Cerebrovascular Events Research Articles

Changes of Dental Implant Surgery-Related Anxiety and Pain with Respect to ASA-Physical Status.

Background/Objectives: Rehabilitation of missing teeth with dental implants is a strong trigger of dental anxiety. The sympathetic response caused by anxiety can lead to cardiovascular and cerebrovascular incidents, especially in patients at systemic risk (ASA Physical Status-II and ASA Physical Status-III). Dental anxiety can affect physical health by activating the sympathetic response, and the patient's physical health status may also affect dental anxiety. The aim of this study was to analyze the factors that may reduce anxiety and pain, considering the patient's physical health status according to American Society of Anesthesiologists (ASA-PS). Methods: A total of 562 implants were placed under local anesthesia in 201 patients with ASA PS-I (healthy) and ASA PS-II and III (comorbid). The effect of patient-, dentist-, and surgery-related variables on dental anxiety and pain perception were evaluated. Modified Corah Dental Anxiety Scale and Numerical Rating Scale for Pain scores were measured and recorded preoperatively (T0) and 1 week postoperatively (T1). The effects of the associated variables were analyzed using binary logistic regression and non-parametric tests (p < 0.05). Results: Age (OR = 1.089), gender (OR = 6.493), ASA-PS (OR = 13.912), and the number of placed implants (OR = 0.807) were significantly associated with reduction in dental anxiety. There were statistically significant differences between the study groups in terms of mDAS score reduction (p = 0.028). Conclusions: ASA-PS, gender and the number of placed implants affected the anxiety of the patients. Age and number of implants seem to be variables with a relative influence that depends on other factors.

Atrial Fibrillation in Patients with Very High Risk for Stroke and Adverse Events-Insights from the Observational ARENA Study.

Background: Atrial fibrillation (AF) is a major cause of stroke. An individual risk estimation remains challenging, as AF patients with and without cerebrovascular event (CVE) may differ in yet unknown factors beyond those covered by the CHA2DS2-VASc score. We aimed to identify differences between AF patients with and without CVE with regard to AF characteristics and treatment, vascular risk factors and comorbidities, prognosis and outcome. Methods: We analyzed patients included in the Atrial Fibrillation Rhine-Neckar Region (ARENA) Project, an observational cohort study of patients with AF. Patients were recruited by their general practitioner or during a hospital stay and were divided into two groups for the present analysis: patients with acute CVE at baseline and/or history of CVE versus patients without CVE. Follow-up at 1 year was conducted via phone call. Results: Of 2061 included patients (60.6% male), 292 (14.2%) belonged to the CVE group. Patients in the CVE group were older (mean age 74.6 versus 71.7 years; p < 0.001) and had a higher CHA2DS2-VASc score at baseline (5.3 versus 3.3 points; p < 0.001) based on the preceding CVE. Moreover, patients with either acute or chronic CVE had a larger left atrium (median diameter 47/46 mm versus 44 mm; p = 0.001). Patients with acute CVE had structural heart diseases (p < 0.001) less frequently than patients with previous or without CVE. Mortality at 1 year (HR 1.95; 95%-CI 1.37-2.78) was more frequent in the CVE group (p < 0.001). During 1-year of follow-up, stroke occurred more frequently in survivors with CVE (2.9% versus 0%; p < 0.001). Conclusions: AF patients with CVE have a significantly worse prognosis than AF patients without CVE. Atrial structural remodeling, underlying cardiovascular disease, stroke-induced heart injury and further unidentified factors may account for this finding. Characterization of AF patients including echocardiography to detect atrial structural remodeling may be helpful in risk stratification beyond classical scores.

Development and Validation of a Predictive Model for Maternal Cardiovascular Morbidity Events in Patients With Hypertensive Disorders of Pregnancy.

Hypertensive disorders of pregnancy (HDP) are a major contributor to maternal morbidity, mortality, and accelerated cardiovascular (CV) disease. Comorbid conditions are likely important predictors of CV risk in pregnant people. Currently, there is no way to predict which people with HDP are at risk of acute CV complications. We developed and validated a predictive model for all CV events and for heart failure, renal failure, and cerebrovascular events specifically after HDP. Models were created using the Premier Healthcare Database. The inclusion criteria for the model dataset were delivery with an HDP with discharge from October 1, 2015 to December 31, 2020. Machine learning methods were used to derive predictive models of CV events occurring during delivery hospitalization (Index Model) or during readmission (Readmission Model) using a training set (60%) to estimate model parameters, a validation set (20%) to tune model hyperparameters and select a final model, and a test set (20%) to evaluate final model performance. The total model cohort consisted of 553,658 deliveries with an HDP. A CV event occurred in 6501 (1.2%) of the delivery hospitalizations. Multilabel neural networks were selected for the Index Model and Readmission Model due to favorable performance compared to alternatives. This approach is designed for prediction of multiple events that share risk factors and may cooccur. The Index Model predicted all CV events with area under the receiver operating curve (AUROC) 0.878 and average precision (AP) 0.239 (cerebrovascular events: AUROC 0.941, heart failure: AUROC 0.898, and renal failure: AUROC 0.885). With a positivity threshold set to achieve ≥90% sensitivity, model specificity was 65.0%, 83.5%, 68.6%, and 65.6% for predicting all CV events, cerebrovascular events, heart failure, and renal failure, respectively. CV events within 1 year of delivery occurred in 3018 (0.6%) individuals. The Readmission Model predicted all CV events with AUROC 0.717 and AP 0.022 (renal failure: AUROC 0.748, heart failure: AUROC 0.734, and cerebrovascular events AUROC 0.698). Feature importance analysis indicated that the presence of chronic renal disease, cardiac disease, pulmonary hypertension, and preeclampsia with severe features had the greatest effect on the prediction of CV events. Among individuals with HDP, our multilabel neural network model predicted CV events at delivery admission with good classification and events within 1 year of delivery with fair classification.

Impact of a Chronic Total Occlusion on Outcomes After FFR-Guided PCI or Coronary Bypass Surgery: A FAME 3 Substudy.

The clinical impact of a chronic total occlusion (CTO) in patients with 3-vessel coronary artery disease undergoing fractional flow reserve-guided percutaneous coronary intervention (PCI) with current-generation drug-eluting stents or coronary artery bypass grafting (CABG) is unclear. The FAME 3 trial (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation 3) compared fractional flow reserve-guided PCI with CABG in patients with 3-vessel coronary artery disease. The primary end point was major adverse cardiac and cerebrovascular events, a composite of death, myocardial infarction, stroke, or repeat revascularization at 1 year. In this substudy, the 3-year outcomes were analyzed in patients with or without a CTO. Of the patients randomized to PCI or CABG in the FAME 3 trial, 305 (21%) had a CTO. In the PCI arm, revascularization of the CTO was attempted in 61% with a procedural success rate of 88%. The incidence of major adverse cardiac and cerebrovascular events at 3 years was not significantly different between those with or without a CTO in both the PCI (15.2% versus 20.1%; adjusted hazard ratio, 0.62 [95% CI, 0.38-1.03]; P=0.07) and the CABG (13.0% versus 12.9%; adjusted hazard ratio, 0.96 [95% CI, 0.55-1.66]; P=0.88) arms. In those without a CTO, PCI was associated with a significantly higher risk of major adverse cardiac and cerebrovascular events compared with CABG (adjusted hazard ratio, 1.61 [95% CI, 1.20-2.17]; P<0.01) but not in those with a CTO (adjusted hazard ratio, 1.21 [95% CI, 0.64-2.28]; P=0.56; Pinteraction=0.31). The presence of a CTO did not significantly impact the treatment effect of PCI versus CABG at 3 years in patients with 3-vessel coronary artery disease. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02100722.

Role of Serum Ferritin and Prediction of Neurological Outcome in Acute Ischemic Stroke Patients

Background: Stroke, also known as cerebrovascular accident (CVA), is an abrupt onset of neurological deficiency caused by a specific vascular aetiology. Aim: This study aimed to assess the role of serum ferritin in acute ischaemic stroke patients to correlate serum ferritin and neurological scales on the day of admission and during follow-up and to predict neurological outcomes. Methods: This prospective observational study included 100 patients who presented with acute ischaemic stroke clinically and with radiological imaging in the General Medicine and Neurology departments of Saveetha Medical College and Hospital for 18 months. Functional disability was assessed for all patients after 3 months based on the correlation of serum ferritin levels with the neurological scales, and the outcome was estimated. Results: The mean age of the patients was 59.45 ± 14.39. The serum ferritin level and Canadian Stroke Scale score during admission on day 7th and day 30th, were significantly different (p &lt; 0.01). Serum ferritin levels were positively associated with the Glasgow Coma Scale score at admission and on the 7th and 30th days after admission. Ferritin levels were significantly higher in the moderate category under all circumstances (p &lt; 0.01). Patients with mRS scores of 2, 3, and 4 were compared with serum ferritin levels and found to be significantly associated with serum ferritin levels. Conclusion: This study found that patients with higher serum ferritin levels experienced increased stroke severity and lower GCS and mRS scores, which correlated with increased morbidity.

Predictors of recurrent ischemic stroke: A retrospective cohort study

Introduction: Cerebrovascular events are one of the most common causes of disability and the third leading cause of death in developed countries. Herein, we aimed to investigate the potential underlying causes of recurrent ischemic stroke. Methods: This study was a retrospective cohort study conducted in Razi Hospital, Tabriz, Iran between March 2018 and September 2020. Patients with the diagnosis of recurrent ischemic stroke during the study period were eligible to be included. Baseline characteristics and data on the recurrence were collected using chart reviews. Also, binary logistic regression was used to examine the factors related to recurrence. Results: Among one hundred participants with a mean age of 68.88 years, 59% were male. Hypertension, diabetes, heart disease, smoking, and hyperlipidemia were identified in 79%, 42%, 24%, 15%, and 15%, respectively. The average recurrence time of stroke was about 2.52 years. According to our findings, a significant relationship between the history of heart diseases and ischemic stroke recurrence was observed (risk ratio: 0.10: 95% confidence interval: 0.03-0.33). Conclusion: We found no significant association between ischemic stroke recurrence and underlying diseases except for heart diseases. Further large-scale observational studies and meta-analyses are recommended to evaluate the possible association.

Evaluation of Hypertension-Related Knowledge, Medication Adherence, and Associated Factors Among Hypertensive Patients in the Aljouf Region, Saudi Arabia: A Cross-Sectional Study.

Background and Objectives: Hypertensive patients' knowledge and adherence to prescribed medicines are critical in managing their condition, as poor adherence may lead to adverse cardiac and cerebrovascular events. The present study assessed hypertension-related knowledge and medication adherence among hypertensive patients attending primary health centers (PHCs) in the Aljouf Province, Saudi Arabia. Materials and Methods: Using a cross-sectional design, we conducted this survey on 390 patients. Self-reported hypertension knowledge was assessed using the Hypertension Knowledge Level Scale (HK-LS), and medication adherence was determined using the Hill-Bone Medication Adherence Scale. We used binomial regression analysis (adjusted with other variables) to find the associated factors of medication adherence. Results: This study found that nearly half (49.2%) of the participants had inadequate knowledge, and poor medication adherence was noted in 40.8% of the participants. We found a positive correlation between HK-LS and the Hill-Bone Medication Adherence Scale scores (Spearman's rho = 0.312, p = 0.002). Medication adherence was significantly associated with job status (private sector (ref: public sector, adjusted odds ratio [AOR] = 2.02, 95% CI = 1.18-3.62, p = 0.005)), living in an urban region (ref: rural, AOR = 3.61, 95% CI = 1.85-5.72, p = 0.002), and duration since diagnosis of more than 5 years (ref: ≤1 year, AOR = 3.53, 95% CI = 2.36-4.95, p = 0.001). Conclusions: The present study findings indicate that there is still a critical gap in managing hypertension at the PHCs in this region, and this may lead to poor health outcomes among the patients and burden the healthcare system. Hence, continuous patient education and targeted counseling are recommended for those with poor medication adherence.

Assessment of the Sokolow Lyons Criteria of Left Ventricular Hypertrophy in Comparison with Echocardiography in Hypertensive Patients

Around 65.4% of people over the age of 60 have hypertension, and it's the underlying cause of 6% of all fatalities globally. The left ventricle enlarges, or hypertrophies, in people with hypertension. If the left ventricle of the heart thickens its walls or the chamber of the left ventricle expands, or if both happen at once, the condition is called left ventricular hypertrophy (LVH) [1]. This condition impacts approximately 15 -20% of the general population and has similar rates in men and women. Serious health complications such as cardiovascular diseases, stroke, congestive heart failure, irregular heart rhythms (ventricular arrhythmias), and sudden cardiac death are linked to it.Rationale of the study: In people with slightly hypertensive conditions, the prevalence of LVH is 20%; in those with severe or complex hypertension, it approaches 100%. LVH is also a result of valve disorders, which cause pressure and/or volume overload. Furthermore, "physiological" LVH—which occurs in well-trained athletes in reaction to job overload—can arise. About 0.2% of the general population has hypertrophic cardiomyopathy, a hereditary condition caused by mutations in the sarcomere protein genes. It is characterized by severe cardiac tissue disarray, fibrotic scarring, and aberrant internal coronary arteries.Background and statement of the problem: Hypertension is a leading cause of many cardiovascular problems and cerebrovascular accidents Aim: Assessment of the Sokolowlyon’s Criteria of Left Ventricular Hypertrophy in comparison with Echocardiography Inhypertensives PatientsObjective: To determine whether the ECHO of left ventricular hypertrophy significantly coincides with the Sokolow Lyon criterion of the ECG.Methodology: This cross-sectional study was carried out at the Shree Balaji Medical College and Hospital's general medicine department in Chromepet, Tamil Nadu, India. The study ran from June 2022 to December 2023, a duration of eighteen months.Results: The study focused on assessing the correlation between Sokolow-Lyon criteria on (ECG) and (LVH) as determined by echocardiography (ECHO). The results revealed that among the 125 participants, 88 cases (70.40%) were identified as having LVH based on Sokolow-Lyon criteria, while 37 cases (29.60%) showed no signs of LVH. These findings provide a quantitative breakdown of the prevalence of LVH according to ECG criteria within the study population.Conclusion: Our investigation's findings showed that the ECG LVH Sokolow Lyon criteria had a satisfactory level of specificity and sensitivity in the diagnosis of left ventricular hypertrophy (LVH). The most sensitive diagnostic criteria turned out to be the ECG LVH Sokolow Lyon criteria, especially when it came to patients with co-morbidities. We found that the Sokolow Lyon criteria had a 36% sensitivity in the current investigation. As such, we suggest applying these criteria to assist in verifying the diagnosis of LVH, particularly in low-complexity healthcare environments without image-based diagnostic techniques like MRI and ECHO.

The Impact of Triglyceride-Glucose (TyG) Index on Future Cardio and Cerebrovascular Events in Patients with Acute Coronary Syndrome, During 3 Years of Follow-Up.

Background: The triglyceride-glucose (TyG) index is a new alternative insulin resistance (IR) biomarker. The purpose of this study was to assess whether the TyG index can have a prognostic value in patients with acute coronary syndrome (ACS). Moreover, we wanted to compare the TyG index with HOMA index. Methods: We retrospectively enrolled 115 consecutive subjects, 81 males and 34 females, referred for ACS to our Unit of Cardiovascular Care of Policlinico Paolo Giaccone, Palermo. The subjects were divided into tertiles according to TyG index values and we performed a 3-year follow-up study. We considered as an end point new cardiovascular and cerebral events (MACCEs) during follow-up. Results: We found a significant statistical correlation between the HOMA index and the TyG index (p = 0.001). Patients with elevated TyG index have a higher incidence of MACCE at a 3-year follow-up. In our study the TyG index was an independent predictor of MACCEs (95% CI 1.8158 to 16.8068; P 0.0026) and the optimal TyG index cut-off for predicting MACCEs was 4.92 (sensitivity 76.56% and specificity 72.55%). Conclusions: The TyG index seems to significantly have an important prognostic role in patients with ACS and high values of TyG index are superior to HOMA-IR in predicting MACCEs.

Efficacy and diabetes risk of moderate-intensity statin plus ezetimibe versus high-intensity statin after percutaneous coronary intervention

BackgroundsHigh-intensity statin is recommended for patients undergoing percutaneous coronary intervention (PCI), and ezetimibe is recommended to be added in patients not achieving low-density lipoprotein cholesterol (LDL-C) targets. Moderate-intensity statin plus ezetimibe can reduce LDL-C levels similar to high-intensity statin. The aim of this study is to examine the long-term efficacy and safety of moderate-intensity statin plus ezetimibe as the first-line strategy compared to high-intensity statin in patients undergoing PCI.MethodData was obtained from the Health Insurance Review and Assessment Service database of South Korea. Patients who underwent PCI from 2012 to 2017 were included. The primary efficacy endpoint was major adverse cardiac cerebrovascular events (MACCEs), a composite of all-cause death, revascularization, or ischemic stroke. The safety endpoint was new-onset diabetes mellitus (DM).ResultsA total of 45,501 patients received high-intensity statin (n = 38,340) or moderate-intensity statin plus ezetimibe (n = 7,161). Among propensity-score-matched 7,161 pairs, MACCEs occurred in 1,460 patients with high-intensity statin and 1,406 patients with moderate-intensity statin plus ezetimibe (33.8% vs. 31.9%, hazard ratio 0.96, 95% confidence interval 0.89–1.03, P = 0.27) at a median follow-up of 2.7 years. DM was newly diagnosed in 398 patients with high-intensity statin and 342 patients with moderate-intensity statin plus ezetimibe (12.5% vs. 10.7%; hazard ratio 0.84, 95% confidence interval 0.73–0.97, P = 0.02).ConclusionIn patients undergoing PCI, moderate-intensity statin plus ezetimibe demonstrated a similar risk of MACCEs but a lower risk of new-onset DM than high-intensity statin. Early combination treatment of moderate-intensity statin and ezetimibe may be a useful and safe lipid-lowering strategy after PCI.Graphical abstractCumulative incidence according to the first-line lipid-lowering strategy in patients undergoing percutaneous coronary intervention. Abbreviation: MACCE, major adverse cardiac cerebrovascular events; PCI, percutaneous coronary intervention.

Prevalence and Prognostic Significance of Right Ventricular Dysfunction in Patients With Severe Low-Flow, Low-Gradient Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement.

Whether the presence of right ventricular (RV) dysfunction may influence the clinical outcome of patients with low-flow, low-gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve replacement (TAVR) has not yet been established. This study included consecutive patients with LFLG-AS undergoing TAVR at 2 high-volume Italian centers. RV dysfunction before TAVR procedure was defined as tricuspid annular plane systolic excursion assessed by transthoracic echocardiography lower than <17 mm. The primary outcome was all-cause death at 1 year. The propensity score weighting technique was implemented to account for potential selection bias between patients with and without RV dysfunction. A prespecified subgroup analysis was conducted to evaluate the consistency of the results in patients with classical and paradoxical LFLG-AS forms. This study included 392 patients; of them, 97 (24.7%) patients showed RV dysfunction before TAVR. At propensity score-weighted adjusted Cox regression analysis, RV dysfunction, according to dichotomous definition, was associated with an increased risk for the primary outcome (adjusted hazard ratio [HR], 3.11 [95% CI, 1.58-6.13]), cardiovascular death (adjusted HR, 3.26 [95% CI, 1.58-6.72]), and major adverse cardiovascular and cerebrovascular events (adjusted HR, 3.39 [95% CI, 1.76-6.53]). Conversely, no difference was detected for the risk of stroke and of permanent pacemaker implantation. No significant interaction of the classical and paradoxical LFLG-AS subgroups was detected for all the outcomes of interest. This study suggests that RV dysfunction echocardiographically assessed by tricuspid annular plane systolic excursion may improve the prognostic stratification of patients with LFLG-AS undergoing TAVR.

Association between stress hyperglycemia ratio and postoperative major adverse cardiovascular and cerebrovascular events in noncardiac surgeries: a large perioperative cohort study

BackgroundThere has been a concerning rise in the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) following noncardiac surgeries (NCS), significantly impacting surgical outcomes and patient prognosis. Glucose metabolism abnormalities induced by stress response under acute medical conditions may be a risk factor for postoperative MACCE. This study aims to explore the association between stress hyperglycemia ratio (SHR) and postoperative MACCE in patients undergoing general anesthesia for NCS.MethodsThere were 12,899 patients in this perioperative cohort study. The primary outcome was MACCE within 30 days postoperatively, defined as angina, acute myocardial infarction, cardiac arrest, arrhythmia, heart failure, stroke, or in-hospital all-cause mortality. Kaplan-Meier curves visualized the cumulative incidence of MACCE. Cox proportional hazard models were utilized to assess the association between the risk of MACCE and different SHR groups. Restricted cubic spline analyses were conducted to explore potential nonlinear relationships. Additionally, exploratory subgroup analyses and sensitivity analyses were performed.ResultsA total of 592 (4.59%) participants experienced MACCE within 30 days after surgery, and 1,045 (8.10%) within 90 days. After adjusting for confounding factors, compared to the SHR T2 group, the risk of MACCE within 30 days after surgery increased by 1.34 times (95% CI 1.08–1.66) in the T3 group and by 1.35 times (95% CI 1.08–1.68) in the T1 group respectively. In the non-diabetes group, the risk of MACCE within 30 days after surgery increased by 1.60 times (95% CI 1.21–2.12) in the T3 group and by 1.61 times (95% CI 1.21–2.14) in the T1 group respectively, while no statistically significant increase in risk was observed in the diabetes group. Similar results were observed within 90 days after surgery in the non-diabetes group. Additionally, a statistically significant U-shaped nonlinear relationship was observed in the non-diabetes group (30 days: P for nonlinear = 0.010; 90 days: P for nonlinear = 0.008).ConclusionIn this large perioperative cohort study, we observed that both higher and lower SHR were associated with an increased risk of MACCE within 30 and 90 days after NCS, especially in patients without diabetes. These findings suggest that SHR potentially plays a key role in stratifying cardiovascular and cerebrovascular risk after NCS.

P39 Primary antiphospholipid syndrome before development of severe systemic lupus erythematosus – a case report

Abstract Introduction Antiphospholipid syndrome (APS) has long been associated with systemic lupus erythematosus (SLE). Graham Hughes first reported APS in 1983 in cohorts of SLE patients with recurrent thrombosis. We present a case of a young man who developed severe manifestations of SLE 7 years after the diagnosis of primary APS and we look at the literature for predictors in primary APS to develop into SLE. Case description A 28 year old Caucasian male with Turkish ancestry was diagnosed with triple positive primary APS at the age of 21 when he presented with bilateral pulmonary embolisms. He was stable on warfarin with target INR between 3-4. He had been having occasional mouth ulcers, lethargy, mild paraesthesia of his feet and headaches for 2 months. He then presented in February 2024 with short history of pleuritic chest pain and marked breathlessness. Initial cross sectioning imaging did not reveal pulmonary embolism. A week later, echocardiogram demonstrated large global pericardial effusion and small pleural effusions. Ejection fraction was preserved. Interval MRI scan showed pericarditis without evidence of myocarditis. Almost 600 mls of heavily blood stained pericardial fluid was drained. Analysis of the pericardial fluid showed inflammatory processes with macrophages, neutrophil and lymphocytes. Culture was negative including for tuberculosis and cytology negative for malignancy. Immunology revealed ANA 1:160, ENA normal, dsDNA was initially negative but upon interval testing was high at 27.5 IU/mL, IgG 13.1 g/L, C3 1.2 g/L, C4 &amp;lt;0.1 g/L, CRP 143, ESR 30. He had anaemia, lymphopenia and positive direct antiglobulin test. ANCA and rheumatoid factor were unremarkable. Renal and joints were unaffected. Due to his Turkish ancestry, he was extensively investigated for the possibility of Behcet’s with normal femoral vein ultrasound and negative HLA-B51 genotype. His manifestations fulfilled the SLICC criteria to be diagnosed with SLE. His response to intravenous methylprednisolone infusions and subsequent oral steroid was marked. He was initiated on dual treatment of hydroxychloroquine and mycophenolate mofetil and is currently recovering. Discussion We relooked at this immunology when he was first diagnosed with primary APS in 2017. He was strongly positive for ANA at titre of 1:640 but did not have manifestations of SLE then. We researched literature on the predictors for primary APS to develop into SLE. Both disease spectrums have several overlapping manifestations including haemolytic anaemia, thrombocytopenia, lymphopenia, neurological symptoms, renal manifestations and livedo reticularis. Freire et al (1) retrospectively analysed 80 patients with primary APS and found 14 (17.5%) progressed to develop APS-SLE in 5.2 +/- 4 years. ANA positivity was found in 100% those who eventually developed APS-SLE. Other specific autoantibodies including anti-dsDNA, anti-ribosomal P, anti-Ro, anti-La and anti-U1RNP are found more commonly in the cohort too. In their APS-SLE cohort, they also found a correlation with younger age at the time of diagnosis of APS and the duration of the disease. Andreoli L et al (2) demonstrated anti-nucleosome antibody (anti-NCS) was frequently found in their cohort of APS-SLE patients but no relationship between clinical-serological was found, except for a weak correlation between anti-dsDNA antibodies. 2 of their primary APS who developed severe SLE had displayed high titres of anti-NCS years before. Tarr T et al (3) found 4 of their primary APS who developed SLE all presented with cerebrovascular events as the thrombotic manifestation. Key learning points • Primary APS has been associated with the development of SLE • Certain antibody profile such as ANA, anti-nucleosome antibody may predict the development of SLE in primary APS patients • Younger age, cerebrovascular events as thrombotic manifestation at diagnosis of primary APS and the length of duration of primary APS may be associated with the development of SLE at a later stage

Catheter ablation for atrial fibrillation and risk of neurologic disease

BackgroundCatheter ablation (CA) of atrial fibrillation (AF) has been proven to benefit patients with symptomatic AF and heart failure. However, the data on neurological outcomes including cerebrovascular accidents (CVA) and dementia remain controversial. ObjectiveWe aimed to determine the effect of CA on neurological events during long-term follow up. MethodsWe performed a systematic review and meta-analysis of patients with AF who underwent CA of AF. MEDLINE, EMBASE, and Web of Science databases were comprehensively searched from inception to January 2024. Studies that reported incidence of CVA and dementia in patients with AF were. Data from each study were combined by random effects model. The results were reported in risk ratios (RR) with 95% confidence intervals. ResultsA total of 29 studies and 379,993 patients (mean age: 58±4 years, 30% women) were included in the analysis. Mean follow up was 36±23 months (12-120). Patients who underwent CA of AF had a lower risk of developing CVA compared to medical management (OR 0.54; 95% CI 0.42 - 0 69, I2 = 91%). Moreover, the risk of dementia was lower in CA group compared to medical management (OR 0.51; 95% CI 0.4-0.66, I2 74%). The incidence of CVA in CA group was 1% (95% CI 1 - 2%, I2 = 97%) and incidence of dementia was 2% (95% CI 2-8%, I2 = 97%). ConclusionCatheter ablation of AF resulted in lower risk of CVA and dementia compared to medical management alone at long-term follow up.

Narrative Accounts of Language Recovery through Music Therapy

The language of healing involves the use of medical terminology related to critically ill patients and their recovery. The present research focuses on the role of music therapy as a nonverbal form of healing. A vast array of neurological disorders affect nowadays both young and elderly patients. Among the most devastating illnesses, the stroke or cerebrovascular accident (CVA), in medical terms, disables many patients who lose the power of communication. A stroke, among other terrible paralyzing effects, may cause a condition named aphasia, which is the loss of the ability to communicate normally due to the damage produced to the left side of the brain which is the centre of communication. The power of language in healing such patients is often beyond our grasp as the linguistic means used for this purpose may include confessions, incantations, and lyrics. The present study will focus on the mechanisms of speech recovery through music therapy and its benefits on the life of patients with aphasia. In addition to listing different types of aphasia, with particular focus on Broca’s aphasia, we bring to attention two medical cases of aphasic patients, of which one involves music therapy as a nonverbal recovery tool. The detailed narrative account of this successful case history provided by neurologist Oliver Sacks (2011) represents valuable evidence that supports the idea of the beneficial effects of enduring music therapy.

Rituximab and Intravenous Immunoglobulin in the Treatment of Cicatrizing Conjunctivitis Associated with Pemphigoid

PurposeTo characterize the use of rituximab (RTX) and intravenous immunoglobulin (IVIG) in the treatment of cicatrizing conjunctivitis associated with pemphigoid. DesignRetrospective consecutive case series of patients with ocular cicatricial pemphigoid (OCP) and mucous membrane pemphigoid with ocular involvement (ocMMP) treated with RTX/IVIG. MethodsA retrospective chart review was performed on patients at the University of Texas Southwestern Medical Center between 2012-2024 with ocMMP or OCP undergoing treatment with RTX/IVIG. Data collected included patient demographics, ocular history, response to RTX/IVIG, and adverse events. Primary outcomes were ocular response to the treatment. The secondary outcome was the change or decrease in concomitant steroid dependence. ResultsA total of 31 patients (20, 64.5% female) met inclusion criteria. There were 20 (64.5%) patients with ocMMP, and 11 (35.5%) patients with OCP. The mean age at initiation of RTX was 64 years. In our cohort, 2 (6.5%) patients had no response to treatment, 10 (32.3%) achieved a partial response, 6 (19.4%) achieved clinical remission with steroids, 11 (35.5%) achieved steroid-free remission, and 2 (6.5%) achieved durable remission. The mean time to remission was 9.0 months. Mean follow up time was 54 months and the mean time to relapse was 32 months. There were five adverse events in our cohort: 1 case of neutropenia, 1 cerebrovascular accident, and 3 malignancies. ConclusionHigh dose RTX/IVIG is an effective treatment for cicatrizing conjunctivitis associated with pemphigoid, particularly in patients with severe recalcitrant disease. Judicious use due to risk of serious adverse events may limit widespread use.

Course of brain damage following malignant hypertension.

Malignant hypertension (MHT) crisis triggers widespread microvascular damage, particularly in the brain. Despite recent MRI evidence highlighting acute cerebral injuries during MHT crises, follow-up data remain scarce. This study seeks to fill this gap by exploring how brain MRI markers evolve following acute MHT crisis management. We conducted a retrospective analysis of brain MRI data from MHT patients admitted to Bordeaux University Hospital between 2008 and 2022. Eligible patients had at least one follow-up MRI. Analysis blinded to clinical data was performed to identify markers of posterior reversible encephalopathy syndrome (PRES), acute stroke, cerebral hemorrhage, and microangiopathy. Out of 149 patients, 47 had follow-up MRIs. Most were male (72.3%) with a mean age of 48.2 ± 10.8 years. The median interval between initial and follow-up MRI was 228 days. Follow-up MRIs revealed new strokes in 10.6% of patients, cerebral hemorrhages in 4.3%, and no cases of PRES. Additionally, more patients exhibited chronic lacunar infarcts and/or microbleeds, with overall Fazekas scores remaining stable in 66.0%, improving in 31.9%, and worsening in 2.1%. Subgroup analyses based on blood pressure control or follow-up duration showed no significant differences in MRI markers. This study sheds light on the risk of new cerebrovascular events and the dynamic changes in brain MRI markers following acute MHT crisis management. Understanding these changes could lead to improved diagnosis, personalized treatment strategies, and proactive patient care for individuals with MHT.

Minimally Invasive vs Conventional Coronary Bypass Surgery for Multivessel Coronary Disease

BackgroundDespite sternum sparing and without cardiopulmonary bypass, the actual value of minimally invasive coronary surgery (MICS) is still debatable. This study aimed to compare the completeness of revascularization and intermediate-term outcomes of MICS with conventional sternotomy coronary artery bypass grafting (CABG). MethodsTwo groups of 244 patients each receiving MICS-CABG and sternotomy-CABG between November 2015 and March 2019 were matched by propensity score matching. The completeness of revascularization and major adverse cardiovascular and cerebrovascular events (MACCE; a composite of death, myocardial infarction, stroke, or repeated target vessel revascularization) were compared between the groups. ResultsIn the MICS-CABG group, the percentages of bypassed vessels 2, 3, and ≥4 were 53.7%, 36.1%, and 10.2%, respectively. Completeness of revascularization (95.5% vs 96.3%; P = .65) was comparable between MICS-CABG and sternotomy-CABG groups. Postprocedural angiography revealed an overall patency of 96.2% (578/601) for the MICS-CABG group. At 5 years, rates of MACCE (19.9% vs 22.1%; hazard ratio [HR], 0.80; 95% CI, 0.49-1.32; P = .39), death (10.6% vs 12.9%; HR, 0.87; 95% CI, 0.46-1.65; P = .67), myocardial infarction (5.6% vs 4.2%; HR, 0.82; 95% CI, 0.27-2.52; P = .73), stroke (6.7% vs 6.6%; HR, 1.11; 95% CI, 0.43-2.86; P = .83), and repeated target vessel revascularization (1.9% vs 1.8%; HR, 0.85; 95% CI, 0.17-3.15; P = .84) were similar between MICS-CABG and sternotomy-CABG. ConclusionsMICS-CABG, which appeared to yield noninferior completeness of revascularization and intermediate-term MACCE compared with sternotomy-CABG, could be an alternative for patients with multivessel coronary diseases.

Safety and efficacy of antiplatelet therapy in patients with intermediate coronary artery stenosis and deferred revascularization

Introduction and objectives: This study investigated the safety and efficacy of antiplatelet therapy in patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their fractional flow reserve (FFR).Methods: A nationwide cohort study was conducted using the Korean National Health Insurance Service database. A total of 4657 patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their FFR were identified from 2013 to 2020. FFR was indicated in patients with no prior evidence of myocardial ischemia and intermediate coronary artery stenosis (50%-70%) as determined by quantitative coronary angiography. Patients were classified according to whether antiplatelet therapy was initiated after the index procedure. The primary efficacy outcome was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, myocardial infarction, unplanned revascularization, and stroke, during a 5-year follow-up period. The primary safety outcome was any gastrointestinal bleeding.Results: After propensity score matching, there were 1634 patients in the antiplatelet therapy group and 1634 in the nonantiplatelet therapy group. The risk of MACCE was similar between the 2 groups (24.8% vs 24.7%; adjusted HR, 0.97; 95%CI, 0.84-1.13; P = 0.745). The risk of gastrointestinal bleeding was higher in the antiplatelet therapy group than in the nonantiplatelet therapy group (2.2% vs 1.2%; aHR, 2.07; 95%CI, 1.08-4.00). These results were similar in subgroup analyses.Conclusions: In patients with intermediate coronary artery stenosis who underwent deferred revascularization due to their FFR, antiplatelet therapy may increase the risk of gastrointestinal bleeding without reducing the risk of future ischemic events.

New progress in screening and treatment of carotid atherosclerotic stenosis

Carotid atherosclerotic plaque is the main cause of ischemic stroke. In recent years, with the continuous innovation of novel imaging technologies, numerous classification standards for carotid plaques provide more powerful evidence for the features of carotid plaques and perioperative vascular assessment, as well as the reference for surgeons in choosing therapeutic decisions. Ultrasound is the preferred non-invasive and convenient screening tool for carotid stenosis. Invasive examinations such as CT angiography and magnetic resonance angiography are suitable for carotid stenosis patients to determine the plaque composition and stability, which can guide surgical decision-making and help to prevent serious cardiovascular and cerebrovascular adverse events. Advances in the treatment of carotid artery stenosis have focused on the improvement and innovation of vascular interventional devices and surgical procedures, including double-layer stents, coated stents and transcarotid artery revascularization. As technology continues to evolve, molecular imaging and more minimally invasive screening as well as therapies will be the way forward.