately, considerable research has brought the extra-skeletal role of vitamin D under the spotlight, including its anti-cancer activity. Colorectal cancer (CRC) is the most extensively studied neoplasia that has been observed to be affected by vitamin D; the list includes breast, prostate, and ovarian cancer. This review aims to shine a light on the influence of vitamin D over CRC and to further understand its ability to be used as a potential economical treatment for CRC patients. For this review, PubMed was used as the main database for the literature search. Studies on the role of vitamin D on CRC within 10 years and all of the study types were included. Post the extensive research over PubMed, it was noted that vitamin D, through its effect on multiple pathways, especially Wnt/ß-catenin, apoptosis, and inflammation, hinders the progression of CRC carcinogenesis. High levels of this steroid hormone can delay the progression and may provide a cost-effective way of treating CRC patients. Further research and additional human trials are still due to bring about more knowledge on this topic. In conclusion, high serum levels of vitamin D are associated with a lower risk of incidence and progression of CRC.

Medical Education, Pre- and Post-Pandemic Era: A Review Article.

A pandemic is the worldwide outbreak and spread of a disease. Although pandemics of influenza have occurred rarely, approximately once every few decades in more than three centuries, the outbreaks of H1N1 and H5N1 influenza, the severe acute respiratory syndrome (SARS), and most recently, the novel coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have necessitated the institution of protective and preventive measures such as school closure and mandatory quarantine of infected people, as social distancing is considered to be the most effective preventative strategy until the development of a vaccine, treatment, or both. The current pandemic has also resulted in a transformation in medical education for both undergraduate and postgraduate medical students. Clinical rotations for undergraduates have been suspended all over the world; inter-hospital residency rotations and combined teaching sessions have also been curtailed until further notice. During this most recent pandemic, a number of medical schools have immediately converted their whole clinical curriculum into online formats. Similarly, educational and clinical assessments have been converted into online assessments. However, as the pandemic eras tend to recur over time and epidemics will continue to break out, medical students and healthcare workers will remain susceptible to contagion. Hence, we need to adopt a new educational system that would be safe and sustainable in the long run.

Pleiotropic Effects of Statins in the Light of Non-Alcoholic Fatty Liver Disease and Non-Alcoholic Steatohepatitis.

Statins, the lipid-lowering drugs, and non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH), a lipid-related pathology, share a complex relationship, one known to be hepatotoxic and other being hepatic injury. NASH is an unresolved mystery in terms of treatment. Could statins prove to be a promising solution due to their pleiotropic properties in addition to the cholesterol-lowering effect? This study aims to find statin effectiveness in NAFLD/NASH treatment and prevention of associated adverse outcomes. An extensive data search was done to identify the studies assessing statin effect on NAFLD/NASH and then analyzed to establish the relationship. Several studies demonstrated a reduction in NAFLD/NASH-associated inflammation and fibrosis with statin treatment. These anti-inflammatory and anti-fibrotic effects were through their pleiotropic properties, which were in addition to their cholesterol-lowering effect. In various animal studies, statins were found to improve hepatic lipotoxicity, oxidative stress, inflammatory responses, and fibrosis associated with NASH through multiple pathways. Statins exert these protective effects by recovering the gene expression level of peroxisomal proliferator-activated receptor alpha (PPARα) and therefore restore the mitochondrial and peroxisomal fatty acid oxidation (FAO). Statin treatment also increased the levels of paraoxonase 1 (PON1), an antioxidant and antiatherogenic enzyme that is reduced in NAFLD as well as encounter the hepatic lipotoxicity by resolving cholesterol crystals and Kupffer cells (KCs) with crown-like structures (CLSs). They exhibited antitumor properties by inhibiting proinflammatory cytokines and vascular proliferative factors. Moreover, they restored a healthy liver sinusoidal endothelial cell (LSEC) and hepatic stellate cells (HSC) along with inhibiting the activation of HSC via modulating inducible nitric oxide synthase (iNOS) and expressions of endothelial nitric oxide synthase (eNOS). Besides, they were protective against cardiovascular disease (CVD)-related morbidity and mortality, hepatocellular carcinoma (HCC), and metabolic syndrome (MS) associated with NAFLD/NASH. NASH and its precursor, NAFLD, could be treated and prevented with statins owing to their pleiotropic properties. This study helps to prove this by looking back at different literature and has successfully enlightened the point. Once proved through large clinical trials on humans, it could revolutionize the NASH therapy.