Life-threatening Cardiovascular Condition Research Articles

Machine Learning for Aortic Stenosis: Enhancing Diagnostic Accuracy and Security in Health Information Systems

Aortic Stenosis (AS) is a prevalent and potentially life-threatening cardiovascular condition that requires accurate diagnosis for optimal management. Traditional diagnostic methods, while effective, face limitations in terms of precision, timely detection, and clinician workload. The emergence of Machine Learning (ML) offers an innovative solution to these challenges, enhancing diagnostic accuracy and improving patient outcomes. This article explores how ML algorithms can be utilized to refine AS diagnosis, particularly through medical imaging and predictive modeling. In addition, the integration of ML in health information systems must be coupled with robust data security measures to protect sensitive patient information. We discuss the intersection of machine learning and healthcare IT security, focusing on innovative methods for safeguarding health data while improving diagnostic efficiency. The paper examines various ML techniques applied to AS, evaluates their impact on clinical workflows, and identifies the security protocols necessary to ensure compliance with privacy regulations. Finally, the study presents the potential challenges and future directions for integrating ML and health information security in clinical practice.

Optimal triage of patients with acute chest pain.

Acute chest pain (ACP) is one of the most common symptoms in patients admitted to emergency departments (ED). It can be related to several life-threatening cardiovascular conditions such as acute coronary syndrome (ACS), aortic dissection, and pulmonary embolism. The optimal triage of patients with ACP is a clinical and healthcare necessity given the large number of patients daily admitted to ED with this symptom. The first contact with the patient in ED includes the clinical appraisal of the characteristics of ACP and coexisting symptoms, and the assessment of the patient's medical history. Risk scores may help stratify a patient's likelihood of having cardiac chest pain. The ECG examination allows the identification of patients with ST-segment elevation, depression, or T-wave changes, but may be normal in patients with non-ST-segment elevation ACS. Rapid protocols based on serial high-sensitivity cardiac troponin assays within one or two hours are recommended for identifying candidates for early discharge. Due to the bedside feasibility, non-invasiveness, and wide availability, transthoracic echocardiography represents the first-line imaging modality for evaluating patients with ACP. In selected cases, computed tomography angiography may also be performed. A practical approach to ACP in ED should improve patient outcomes and reduce healthcare system costs. This review aimed to provide an overview of the characteristics of patients with ACP of cardiac origin and to describe the state of the art about their management in the ED.

Insulin-like Growth Factor-Binding Protein 2 in Severe Aortic Valve Stenosis and Pulmonary Hypertension: A Gender-Based Perspective.

Severe aortic valve stenosis (AS) and pulmonary hypertension (PH) are life-threatening cardiovascular conditions, necessitating early detection and intervention. Recent studies have explored the role of Insulin-like Growth Factor-Binding Protein 2 (IGF-BP2) in cardiovascular pathophysiology. Understanding its involvement may offer novel insights into disease mechanisms and therapeutic targets for these conditions. A total of 102 patients (46 female, 56 male) with severe AS undergoing a transcatheter aortic valve replacement (TAVR) in a single-center study were classified using echocardiography tests to determine systolic pulmonary artery pressure (sPAP) and the presence (sPAP ≥ 40 mmHg) or absence (sPAP < 40 mmHg) of PH. Additionally, serial laboratory determinations of IGF-BP2 before, and at 24 h, 96 h, and 3 months after intervention were conducted in all study participants. Considering the entire cohort, patients with PH had significant and continuously higher serum IGF-BP2 concentrations over time than patients without PH. After subdivision by sex, it could be demonstrated that the above-mentioned results were only verifiable in males, but not in females. In the male patients, baseline IGF-BP2 levels before the TAVR was an isolated risk factor for premature death after intervention and at 1, 3, and 5 years post-intervention. The same was valid for the combination of male and echocardiographically established PH patients. The predictive role of IGF-BP2 in severe AS and concurrent PH remains unknown. A more profound comprehension of IGF-BP2 mechanisms, particularly in males, could facilitate the earlier consideration of the TAVR as a more effective and successful treatment strategy.

Pediatric dilated cardiomyopathy: a review of current clinical approaches and pathogenesis.

Pediatric dilated cardiomyopathy (DCM) is a rare, yet life-threatening cardiovascular condition characterized by systolic dysfunction with biventricular dilatation and reduced myocardial contractility. Therapeutic options are limited with nearly 40% of children undergoing heart transplant or death within 2 years of diagnosis. Pediatric patients are currently diagnosed based on correlating the clinical picture with echocardiographic findings. Patient age, etiology of disease, and parameters of cardiac function significantly impact prognosis. Treatments for pediatric DCM aim to ameliorate symptoms, reduce progression of disease, and prevent life-threatening arrhythmias. Many therapeutic agents with known efficacy in adults lack the same evidence in children. Unlike adult DCM, the pathogenesis of pediatric DCM is not well understood as approximately two thirds of cases are classified as idiopathic disease. Children experience unique gene expression changes and molecular pathway activation in response to DCM. Studies have pointed to a significant genetic component in pediatric DCM, with variants in genes related to sarcomere and cytoskeleton structure implicated. In this regard, pediatric DCM can be considered pediatric manifestations of inherited cardiomyopathy syndromes. Yet exciting recent studies in infantile DCM suggest that this subset has a distinct etiology involving defective postnatal cardiac maturation, such as the failure of programmed centrosome breakdown in cardiomyocytes. Improved knowledge of pathogenesis is central to developing child-specific treatment approaches. This review aims to discuss the established biological pathogenesis of pediatric DCM, current clinical guidelines, and promising therapeutic avenues, highlighting differences from adult disease. The overarching goal is to unravel the complexities surrounding this condition to facilitate the advancement of novel therapeutic interventions and improve prognosis and overall quality of life for pediatric patients affected by DCM.

Modelling years of life lost due to acute type A aortic dissection in the German healthcare setting: a predictive study

ObjectivesThis study aimed to develop a patient-centred approach to the burden of acute type A aortic dissection (ATAAD) through modelling. The main objective was to identify potential improvements in managing...

Enhancing Diagnosis of Anterior and Inferior Myocardial Infarctions Using UWB Radar and AI-Driven Feature Fusion Approach.

Despite significant improvement in prognosis, myocardial infarction (MI) remains a major cause of morbidity and mortality around the globe. MI is a life-threatening cardiovascular condition that requires prompt diagnosis and appropriate treatment. The primary objective of this research is to identify instances of anterior and inferior myocardial infarction by utilizing data obtained from Ultra-wideband radar technology in a hospital for patients of anterior and inferior MI. The collected data is preprocessed to extract spectral features. A novel feature engineering approach is designed to fuse temporal features and class prediction probability features derived from the spectral feature dataset. Several well-known machine learning models are implemented and fine-tuned to obtain optimal performance in the detection of anterior and inferior MI. The results demonstrate that integration of the fused feature set with machine learning models results in a notable improvement in both the accuracy and precision of MI detection. Notably, random forest (RF) and k-nearest neighbor showed superb performance with an accuracy of 98.8%. For demonstrating the capacity of models to generalize, K-fold cross-validation is carried out, wherein RF exhibits a mean accuracy of 99.1%. Furthermore, the examination of computational complexity indicates a low computational complexity, thereby indicating computational efficiency.

The diagnostic and prognostic value of SAA1 as a novel biomarker for acute aortic dissection

Background and aimsAcute aortic dissection (AAD) is a serious life-threatening cardiovascular condition. It is necessary to find rapid and accurate biomarkers for the diagnosis of AAD. This study aimed to determine the efficacy of serum amyloid A1 (SAA1) in the diagnosis and prediction of long-term adverse events in AAD. Materials and methodsFour-dimensional label-free quantification (4D-LFQ) technique was used to identify the differentially expressed proteins (DEPs) in aortic tissues of AAD. After comprehensive analysis, SAA1 was identified as a potential biomarker of AAD. ELISA was used to confirm the expression of SAA1 in serum of AAD patients. Moreover, the source of SAA1 in serum was explored by constructing AAD mouse model. ResultsA total of 247 DEPs were identified, of which 139 were upregulated while 108 were downregulated. SAA1 was nearly 6.4-fold and 4.5-fold upregulated in AAD tissue and serum. ROC curve and Kaplan-Meier survival curve confirmed the good efficacy of SAA1 for the diagnosis and prediction of long-term adverse events in AAD. In vivo experiments revealed that SAA1 was mainly derived from the liver when AAD occurred. ConclusionSAA1 can be used as a potential biomarker for AAD with effective diagnostic and prognostic value. SignificanceDespite the advances in medical technology in recent years, the mortality rate of acute aortic dissection (AAD) is still high. It is still challenging for clinicians to diagnose AAD patients on time and reduce the mortality rate. In this study, 4D-LFQ technology was used to identify serum amyloid A1 (SAA1) as a potential biomarker of AAD and was verified in subsequent work. The results of this study determined the efficacy of SAA1 in the diagnosis and prediction of long-term adverse events in patients with AAD.

Detection of Pulmonary Embolism: Workflow Architecture and Comparative Analysis of the CNN Models

Machine learning has proven to be a practical medical image processing technique for pattern discovery in low-quality labelled and unlabeled datasets. Deep vein thrombosis and pulmonary embolism are both examples of venous thromboembolism, which is a key factor in patient mortality and necessitates prompt diagnosis by experts. An immediate diagnosis and course of treatment are necessary for the life-threatening cardiovascular condition known as pulmonary embolism (PE). In the study of medical imaging, especially the identification of PE, machine learning (ML) algorithms have produced encouraging results. This study's objective is to assess how well machine learning (ML) algorithms perform in identifying PE in computed tomography (CT) scans. A range of ML approaches were used to the dataset, including deep learning algorithms such as convolutional neural networks. The effectiveness of PE detection systems can be greatly enhanced by the use of cutting-edge methodologies like deep learning, which lowers the possibility of incorrect diagnoses and enables the quick administration of therapy to individuals who require it. This work contributes to the growing body of evidence that supports the use of ML in medical imaging and diagnosis. Future research should examine how these algorithms might be included into clinical workflows, resolving any potential implementation challenges, and making sure their adoption is done so in a secure and efficient way. In this study, we provide a thorough evaluation of three different models: the streamlined architecture MobileNetV2 with an accuracy of 96%, compared to other models like the Xception model with an accuracy of 91%, and the Efficientnet B5 model with an accuracy of 97%, after observation and process following.

Outpatient versus inpatient treatment for acute pulmonary embolism.

Pulmonary embolism (PE) is a common life-threatening cardiovascular condition, with an incidence of 23 to 69 new cases per 100,000 people each year. For selected low-risk patients with acute PE, outpatient treatment might provide several advantages over traditional inpatient treatment, such as reduction of hospitalisations, substantial cost savings, and improvements in health-related quality of life. This is an update of an earlier Cochrane Review. To assess the effects of outpatient versus inpatient treatment in low-risk patients with acute PE. We used standard, extensive Cochrane search methods. The latest search date was 31 May 2021. We included randomised controlled trials (RCTs) of outpatient versus inpatient treatment of adults (aged 18 years and over) diagnosed with low-risk acute PE. We used standard Cochrane methods. Our primary outcomes were short- and long-term all-cause mortality. Secondary outcomes were bleeding, adverse effects, recurrence of PE, and patient satisfaction. We used GRADE to assess certainty of evidence for each outcome. We did not identify any new studies for this update. We included a total of two RCTs involving 453 participants. Both trials discharged participants randomised to the outpatient group within 36 hours of initial triage, and both followed participants for 90 days. One study compared the same treatment regimens in both outpatient and inpatient groups, and the other study used different treatment regimens. There was no clear difference in treatment effect for the outcomes of mortality at 30 days (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.01 to 7.98; 2 studies, 453 participants; low-certainty evidence), mortality at 90 days (RR 0.98, 95% CI 0.06 to 15.58; 2 studies, 451 participants; low-certainty evidence), major bleeding at 14 days (RR 4.91, 95% CI 0.24 to 101.57; 2 studies, 445 participants; low-certainty evidence) and at 90 days (RR 6.88, 95% CI 0.36 to 132.14; 2 studies, 445 participants; low-certainty evidence), minor bleeding (RR 1.08, 95% CI 0.07 to 16.79; 1 study, 106 participants; low-certainty evidence), recurrent PE within 90 days (RR 2.95, 95% CI 0.12 to 71.85; 2 studies, 445 participants; low-certainty evidence), and patient satisfaction (RR 0.97, 95% CI 0.90 to 1.04; 2 studies, 444 participants; moderate-certainty evidence). We downgraded the certainty of the evidence because the CIs were wide and included treatment effects in both directions, the sample sizes and numbers of events were small, and it was not possible to determine the effect of missing data or the presence of publication bias. The included studies did not assess PE-related mortality or adverse effects, such as haemodynamic instability, or adherence to treatment. Currently, only low-certainty evidence is available from two published randomised controlled trials on outpatient versus inpatient treatment in low-risk patients with acute PE. The studies did not provide evidence of any clear difference between the interventions in overall mortality, bleeding, or recurrence of PE.

AAA Revisited: A Comprehensive Review of Risk Factors, Management, and Hallmarks of Pathogenesis.

Despite declining incidence and mortality rates in many countries, the abdominal aortic aneurysm (AAA) continues to represent a life-threatening cardiovascular condition with an overall prevalence of about 2–3% in the industrialized world. While the risk of AAA development is considerably higher for men of advanced age with a history of smoking, screening programs serve to detect the often asymptomatic condition and prevent aortic rupture with an associated death rate of up to 80%. This review summarizes the current knowledge on identified risk factors, the multifactorial process of pathogenesis, as well as the latest advances in medical treatment and surgical repair to provide a perspective for AAA management.

A genome-wide association study identifies novel genetic loci associated with pulmonary embolism

Abstract Background Pulmonary embolism (PE) is a life-threatening cardiovascular condition. Studies showed that PE patients were associated with disorders of lipid metabolism and had higher triglyceride and lower HDL-C levels compared with healthy. We conducted the genome-wide association study to identify novel loci contributing to PE. Methods We conducted a large-scale GWAS of PE in 5,466 PE cases and 461,219 controls of European ancestry from the UK Biobank (466,685 participants total). We used genome-wide summary statistics to test for enrichment of functional annotations using ENRICHR. Example pathways included in Enrichr for testing include membership of genes in pathway databases such as the Kyoto Encyclopedia of Genes and Genomes (KEGG), Wikipathway, PANTHER, BioCarta or NCI-Nature pathways. We analyzed the pathways using combined score and p-values which were well validated by comparing to several methods. For pathway analyses, we considered a nominal P-value threshold of 0.05. Results We identified genome-wide significant genetic associations in 63 independent genetic loci for PE (P&amp;lt;5.0x10–7). Our findings for top pathways highlight that lipid metabolism (LIPC, LCAT, NPC2), caffeine metabolism (NAT2), and sudden cardiac death (ABCG8) related genetic loci play an important role in PE alongside genes already associated with coagulation-thrombosis pathway (VWF, THPO, PTPN11, INPP5D, UROS, HMBS) (all p-values p-values &amp;lt;0.05). Conclusion Our findings uncovered unexpected novel factors of PE etiology, suggesting novel mechanistic concepts of PE pathophysiology. Funding Acknowledgement Type of funding source: None

AIR TEMPERATURE AND OZONE CONCENTRATION AS RISK FACTORS FOR LIFE-THREATENING CARDIOVASCULAR CONDITIONS IN SOUTHERN RUSSIA

Heat waves and increasing tropospheric ozone concentration accompanying global warming are recognized as risk factors for public health. The aim of the study was to assess the associations between atmospheric air temperature, ozone concentration as risk factors for life-threatening cardiovascular conditions in Southern Russia. Methods. An ecological study was performed. The number of ambulance calls (the monthly average for 2017 and daily for January, April, July and October) for acute cerebrovascular conditions, hypertensive crises, and acute myocardial infarction were analyzed. Data on mean daily air temperature was obtained from the weather reports (https://rp5. ru). The ozone concentration was determined by the optical method using an automatic gas analyzer at the environmental monitoring station in the Karadagsky State Nature Reserve. Spearman nonparametric correlation analysis was applied to study associations between the outcomes and the selected environmental conditions. Results. During 2017, the average daily concentration of ozone in the surface layer of the atmosphere exceeded the norm by 50-150 %s. The largest number of significant correlations between all recorded cardiovascular life-threatening conditions and air temperature and ozone concentration was detected in July (0,38 &lt; rs &lt; 0,79; all p-values &lt; 0,05). In other seasons of the year, this correlation was somewhat weaker (0,43 &lt; rs &lt; 0,47; all p-values &lt; 0,05). Associations between hypertensive crises and myocardial infarction and average daily temperature were found in January. An association between myocardial infarction and the surface ozone concentration was observed in October. Conclusion. The maximum number of emergency conditions occurring in the summer months may be associated with the synergistic effects of of high levels of ozone and air temperature.

Automated detection of premature ventricular contraction in ECG signals using enhanced template matching algorithm

Nowadays, with the increasing number of people who suffer from cardiovascular diseases such as irregular heartbeats (arrhythmia), there is a vital need to pay more attention to healthcare conditions. Therefore, the production of smart biomedical garments becomes of great necessity. The first step of manufacturing such smart garments is to build an electrocardiogram (ECG) analysis system. In this paper, the premature ventricular contraction (PVC), which is a serious life-threatening cardiovascular condition, is recognised. In addition, an improved template matching technique is developed, implemented, and evaluated to identify the irregularity of PVC beats in the QRS complex and T wave. The improvement in this technique is that a PVC recogniser is established by analysing the maximum and minimum correlation coefficient values instead of the maximum values only. Moreover, a sufficient number of features are relied upon for the accurate detection of PVC beats. The template matching algorithm is evaluated on the MIT-BIH arrhythmia, St. Petersburg Institute of Cardiological Technics (INCART), QT, MIT-BIH Supraventricular Arrhythmia, and Fantasia databases. The results show a valuable accuracy enhancement when compared with those of other recent approaches.

Efficacy of pre-participation cardiac evaluation recommendations among athletes participating in World Athletics Championships.

Athletes competing in athletics (track and field) at international level may be participating with underlying undiagnosed life-threatening cardiovascular conditions. Our objective was to analyse variations in pre-participation cardiac evaluation prevalence among athletes participating in two International Association of Athletics Federations (IAAF) World Athletics Championships, with regard to the human developmental level and global region of their home countries, as well as athletes' age category, gender, event group and medical insurance type. Cross-sectional web-based survey. A total of 1785 athletes competing in the IAAF World Under 18 Championships Nairobi 2017 and World Championships London 2017 were invited to complete a pre-participation health questionnaire investigating the experience of a pre-participation cardiac examination. A total of 704 (39%) of the athletes participated. Among these, 59% (60% of women; 58% of men) reported that they had been provided at least one type of pre-participation cardiac evaluation. Athletes from very high income countries, Europe and Asia, showed a higher prevalence of at least one pre-participation cardiac evaluation. The prevalence of pre-participation cardiac evaluation in low to middle income countries, and the African continent in particular, needs urgent attention. Furthermore, increases in evaluation prevalence should be accompanied by the development of cost-effective methods that can be adopted in all global regions.

Research progress on management of blood pressure in patients with aortic dissection

Aortic dissection is a life-threatening cardiovascular condition. The elevated blood pressure plays an important role in the development and the formation of aortic dissection, thus treatment of aortic dissection requires the management of blood pressure control. In this paper, we reported the current situation and summarized the influencing factors of blood pressure management in the treatment of patients with aortic dissection. Suggestions were provided to improve the management of blood pressure control and to support the future research in China. Key words: Aortic dissection; Blood pressure management; Influencing factors; Interventions; Literature review

P063 Loeys-Dietz syndrome presenting with inflammatory bowel disease symptoms

BACKGROUND: Loeys-Dietz syndrome (LDS) is a rare autosomal dominant disorder of connective tissue caused by mutations in the genes encoding receptor subunits for TGFβ, TGFBR1 and TGFBR2. It is characterized by arterial aneurysms and dissections, skeletal abnormalities, joint laxity and craniofacial abnormalities. There is an increased risk of immunologic diseases including allergic and eosinophilic gastrointestinal disorders, as well as inflammatory bowel disease (IBD). TGF-β signaling plays an important role in regulating mucosal immune responses likely leading to increased propensity for development of IBD. This case highlights a rare presentation of LDS, with symptoms of IBD presenting in advance of cardiac symptoms, leading to diagnosis of this rare connective tissue disorder. CASE: A 14 yo Male presented with 1 year of intermittent bloody stools, diarrhea and fatigue. Physical exam was only positive for a bifid uvula and marfanoid body habitus. Laboratory testing showed microcytic anemia, elevated C-reactive protein, erythrocyte sedimentation rate, and hypoalbuminemia. Stool tests were negative for infectious causes of diarrhea. Esophagogastroduodenoscopy and colonoscopy showed gross findings of duodenal ulcer and mucosal ulceration throughout the colon. Histology showed chronic focal active duodenitis with intramucosal granuloma, and chronic active pancolitis. No eosinophils were observed. Findings were thought to be consistent with diagnosis of IBD, so patient was initially treated with Mesalamine and Prednisone. After treatment failure, therapy was switched to infliximab plus oral methotrexate, and responded well, clinically. Approximately 6 months after diagnosis of IBD, the patient developed chest pain, tachycardia, and shortness of breath. Due to new elevation of CRP and ESR, there was a suspicion for myocarditis. Echocardiogram, however, showed bicuspid aortic valve with dilated aortic root. Given this finding, the cardiologists suspected a collagen disorder and subsequently started patient on Losartan. After being seen by Genetics, a next generation sequencing panel demonstrated mutation of the TGFBR2 (p.C61Y) gene. He was diagnosed with LDS. Three years after diagnosis, patient has remained in deep remission of his IBD with combination of infliximab and methotrexate. One year after diagnosis of LDS, the patient’s aortic root dilation reached critical limits and he successfully underwent ascending aortic graft and aortic root replacement with On-X 25 valve. He tolerated this procedure well and remains on lifelong anticoagulation therapy. DISCUSSION: It is thought that patients with LDS are 10 times more likely to have IBD than the general population. However, the occurrence of non-eosinophilic chronic IBD in patients with LDS has been reported but has been poorly documented. Typical cases of LDS described in literature present with eosinophilic gastrointestinal disorders, food allergies and rarely IBD. Typically, cardiac and skeletal disorders precede the GI manifestations. Our case is remarkable in that the patient first diagnosed with IBD and then later presented with cardiac symptoms finally leading to diagnosis of LDS. Currently, there is no established protocol for the evaluation and management of IBD in LDS patients. This case highlights life-threatening aortic or cardiovascular conditions linked with LDS. As such, a low index of suspicion is needed when managing IBD in patients with features suggestive of LDS.

Outpatient versus inpatient treatment for acute pulmonary embolism.

Pulmonary embolism (PE) is a common life-threatening cardiovascular condition, with an incidence of 23 to 69 new cases per 100,000 people each year. For selected low-risk patients with acute PE, outpatient treatment might provide several advantages over traditional inpatient treatment, such as reduction of hospitalisations, substantial cost savings, and improvements in health-related quality of life. This is an update of the review first published in 2014. To compare the efficacy and safety of outpatient versus inpatient treatment in low-risk patients with acute PE for the outcomes of all-cause and PE-related mortality; bleeding; adverse events such as haemodynamic instability; recurrence of PE; and patients' satisfaction. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers, to 26 March 2018. We also undertook reference checking to identify additional studies. We included randomised controlled trials of outpatient versus inpatient treatment of adults (aged 18 years and over) diagnosed with low-risk acute PE. Two review authors selected relevant trials, assessed methodological quality, and extracted and analysed data. We calculated effect estimates using risk ratio (RR) with 95% confidence intervals (CIs), or mean differences (MDs) with 95% CIs. We used standardised mean differences (SMDs) to combine trials that measured the same outcome but used different methods. We assessed the quality of the evidence using GRADE criteria. One new study was identified for this 2018 update, bringing the total number of included studies to two and the total number of participants to 451. Both trials discharged patients randomised to the outpatient group within 36 hours of initial triage and both followed participants for 90 days. One study compared the same treatment regimens in both outpatient and inpatient groups, and the other study used different treatment regimes. There was no clear difference in treatment effect for the outcomes of short-term mortality (30 days) (RR 0.33, 95% CI 0.01 to 7.98, P = 0.49; low-quality evidence), long-term mortality (90 days) (RR 0.98, 95% CI 0.06 to 15.58, P = 0.99, low-quality evidence), major bleeding at 14 days (RR 4.91, 95% CI 0.24 to 101.57, P = 0.30; low-quality evidence) and at 90 days (RR 6.88, 95% CI 0.36 to 132.14, P = 0.20; low-quality evidence), minor bleeding (RR 1.08, 95% CI 0.07 to 16.79; P = 0.96, low-quality evidence), recurrent PE within 90 days (RR 2.95, 95% CI 0.12 to 71.85, P = 0.51, low-quality evidence), and participant satisfaction (RR 0.97, 95% CI 0.90 to 1.04, P = 0.39; moderate-quality evidence). We downgraded the quality of the evidence because the CIs were wide and included treatment effects in both directions, the sample sizes and numbers of events were small, and because the effect of missing data and the absence of publication bias could not be verified. PE-related mortality, and adverse effects such as haemodynamic instability and compliance, were not assessed by the included studies. Currently, only low-quality evidence is available from two published randomised controlled trials on outpatient versus inpatient treatment in low-risk patients with acute PE. The studies did not provide evidence of any clear difference between the interventions in overall mortality, bleeding and recurrence of PE.

Point-of-care ultrasound diagnosis of thoracic aortic aneurysm in a patient presenting with hemoptysis

IntroductionHemoptysis is rarely reported as the chief complaint of thoracic aortic aneurysm (TAA). It usually occurs due to aneurysm erosion into the lung parenchyma or rupture into the lung [1]. Point-of-care ultrasound (POC-US) is now widely used by emergency physicians (EP) to help diagnose life-threatening cardiovascular pathologic conditions.Case ReportA 78-year-old bedridden man with a past history of hypertension and traumatic intracranial hemorrhage presented to the emergency department with massive hemoptysis that was preceded by intermittent hemoptysis for the past 3 days. On arrival, his vital signs were as follows: respiratory rate, 18 breaths/min; pulse rate, 92 beats/min; blood pressure, 82/56 mmHg; and temperature, 36.0 celsius degrees. His consciousness level was clear. POC-US was performed by EP, which revealed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma. Subsequent computed tomography angiography (CTA) of the aorta confirmed the diagnosis. The patient and his family refused operation, and he died the same day.DiscussionThe vast majority of patients with thoracic aortic aneurysms are asymptomatic [2]. When symptoms occur, classic manifestations are chest or upper back pain or symptoms related to compression of local structures leading to nerve dysfunction or vessel compression. Hemoptysis is uncommon as the sole presentation of thoracic aortic aneurysm [1,3]. The traditional imaging modalities of choice for TAA include CTA, magnetic resonance imaging, and transesophageal echocardiography. In the recent decades, EP have performed POC-US not only for the detection of pericardial effusion, cardiac function, and abdominal aorta but also for the evaluation of the thoracic aorta. Nowadays, POC-US plays an important role in initiating emergent treatment and triage decisions in the emergency department. EP should carefully consider the atypical presentation of aortic aneurysms and dissection and the applicability of POC-US for first-line decision-making. Hemoptysis is rarely reported as the chief complaint of thoracic aortic aneurysm (TAA). It usually occurs due to aneurysm erosion into the lung parenchyma or rupture into the lung [1]. Point-of-care ultrasound (POC-US) is now widely used by emergency physicians (EP) to help diagnose life-threatening cardiovascular pathologic conditions. A 78-year-old bedridden man with a past history of hypertension and traumatic intracranial hemorrhage presented to the emergency department with massive hemoptysis that was preceded by intermittent hemoptysis for the past 3 days. On arrival, his vital signs were as follows: respiratory rate, 18 breaths/min; pulse rate, 92 beats/min; blood pressure, 82/56 mmHg; and temperature, 36.0 celsius degrees. His consciousness level was clear. POC-US was performed by EP, which revealed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma. Subsequent computed tomography angiography (CTA) of the aorta confirmed the diagnosis. The patient and his family refused operation, and he died the same day. The vast majority of patients with thoracic aortic aneurysms are asymptomatic [2]. When symptoms occur, classic manifestations are chest or upper back pain or symptoms related to compression of local structures leading to nerve dysfunction or vessel compression. Hemoptysis is uncommon as the sole presentation of thoracic aortic aneurysm [1,3]. The traditional imaging modalities of choice for TAA include CTA, magnetic resonance imaging, and transesophageal echocardiography. In the recent decades, EP have performed POC-US not only for the detection of pericardial effusion, cardiac function, and abdominal aorta but also for the evaluation of the thoracic aorta. Nowadays, POC-US plays an important role in initiating emergent treatment and triage decisions in the emergency department. EP should carefully consider the atypical presentation of aortic aneurysms and dissection and the applicability of POC-US for first-line decision-making. Figure 1. POC-US of suprasternal notch view showed a proximal thoracic aortic aneurysm with extraluminal area of heterogeneous echogenicity adjacent hematoma (arrow). Figure 2. CTA of the aorta revealed proximal ruptured thoracic aortic aneurysm with adjacent hematoma.•Sun D, Mehta S. Hemoptysis caused by erosion of thoracic aortic aneurysm. CMAJ. 2010; 182:186.•Pressler V, McNamara JJ. Aneurysm of the thoracic aorta. Review of 260 cases. J Thorac Cardiovasc Surg 1985; 89:50.•Nair G, Jindal S, Chandra A, Swami S, Garg P. Haemoptysis - a rare presentation of aortic aneurysm. Lung India. 2008;25:20.

Novel genetic predictors of venous thromboembolism risk in African Americans

AbstractVenous thromboembolism (VTE) is the third most common life-threatening cardiovascular condition in the United States, with African Americans (AAs) having a 30% to 60% higher incidence compared with other ethnicities. The mechanisms underlying population differences in the risk of VTE are poorly understood. We conducted the first genome-wide association study in AAs, comprising 578 subjects, followed by replication of highly significant findings in an independent cohort of 159 AA subjects. Logistic regression was used to estimate the association between genetic variants and VTE risk. Through bioinformatics analysis of the top signals, we identified expression quantitative trait loci (eQTLs) in whole blood and investigated the messenger RNA expression differences in VTE cases and controls. We identified and replicated single-nucleotide polymorphisms on chromosome 20 (rs2144940, rs2567617, and rs1998081) that increased risk of VTE by 2.3-fold (P < 6 × 10−7). These risk variants were found in higher frequency among populations of African descent (>20%) compared with other ethnic groups (<10%). We demonstrate that SNPs on chromosome 20 are cis-eQTLs for thrombomodulin (THBD), and the expression of THBD is lower among VTE cases compared with controls (P = 9.87 × 10−6). We have identified novel polymorphisms associated with increased risk of VTE in AAs. These polymorphisms are predominantly found among populations of African descent and are associated with THBD gene expression. Our findings provide new molecular insight into a mechanism regulating VTE susceptibility and identify common genetic variants that increase the risk of VTE in AAs, a population disproportionately affected by this disease.

Alternative cannulation techniques in surgical repair for acute type A aortic dissection

In this issue of the European Research Journal, Yalcin et al. [1] reported an experience with ascending aorta cannulation for surgical repair in a case with acute type A aortic dissection (AAAD). This presentation raises many questions that should be answered by the authors. They reported direct true lumen cannulation of the ascending aorta under visual control but this technique has not clearly been explained in detail. How was the aortic cannula introduced? What was arterial systolic pressure before procedure? Was venous exsanguination from the right atrium performed? The answers to these questions have not been explicitly stated in the text. Another very important issue is cerebral protection. There is also no an information about protection of the brain during the open distal anastomosis. The technique has not satisfactorily been discussed. Despite all these shortcomings, the authors are to be congratulated on their successful dissection repair with this technique and for bringing it to our attention. I would also like to share additional comments on alternative cannulation techniques for arterial inflow in these complicated patients. AAAD is one of the life-threatening cardiovascular conditions and associated with an increased risk of mortality and morbidity. It requires immediate surgical intervention to avoid catastrophic complications such as aortic rupture or organ malperfusion (brain or visceral). The most important stages for succesful surgical treatment of AAAD include the excision of the primary entry tear in the aorta, the elimination of aortic valve insufficiency, and the establishment of the true lumen flow to correct the distal malperfusion [2]. The best arterial cannulation site for a prompt induction of CPB in surgical repair of AAAD remains controversial [3]. The most important objective for the arterial cannulation in this lethal condition is to allow antegrade blood flow through the true lumen. The choice of arterial inflow site is influenced by many factors including hemodynamic instability (cardiac tamponade or shock), the presence of malperfusion, the extent of dissection, possible involvement of the cannulation site, peripheral vascular disease, a history of stroke, the patient’s age or the preference of the surgeon. Many different inflow sites for arterial cannulation have been described. Possible access points for cannulation include the femoral artery, the axillary artery, the brachial artery, the innominate artery, the carotid artery, the subclavian artery, the ascending aorta, the transverse arch of the aorta, and the left ventricular apex. Each cannulation site has both the advantages and disadvantages [3]. In current cardiovascular practice, the femoral arteries and the axillary arteries are the most commonly used cannulation sites for repair of AAAD. Excellent results have been reported with these arterial inflow sites [4-6]. Femoral artery cannulation is the standard cannulation technique and allows for the rapid institution of CPB in hemodynamically unstable patients with AAAD. However, it has disadvantages of retrograde arterial perfusion such as an increased risk of retrograde cerebral embolization due to atherosclerotic debris or thrombus in the descending