History Of Ischemic Heart Disease Research Articles

Management of Patients with Ischemic Heart Disease in Spine Surgery.

In ischemic heart disease (IHD), the myocardium does not receive enough blood and oxygen. Although the IHD-related mortality rate is decreasing, the risk remains and is a major predictor of cardiac complications following noncardiac surgery. Given the increase in the older population, the number of patients with spinal diseases requiring surgery is increasing. Among these patients, those with underlying IHD or a high risk of cardiac complications before and after surgery are also increasing. Given that cardiac complications following spinal surgery are associated with delayed patient recovery and even death, spinal surgeons should be knowledgeable about overall patient management, including medication therapy in those at high risk of developing perioperative cardiac complications for successful patient care. Before surgery, the underlying medical conditions of patients should be evaluated. Patients with a history of myocardial infarction should be checked for a history of surgical treatments, and the anticoagulant dose should be controlled depending on the surgery type. In addition, the functional status of patients must be examined before surgery. Functional status can be assessed according to the metabolic equivalent of task (MET). More preoperative cardiac examinations are needed for patients who are unable to perform four METs in daily because of the high risk of postoperative cardiac complications. Patients with a history of IHD require appropriate preoperative management and further postoperative evaluation. When considering surgery, spinal surgeons should be knowledgeable about patient care before and after surgery.

What May Stand Behind Chest Pain: A Case Report on Aortic Dissection

Aortic dissection (AD) is a relatively uncommon, rare disorder and potentially misdiagnosed disease. Early diagnosis and treatment is required for the patient's survival. Aortic dissection can be fatal if misdiagnosed. A 50-year-old adult male presented to emergency with acute chest pain and having a medical history of aortic stenosis post-aortic valve replacement 9 months back and a family history of ischaemic heart disease. Pain was relieved by analgesics. After further investigations by echocardiography and CT Angiography, it was diagnosed as AD Standford type A and DeBakey type 1, in view of the critical nature of illness, patient attenders wanted only medical management. The patient was declared dead after 2 days of diagnosis.

PP90 Artificial Intelligence To Detect Ischemic Heart Disease In Non-traumatic Chest Pain At The Emergency Department – SmartHeart Study

IntroductionAn estimated 17.9 million people died from cardiovascular diseases (CVDs) in 2019, which is 32 percent of all global deaths and 85 percent were due to heart attack and stroke. Chest pain is one of the most common reasons for presenting to the emergency department (ED). It is increasingly recognized that artificial intelligence (AI) will have a significant impact on the practice of medicine in the near future and may help with diagnosis and risk stratification. We aim to estimate a diagnostic prediction of acute myocardial infarction by the development and validation of an AI model.MethodsData on 134 variables of 3,986 consecutive patients who presented to the ED with non-traumatic chest pain were included in the analysis. Using AI tools, a neural network model was developed to establish the risk of acute myocardial infarction (AMI) to achieve n=150 patients over 18 years of age attending the ED.ResultsThe mean age was 65.5 (±13.7) years and 63.6 percent were male. Most (60.1%) patients were admitted to hospital, with only 20.3 percent diagnosed at hospital discharge with ischemic heart disease (IHD). All patients were followed up for two months, and 6.3 percent were readmitted to the ED, but none presented with an episode of IHD. In the data analysis of the entire sample we obtained a probability of diagnosing IHD by the SmartHeart model (S=93.1%, E=47.3%, PPV=31.0%, and NPV=96.4%). When we analyzed the sample of patients with no history of IHD (n=104), the diagnosis accuracy was as follows (S=100%, E=77.5%, PPV=42.8%, and NPV=100%).ConclusionsOur AI model provides information to predict patients who are suffering from acute IHD. AI has been reported to outperform emergency physicians and current risk stratification tools to diagnose IHD, but has rarely been integrated into practice. This study highlights the diagnostic applicability and accuracy of this type of tool and that is why studies should be implemented to see its effectiveness in routine practice in EDs.

Retinal changes and cardiac biomarker assessment in relation to chronic kidney disease: a single centre study

BackgroundThe prevalence of chronic kidney disease (CKD) is rising in Malaysia. Early detection is necessary to prevent disease progression, especially in terms of cardiovascular (CV) risk, the main cause of death in end-stage renal disease (ESRD). Retinal changes have proven to be a good predictor of CKD whereas cardiac biomarkers are useful in cardiovascular risk stratification. We aimed to demonstrate the correlation between retinal changes and cardiac biomarkers with CKD.MethodsThis single-centre cross-sectional study was conducted among patients with CKD stages 3, 4, and 5 (not on dialysis) from the Nephrology Clinic, Universiti Kebangsaan Malaysia Medical Centre. A total of 84 patients were recruited with an even distribution across all three stages. They underwent fundus photography where images were analysed for vessel calibre (central retinal venular equivalent (CRVE), central retinal arterial equivalent (CRAE), and tortuosity indices. Optical coherence tomography was used to measure macular volume. Blood samples were sent for laboratory measurement of high-sensitivity C-reactive protein (hs-CRP) and asymmetric dimethylarginine (ADMA). These parameters were analysed in relation to CKD.ResultsThe mean age was 58.8 ± 11.7 years, with 52.4% male and 47.6% female patients. Among them, 64.3% were diabetics. Retinal vessel tortuosity (r = -0.220, p-value = 0.044) had a negative correlation with the estimated glomerular filtration rate (eGFR). CRVE showed a positive correlation with proteinuria (r = 0.342, p = 0.001) but negative correlation with eGFR (r = -0.236, p = 0.031). Hs-CRP positively correlated with proteinuria (r = 0.313, p = 0.04) and negatively correlated with eGFR (r = -0.370, p = 0.001). Diabetic patients had a higher CRVE compared to non-diabetic patients (p = 0.02). History of ischaemic heart disease was associated with a smaller macula volume (p = 0.038). Male gender (r2 = 0.066, p = 0.031) and HbA1c had a positive influence (r2 = 0.066, p = 0.047) on retinal vessel tortuosity. There was a positive influence of age (r2 = 0.183, p = 0.012) and hs-CRP (r2 = 0.183, p = 0.045) on CRVE. As for macula volume, it negatively correlated with diabetes (r2 = 0.015, p = 0.040) and positively correlated with smoking (r2 = 0.015, p = 0.012).ConclusionOur study showed that eGFR value affects retinal vessel tortuosity, CRVE and hs-CRP. These parameters bear potential to be used as non-invasive tools in assessing CKD. However, only macula volume may be associated with CVD risk among the CKD population.

The Clinical Profile and Hospital-based Outcome of Acute Myocardial Infarction in Elderly Patients More than 60 Years and Patients Younger than 60 Years: A Comparative Study

Background: Acute myocardial infarction refers to a pathological state characterized by the obstruction of blood supply to the myocardium, resulting in the subsequent necrosis of cardiac tissue. It constitutes a significant etiological factor contributing to the development of heart failure and global mortality rates. Objective: The purpose of this study was to conduct a comparative analysis of the clinical characteristics of acute myocardial infarction in old and young individuals who sought medical attention at a tertiary care hospital. Methods: This cross-sectional observational study was done from January 2023 to June 2023 at the Mymensingh Medical College Hospital, Mymensingh, Bangladesh. A total of 100 people were observed in this study. Result: We have two age groups: under 60 (60%) and over 60 (40%). We name them A and B. Group A patients are 86.7% male and 13.3% female. Group A patients are 88.3% Muslim and 7% Hindu. This patient group includes 30% service workers and 20% businesses. The remaining 28.3% were patients from diverse jobs and 1.7% were farmers. With 55% male and 45% female Muslim patients, Group B includes domestic workers (45%) and businessmen (22.5%). Service workers 17%, farmers 2.5%, and other patients 12.5%. Group A had 85% chest pain, 46.7% dyspnea, 90% palpitations, and 86.7% nausea and vomiting. Ischemic chest pain, dyspnea, palpitations, nausea, and vomiting affected 87.5% of Group B.Top MI risk factors. Group A had dyslipidemia (95%), family history of MI (93.3%), sedentary lifestyle (91.7%), smoking (88.3%), hypertension (86.7%), and diabetes (78.3%). The sedentary lifestyle, 100% family history of ischemic heart disease, 97.5% dyslipidemia, and 77.5% diabetes and hypertension characterized Group B. Lastly, our study reports patients' average pulse and blood pressure. In Group A, the average pulse was 81.73 ± 14.60, systolic blood pressure was 129.50 ± 20.28 mmHg, and diastolic blood pressure was 89.41 ± 12.35. Group B had an .......

Risk of myocardial infarction following capecitabine treatment in patients with gastrointestinal cancer - a nationwide registry-based study

Abstract Background Myocardial infarction is a cardiac adverse event associated with fluoropyrimidines such as 5-fluorouracil and its orally available prodrug capecitabine. There are limited data on the incidence, risk, and prognosis of capecitabine associated myocardial infarction. Purpose The aim of this study was to examine the risk of myocardial infarction in patients with gastrointestinal (GI) cancer treated with capecitabine compared with age- and sex-matched population control subjects without cancer (1:2 ratio). Methods Patients with GI cancer treated with capecitabine between 2004-2016 were identified within the Danish National Patient Registry. Those with a history of ischemic heart disease were excluded. Absolute and relative risks of myocardial infarction at 6 months and 1 year were derived from multivariable Cox regression with average treatment effect modeling. Estimates were standardized to the distributions of age, sex, selected comorbidities, and pharmacotherapies of all included subjects. Results A total of 71,460 patients were included in the final analysis of whom 23,820 had GI cancer treated with capecitabine, and 47,640 were population control subjects without cancer. Differences in the prevalences of selected comorbid conditions, including diabetes, hypertension, and other risk factors for coronary artery disease and antianginal medications were not significant (P>0.05 for all). The 6-month absolute risk (AR) of myocardial infarction was significantly higher for capecitabine-treated patients at 0.6% [95% confidence interval (CI): 0.5%-0.7%] versus 0.3% [95% CI: 0.2%-0.3%] in population control subjects, corresponding to a relative risk (RR) of 2.00 [95% CI 1.53-2.48; P <0.001]. The corresponding 1-year ARs were 0.7% [95% CI: 0.6%-0.9%] versus 0.6% [95% CI: 0.5%-0.6%]; RR 1.28 [95% CI 1.03-1.52; P= 0.03]. Six-month and one-year all-cause mortality ARs for patients treated with capecitabine versus controls were 15.2% vs. 0.7% and 29.7% vs. 1.6% respectively. Conclusions The risk of myocardial infarction of capecitabine-treated patients both 6- and 12-month risks were significantly higher compared with population controls. Despite the absolute risk were low, the clinical significance of the differences appears limited in the context of the significant competing risk of death in this population.Risk of Myocardial InfarctionMortality

Effect of sodium-glucose type 2 cotransporter inhibitors on cardiac structure and function in patients with normal ejection fraction

Abstract Introduction Sodium-glucose cotransporter inhibitors (SGLT2i) have proven a reduction in cardiovascular events in diabetic patients with and without heart failure (HF), as well as in non-diabetic patients with heart failure with reduced and preserved ejection fraction (EF). The mechanisms underlying this benefit are not well known, with contradicting data on the changes that SGLT2i produce on cardiac function and structure. Methods Between October 2020 and October 2021, 31 diabetic patients without prior history of SGLT2i use with normal EF (>50%), glycated hemoglobin <6.5%, renal clearance rate of >60 ml/min/1.73 m2 and sinus rhythm were prospectively included. In all of them, SGLT2i were started. At inclusion and 6-months follow-up, different clinical, ECG, analytical and echocardiographic (standard, 3D and speckle tracking) variables were recorded. Results The average age of our population was 66.4 years (±8.4). 90% were male, 71% were hypertensive, 77.4% were dyslipidemic, 22.6% were obese and 87.1% were current or former smokers. 77.4% of patients had a history of ischemic heart disease, and 10% had vascular disease in other territories. At the time of inclusion, 80.6% of the population was treated with ACEI or ARB, 54.8% with beta-blockers, 29% with diuretics, and 93.5% with statins. After an average follow-up period of 6.6 months (±0.8), medication had to be withdrawn in 5 patients (in 3 of them due to repeated genital or urinary infections, and in 2 of them because of patient choice). An average reduction of 0.89 mm (±0.24, p = 0.001) in myocardial thickness was observed, as well as a reduction in the 3D-estimated left ventricle mass of 9.9 g/m2 (±4.5, p = 0.03), and in the E/é ratio of 1.4 (±4.5, p = 0.02). An increase in absolute left ventricle global longitudinal strain (LVGLS) of 0.74 (±0.35, p = 0.05) was observed, as well as an increase in isovolumetric relaxation time (IVRT) of 9.8 ms (±4.8, p = 0.05). An increase in LA strain and indexed volume was noted, although differences did not achieve statistical significance. No relevant differences in LV dimensions and volumes were observed, as well as in the evaluated RV parameters (picture 1). Conclusions It is necessary to understand the mechanism underlying the clinical benefit of these drugs. This will allow us to better understand its effect in patients with HF. Our data shows that the use of SGLT2i is associated with cardiac improvements, both structural (myocardial mass) and functional (IVRT, LVGLS, E/e'), in a population of patients with normal EF.

Sarcoidosis is associated with a higher long-term risk of ischaemic heart disease, venous thromboembolism, and ischaemic stroke: a nationwide study

Abstract Background Sarcoidosis shares a number of pathophysiological mechanisms and risk factors with ischaemic heart disease and thromboembolism. Patients with sarcoidosis are at risk of cardiac involvement with heart failure and arrhythmias, but unlike other inflammatory diseases, such as systemic lupus erythematosus and rheumatoid arthritis, data on the risk of ischaemic heart disease, venous thromboembolism, and ischaemic stroke in patients with sarcoidosis are sparse. This may prevent patients with sarcoidosis from the benefits of screening for these cardiovascular diseases. Purpose To examine the long-term risk of ischaemic heart disease, venous thromboembolism, and ischaemic stroke in patients with sarcoidosis compared to a matched background population. Methods In this Danish nationwide cohort study, all patients >18 years diagnosed with sarcoidosis between 1996-2020 were matched 1:4 by age, sex, and cardiovascular risk factors with individuals from the background population without sarcoidosis. Patients with a history of ischaemic heart disease, venous thromboembolism, and ischaemic stroke were excluded from the sarcoidosis and background population prior to matching. Absolute 10-year risks of outcomes were estimated using the Aalen-Johansen estimator, and rates of outcomes were compared between sarcoidosis patients and the background population using Cox regression. Results We identified 15,454 patients with sarcoidosis and 61,816 matched individuals from the background population (median age 43.8 years, 56% males). The median follow-up was 9.4 years. Absolute 10-year risks of outcomes were as follows: ischaemic heart disease, 5.2% (95% confidence interval [CI], 4.8-5.6%) vs. 3.8% (95% CI, 3.6-4.0%) in the sarcoidosis vs. background population; venous thromboembolism, 3.3% (95% CI, 3.0-3.6%) vs. 1.6% (95% CI, 1.5-1.8%) in the sarcoidosis vs. background population; ischaemic stroke, 2.5% (95% CI, 2.2-2.8%) vs. 2.0 (95% CI, 1.9-2.1%) in the sarcoidosis vs. background population. In multivariable Cox regression analysis, sarcoidosis was associated with an increased risk of ischaemic heart disease (hazard ratio [HR] 1.47 [95% CI, 1.31-1.65]), venous thromboembolism (HR 1.99 [95% CI, 1.70-2.31]), and ischaemic stroke (HR 1.41 [95% CI, 1.21-1.64]) compared with the matched background population (Figure 1). Conclusions In this nationwide cohort study, sarcoidosis was associated with a higher long-term risk of ischaemic heart disease, venous thromboembolism, and ischaemic stroke compared with a matched background population. Although further studies on pathophysiological mechanisms are needed, it may be relevant to screen for cardiovascular diseases in patients with sarcoidosis, as we do in patients with other inflammatory diseases.

Differences in clinical characteristics and outcomes between patients with left ventricular thrombus following non-anterior and anterior ST-elevation myocardial infarction

Abstract Background Left ventricular thrombus (LVT) is a serious complication following ST-elevation myocardial infarction (STEMI), and occurs more frequently in anterior compared to non-anterior myocardial infarction (MI).1 There is limited data on the clinical characteristics and outcomes in patients with LVT following non-anterior MI. Purpose We aimed to describe the clinical characteristics and outcomes of patients with LVT following non-anterior MI, and compare them against patients with LVT associated with anterior MI. Methods We retrospectively studied 217 consecutive patients with post-STEMI LVT from our tertiary centre’s echocardiography database between March 2011 and January 2021. Trans-thoracic echocardiography was performed at day 2 or 3 post-MI. We compared baseline co-morbidities and echocardiographic parameters between patients with LVT following non-anterior versus anterior MI. The Kaplan Meier method with log-rank test was used to compare rates of thrombus resolution, stroke and all-cause mortality between the 2 groups. Multivariable Cox regression models were constructed to correct for potential confounders. Results Mean age of the study population was 56.0 (IQR 48.0, 63.0) years old and 16/217 (7.4%) were female. LVT following non-anterior MI made up 24/217 patients (11.1%), and included lateral (n=3), inferior (n=15), inferoposterior (n=4) and inferolateral (n=2) MI. Patients with LVT associated with non-anterior MI were older and more frequently had a history of ischaemic heart disease (Figure 1). These patients also had a lower median left ventricular ejection fraction (LVEF) of 29% compared to their counterparts with anterior MI (mean LVEF 38%). Rate of anticoagulation was lower in patients with LVT associated with non-anterior MI (75.0% versus 92.2%). There were no differences in rates of thrombus resolution between the 2 groups (Figure 2). Patients with LVT following non-anterior MI had a higher incidence of stroke, however this observation was not present after correction for baseline embolic risk (CHA2DS2-VASc score) and rate of anticoagulation. Mortality rates were similar in patients with LVT following non-anterior MI versus anterior MI, after correction for baseline co-morbidities as well as in-hospital mortality – as this was more likely due to acute MI complications rather than longer term consequences of LVT. Conclusions Patients with LVT following non-anterior MI are older with a greater prevalence of prior ischaemic heart disease. These patients had a greater rate of stroke and mortality, although baseline co-morbidities and less frequent use of anticoagulation may have contributed to these findings. This needs to be clarified in future prospective studies.Figure 1:Baseline characteristicsFigure 2:Outcomes

Epidemiology and prognostic relevance of morphofunctional classification of secondary mitral regurgitation

Abstract Background Mitral regurgitation has traditionally been divided into organic and functional (FMR) due to its different etiology and prognosis. However, FMR is not a homogeneous entity, and may be secondary to annular dilation, ventricular dilation and dysfunction, or posterior leaflet restriction. Purpose Our aim is to assess the epidemiology of these FMR subtypes and their prognostic impact. Methods Patients with FMR from our center who underwent three-dimensional transesophageal echocardiography (3D-TEE) between 2016 and 2020 were retrospectively evaluated. Patients with at least moderate FMR, effective regurgitant orifice (ERO) by 3D-TEE >0.2 cm2 were selected. They were classified according to the predominant mechanism: type 1 or ventricular dysfunction, type 2 or posterior leaflet restriction, and type 3 or annular dilation. 3D-TEE and the closest transthoracic study variables, as well as baseline demographic and clinical characteristics and evolution events, were obtained and statistical analysis was performed according to FMR types. Results 112 patients were included (66.1% male, mean age 72.3 years). 54.5% had previous hospitalization for heart failure and 53.6% had a history of ischemic heart disease. The most frequently identified FMR mechanism was type 1 (61.6%), followed by type 3 (23.2%) and type 2 (15.2%). There were significant differences in epidemiological factors and echocardiographic parameters (Table) between groups. During follow-up, 43.8% died, received a heart transplant or LVAD and 44.6% had any hospitalization for heart failure. There were no significant differences between FMR types in relation to total mortality (p=0.28), mortality due to heart failure (p=0.13), total hospitalizations (p=0.73), or hospitalization for heart failure (p=0.12). Valvular intervention was performed in 54 patients (48.2%), 33 of them percutaneously with a clip, with no differences in FMR subtypes. Conclusions FMR is a heterogeneous entity and different morphotypes with different epidemiology and etiology can be identified. Despite the different mechanism, all subgroups presented a similar unfavorable prognosis and similar intervention rates.

Regional left ventricular longitudinal strain and heart failure in a low-risk community

Abstract Background Global longitudinal strain is a well-established prognosticator of heart failure (HF) in the general population. The prognostic values of regional left ventricular (LV) longitudinal strain of the basal, mid and apical regions remain unexplored in the general population. Purpose The purpose of this study was to investigate the relationship between regional LV strain and incident HF in the general population. Methods This prospective cohort study included randomly selected citizens from a major metropolitan area. All participants were examined with echocardiography. The outcome was incident HF. Participants were excluded if regional LV strain was not assessable in all 3 LV regions or if they had atrial fibrillation or HF at baseline. A multivariable Cox regression model adjusted for sex, age, smoking status, heart rate, systolic blood pressure, history of ischemic heart disease, hypertension, diabetes, LV mass index, LV ejection fraction and E/e’ was used. Results A total of 3,952 individuals were included. Mean age was 56±18 years and 43% were male. Mean basal, mid, and apical LV strain was 16.4±2.6%, 19.5±2.6 and 22.8±3.6% respectively. Median follow-up was 5.4 years (IQR: 4.4; 6.3) and 99 developed HF. In multivariable Cox regressions models, only decreasing LV basal strain was associated with future HF (HR = 1.18, 95%CI (1.06; 1.32), P = 0.003, per 1% decrease) (Figure 1). Additionally, LV basal strain provided incremental prognostic information regarding future HF to the Atherosclerosis Risk in Communities HF risk score (continuous net reclassification index = 0.468, 95% CI (0.155; 0.687)). Conclusion In individuals from the general population, basal LV strain entailed incremental prognostic information regarding the risk of incident HF.Basal strain and incident HF

Cardiac troponin is a strong prognostic biomarker for patients admitted with heart failure

Abstract Background Cardiac troponin T (cTnT) and I (cTnI) are strong prognostic biomarkers in several diseases and play a key role in risk stratification of patients admitted with cardiac disease. Though viewed as equals, there are substantial differences in the biology and frequency of elevations among non-cardiac illnesses between cTnT and cTnI. A recent study of all comers with a measurement of cTn showed that the risk of mortality was highest for patients with low grade elevations of cTn, while high concentrations were associated with a paradoxical decrease in the risk. We aimed to investigate whether this pattern exists among patients with heart failure. Purpose To compare the prognostic ability of cTnT and cTnI among patients admitted with heart failure. Methods This nationwide cohort study includes patients admitted with heart failure who had cTn measurements from 2009-2022 using one of five different cTn assays: Roche high-sensitivity cTnT (hs-cTnT), Abbott Alinity high sensitivity cTnI (hs-cTnI), Siemens Vista Hs-cTnI, Siemens Atellica hs-cTnI and Beckman-Coulter hs-cTnI. We selected the peak concentration of cTn on admission and grouped patients into those with measurements of cTnI and those with cTnT. The primary outcome was all-cause mortality. We divided the peak cTn concentrations into groups based on the bands of concentrations of cTn from <1 times the 99th percentile, 1-2, 2-5, 5-100 and >100 times the 99th percentile and compared cumulative mortality using Kaplan-Meier analysis and the risk of mortality for each group using logistic regression for the 30-day mortality. Results A total of 9,344 patients were included in this study with a median age of 75 years (65-83) and 5,613 (60%) were males. Of these, 2,874 (31%) had a history of heart failure and 2,349 (25%) had a history of ischemic heart disease. When grouping for type of cTn used, there were more patients treated using hs-cTnT (n = 7,131 76%) than hs-cTnI (n = 2,213, 24%). The median age of patients treated who had a measurement of cTnI was slightly higher; 77 years (IQR 67-84) vs cTnT 74 years (64-83) p<0.001. Of the 9,344 patients, 1,096 (12%) died within 30 days of admission. Figure 1 shows the absolute risk of 1-year all-cause mortality for each band of cTn concentration for (panel A) hs-cTnI and (panel B) hs-cTnT. This showed an increase in the risk of mortality for patients up to 2-5 times the 99th percentile for cTnI and 5-100 times the 99th percentile for cTnT. Figure 2 shows the risk of 30-day mortality for patients for each concentration of cTn. There was a much higher risk of mortality associated with elevation of cTnT than cTnI for all bands of concentration. Conclusion Though both cTnI and cTnT are strong prognostic markers of mortality among patients admitted with heart failure, cTnT seemed to be the strongest prognostic marker. The risk of mortality increased with concentration of cTnT up to very high concentrations of >5 times the 99th percentile.Figure 1Figure 2

Molecular alterations of human diabetic heart disease revealed using single nucleus RNA sequencing

Abstract Type 2 diabetes mellitus (T2D) increases the risk for heart failure. Whether mechanisms proposed to underlie cardiac structural and functional alterations in the rodent diabetic heart are recapitulated in humans remains poorly investigated. Here, we studied left ventricular samples of 8 subjects with T2D, preserved ejection fraction (63±5%) and no history of ischemic heart disease (Db-pEF), 7 subjects with T2D, reduced ejection fraction (26±9%) and ischemic heart disease (Db-ICM), and 15 non-diabetic individuals with normal ejection fraction (Non-Db-pEF) serving as controls. 1168 proteins were identified using label-free proteomics by LC-MS/MS. 146 were differentially expressed in Db-ICM, but only 66 in Db-pEF. Bulk RNA sequencing revealed differential expression of 1795 and 527 genes in Db-ICM or Db-pEF, respectively, with only 128 genes being commonly regulated. Pathway analysis revealed a significant regulation of pathways related to inflammation or extracellular matrix remodelling in Db-ICM and Db-pEF, however literally no enrichment in pathways previously related to diabetic cardiomyopathy. To characterize the cardiac cellular heterogeneity, we performed single nucleus RNA sequencing (snRNAseq) that showed no differences in cell frequencies between the groups. However, analysis of genes differentially expressed in cardiomyocytes of diabetic hearts unmasked enrichments in many pathways related to rodent diabetic cardiomyopathy not observed by proteomics or RNA sequencing, including insulin resistance, fatty acid oxidation, oxidative phosphorylation, oxidative stress, and various signaling pathways. Furthermore, interactome analysis revealed fewer cell-cell interactions in Db-pEF and Db-ICM compared to controls and implied differential activation of several signaling pathways to contribute to diabetic heart disease, including adiponectin, hepatocyte growth factor, and natural cell adhesion molecule signaling. Thus, we present the first comprehensive atlas of molecular and cellular alterations in the human diabetic heart, revealing recapitulation of many pathomechanisms previously proposed in animal studies. This analysis represents a decisive step towards understanding the pathology underlying human diabetic heart disease and may help develop future diagnostic and therapeutic strategies.

Study on Risk Factors Associated with Severity of Diabetic Retinopathy in Type-2 Diabetic Patients, Attending a Tertiary Care Centre in Kerala

Introduction: Diabetic retinopathy (DR) is a significant public health concern affecting individuals with diabetes mellitus (DM). Despite treatment advances, a substantial proportion of patients do not respond adequately. This study investigates risk factors associated with the progression of non-proliferative diabetic retinopathy (NPDR) to proliferative diabetic retinopathy (PDR) in type-2 diabetes patients. Methods: A retrospective case-control study was conducted on diabetic patients older than 40 years with at least 5 years of Type-2 Diabetes Mellitus history, attending ophthalmology clinic in Government Medical College, Thrissur, a tertiary care hospital. Data from patients with retinal examination showing diabetic retinopathy were analyzed. Records with missing data were excluded. Patients with Proliferative Diabetic Retinopathy (n=153) were compared with those having Non- Proliferative Diabetic Retinopathy (n=230). Various risk factors were assessed using statistical analysis. Results: Among the studied variables, sex, duration of diabetes, serum urea, serum creatinine, serum triglycerides, and chronic kidney disease were significantly different between Proliferative Diabetic Retinopathy and Non-Proliferative Diabetic Retinopathy patients. Binary logistic regression revealed that duration of diabetes (OR = 1.8, 95% CI = 1.1 - 2.39) and serum creatinine (OR =1.8, 95% CI = 1.1 - 2.39) independently influenced Proliferative Diabetic Retinopathy development. Conclusion: This study highlights that longer diabetes duration and elevated serum creatinine levels independently increase the risk of Non- Proliferative Diabetic Retinopathy progressing to Proliferative Diabetic Retinopathy in type-2 diabetic patients. Other factors such as age, gender, hyperlipidemia, systemic hypertension, type of diabetic treatment, and history of ischemic heart disease did not show significant associations with disease progression. These findings emphasize the importance of close monitoring, early detection, and intervention in patients with Non- Proliferative Diabetic Retinopathy, particularly those with a longer diabetic history, to prevent Proliferative Diabetic Retinopathy development. Further research should explore the causal relationship between serum creatinine and diabetic retinopathy progression and evaluate the impact of renal disease management on disease outcomes. Keywords: Diabetic Retinopathy, diabetes mellitus (DM), Type-2 Diabetes Mellitus (T2DM).

Adaptation of the Healthcare Team as The Key to TAVI Implantation

We present the case of a 79-year-old female patient with a history of ischemic heart disease revascularized with stents and severe aortic stenosis, recently included in the surgical waiting list for treatment. She consulted for syncope and humerus fracture, preceded by chest pain with electrocardiographic changes. During the sequence of diagnostic tests indicated in this context, she suffered a severe clinical worsening, complicating to the point of acute pulmonary edema, cardiogenic shock and requiring mechanical ventilation. The underlying cause was severe aortic stenosis and, therefore, the ideal treatment was urgent percutaneous aortic valve implantation, since he had a peak peak gradient of 64 mmHg. The resolution of the case was not easy, since it required the transfer of a hemodynamically unstable patient from her hospital to the center specialized in TAVI implantation, located only 2 km away. What was new and exceptional was the adaptation of the usual treatment strategy (transfer of the patient to the referral center and scheduled implant) to a patient-centered strategy, which required the transfer of the TAVI expert team (nurses and physicians) together with the implant kit to the hospital where the patient was admitted.

Graded Epidural Anaesthesia as a Sole Anaesthetic Technique for Lower Limb Surgeries in Patients with Low Ejection Fraction: A Case Series

In patients with a history of ischemic heart disease with low ejection fraction, it’s always a challenge for the Anaesthesiologist to make a decision on whether to administer General Anaesthesia (GA), central neuraxial blockade, or both. When the Left ventricular ejection fraction (LVEF) percentage reduces to less than 35%, it indicates the presence of severe systolic dysfunction. Both general anaesthesia and regional anaesthesia carry potential risks due to these patients' low cardiac output status. Hemodynamic fluctuations associated with anaesthesia can be detrimental in these patients. A clear intraoperative plan should be designed to manage the hemodynamics of these patients. Here we report two cases of ischemic heart disease with low ejection fraction posted for orthopedic surgeries. Graded epidural anaesthesia was used as a sole anaesthetic technique. The patients were hemodynamically stable in the intraoperative as well as postoperative period. Keywords: Ischemic heart disease, Low Left Ventricular Ejection Fraction, Graded Epidural Anaesthesia, Cemented modular hemiarthroplasty, PFNA2.

Relationship between Cardiovascular Risk Factors and Development of Acute Coronary Syndrome

Acute coronary syndrome (ACS) which known as subcategory of coronary heart disease is considered a major cause of death. In Saudi Arabia, the prevalence of ACS is 8.2%. Early recognition of risk factors (RFs) associated with ACS is essential to prevent its progression. Therefore, the goals of this study is to estimate the prevalence of cardiovascular RFs among ACS patients and to appraise its association with the development of ACS. This retrospective multi-center cross-sectional study involved 170 patients admitted to Prince Sultan cardiac center, King Saud Hospital, and Bukayriyah General Hospital in Al Qassim, KSA. The participants categorized into three groups UA, NSTEMI, and STEMI. Patients with stable angina or previous MI were excluded from the study. 73.5% were males and 26.5% were females with a mean age of 58.2 ± 11.9. The distribution of ACS subtypes was 51.2%, 27.6%, and 21.2% for STEMI, NSTEMI and UA, respectively. The most common RFs were diabetes mellitus (DM), hypertension (66% each), and dyslipidemia (58%). The prevalence of RFs among STEMI group was 65.6% active smokers, 54.5% dyslipidemia, and 52.2% ischemic heart disease (IHD). On the other hand, in NSTEMI group hypertension and DM were nearly the same (32% & 30% respectively), however family history of IHD was 42.9%. UA revealed a strong association with IHD and family history of IHD (30.4%, 28.6%, respectively).To conclude, most of ACS patients presented with STEMI followed by NSTEMI and the least with UA. Among the cardiovascular risk factors, HTN, DM, and dyslipidemia, were presented in more than half of the patients which strongly suggests an association with developing ACS.

Compliance and satisfaction with treatment as a success of therapy effectiveness in the group of patients with ischemic heart disease: a cross-sectional study.

Non-adherence and non-compliance to pharmaceutical treatment is one of the most common causes of not effective management of patients suffering from ischemic heart disease (IHD). It is crucial to understand the reasons behind it but studies on this subject performed in the Polish population are still lacking. The 329 patients (160 male and 169 female) diagnosed with IHD who reported for follow-up appointments are examined. The following standardized questionnaires were used: Treatment Satisfaction with Medicines Questionnaire (SATMED-Q) and Adherence to Refills and Medication Scale (ARMS), which evaluates the patient's compliance and adherence level, respectively. Patients with IHD showed moderate compliance with pharmacological recommendations and average satisfaction with treatment. Anemia, drugs side effects, and SATMED-Q total score were significant predictors of the overall ARMS score in the univariate analysis, whereas the male gender and satisfaction with treatment improves this results. In multivariate analysis, significant predictors of lower adherence included family history of IHD, anemia and drugs side effects, while higher education and SATMED-Q overall score increased adherence. Treatment satisfaction is a significant predictor of increased overall treatment adherence as well as adherence in terms of drug intake and drug and prescription refills. Raising patient awareness should be an important goal of future educational activities. Int J Occup Med Environ Health. 2023;36(4):465-76.

The significance of historical troponin elevation in acute heart failure: Not as reassuring as previously assumed.

Historical cardiac troponin (cTn) elevation is commonly interpreted as lessening the significance of current cTn elevations at presentation for acute heart failure (AHF). Evidence for this practice is lacking. Our objective was to determine the incremental prognostic significance of historical cTn elevation compared to cTn elevation and ischemic heart disease (IHD) history at presentation for AHF. A total of 341 AHF patients were prospectively enrolled at five sites. The composite primary outcome was death/cardiopulmonary resuscitation, mechanical cardiac support, intubation, new/emergent dialysis, and/or acute myocardial infarction (AMI)/percutaneous coronary intervention (PCI)/coronary artery bypass grafting (CABG) at 90 days. Secondary outcomes were 30-day AMI/PCI/CABG and in-hospital AMI. Logistic regression compared outcomes versus initial emergency department (ED) cTn, the most recent electronic medical record cTn, estimated glomerular filtration rate, age, left ventricular ejection fraction, and IHD history (positive, negative by prior coronary workup, or unknown/no prior workup). Elevated cTn occurred in 163 (49%) patients, 80 (23%) experienced the primary outcome, and 29 had AMI (9%). cTn elevation at ED presentation, adjusted for historical cTn and other covariates, was associated with the primary outcome (adjusted odds ratio [aOR] 2.39, 95% confidence interval [CI] 1.30-4.38), 30-day AMI/PCI/CABG, and in-hospital AMI. Historical cTn elevation was associated with greater odds of the primary outcome when IHD history was unknown at ED presentation (aOR 5.27, 95% CI 1.24-21.40) and did not alter odds of the outcome with known positive (aOR 0.74, 95% CI 0.33-1.70) or negative IHD history (aOR 0.79, 95% CI 0.26-2.40). Nevertheless, patients with elevated ED cTn were more likely to be discharged if historical cTn was also elevated (78% vs. 32%, p = 0.025). Historical cTn elevation in AHF patients is a harbinger of worse outcomes for patients who have not had a prior IHD workup and should prompt evaluation for underlying ischemia rather than reassurance for discharge. With known IHD history, historical cTn elevation was neither reassuring nor detrimental, failing to add incremental prognostic value to current cTn elevation alone.

An Incidental Finding of Chilaiditi's Sign: A Case Report

Chilaiditi’s Sign is a rare radiographic finding in which there is an interposition of the colon between the diaphragm and the liver. The etiology is multifactorial and can be divided into diaphragmatic, hepatic, and colonic causes. Chilaiditi’s sign is considered a cause of pseudo-pneumoperitoneum. On imaging, the sign can easily be misdiagnosed as a ‘true’ pneumoperitoneum, causing the patient to undergo unnecessary investigations and interventions. This case report presents an 88-year-old male with a past medical history of Ischemic Heart Disease (IHD) and Hypertension (HTN) who presented to the Emergency Department (ED) with a clinical picture of obstructive jaundice and was admitted for an Endoscopic Retrograde Cholangiopancreatography (ERCP). Post-ERCP, the patient complained of chest pain, in which a chest X-ray was done, and Chilaiditi’s sign was found.