Acute Myocardial Infarction in a Patient With Elevated ST-Segment in aVR Lead and Diffuse ST Segment Depression in Other Leads: A Case Report

ST elevation in aVR in conjunction with diffuse ST depression in precordial leads may indicate occlusion of very proximal portion of the left anterior descending artery. We present a 54-year old man, with crushing retrosternal pain and ST-segment elevation only in aVR lead and diffuse ST-segment depression in inferior, lateral and precordial leads. The patient was scheduled for emergent coronary angiography, which showed that left anterior descending (LAD) artery was cut off at very proximal portion and urgent CABG was performed for the patient

A Mysterious Case of ST-Elevation Myocardial Infarction; an Old Man with Weight Loss and Dyspepsia

We present a 65-year-old man who developed retrosternal compressive chest pain. A 12-lead electrocardiography demonstrated ST-segment elevation in leads II, III and aVF. Emergent coronary angiography showed significant thrombus in the distal portion of the left main coronary artery. Abdomino-pelvic computed tomography scan, which was performed the next day, confirmed a pancreatic mass with peritoneal seedings, compatible with peritoneal carcinomatosis. This case underscores the importance of malignancies that may lead to a catastrophic ST-elevation myocardial infarction due to a hypercoagulable state and following thrombosis in the left main coronary artery

Strategy to manage T-Wave Oversensing in a Biventricular ICD

T-wave oversensing is a relatively prevalent cause of intracardiac signals oversensing in patients with Implantable Cardioverter Defibrillator (ICD). Some of these oversensings are typically corrected with device reprogramming. If reprogramming fails to resolve the issue, invasive options such as repositioning the implanted lead may be necessary. We present a patient with dilated cardiomyopathy and intermittent T wave oversensing by a cardiac resynchronization therapy (CRT) that was managed by altering V-V timing

Syncope during pregnancy in a patient with permanent cardiac pacemaker, due to increased pacing threshold.

A 22-year-old pregnant woman referred with syncope due to pacemaker malfunction. During the second trimester of pregnancy, the right ventricular (RV) lead pacing threshold increased and led to early generator depletion. We believe that this might happen due to lead micro-dislodgement or less probably effect of hormonal changes during pregnancy on electrode-myocardium interface

Impact of Lesion Length on Functional Significance in Intermediate Coronary Lesions

Introduction: The present study aimed at assessing the role of lesion length in predicting Fractional Flow Reserve (FFR) value for physiological evaluation of intermediate coronary lesions.Methods: In the current study, 68 patients with 83 coronary lesions were enrolled. All of the patients in this study underwent routine coronary angiography, according to appropriate indications. To evaluate physiologically significant intermediate coronary stenosis (defined between 40% and 70% on visual estimation), the Fractional Flow Reserve (FFR) study was performed and the Quantitative Coronary Angiography (QCA) data were also assessed for measurement of lesion length. The correlation between QCA data and FFR values was also examined.Results: Eighty-three lesions were evaluated from 68 patients. Stenosis was considered physiologically significant when FFR was lower than 0.75. The FFR was significant in twelve lesions (14.5%). There was a negative correlation between FFR value and lesion length (r = -0.294 and P = 0.013). Moreover, lesion length in physiologically significant FFR group (21.07 ± 6.9) was greater than that of the non-significant FFR group (15.23 ± 6.5) (P value < 0.05). Furthermore, the correlation between QCA data and FFR values was also investigated, yet, there was only a positive correlation between FFR and Minimum Luminal Diameter (MLD) values (r = 0.248 and P value = 0.04). The Receiver Operating Characteristic (ROC) curve analysis for predicting the significant FFR value demonstrated that a lesion length greater than 17.5 mm was the best cut-off point for prediction of the significant FFR value with acceptable sensitivity and specificity of 83.3% and 68.8%, respectively.Conclusions: There is a negative correlation between lesion length and FFR value in intermediate coronary lesions. In addition, a lesion length greater than 17.5 mm is the best cut- off point for prediction of significant FFR values

Chronic Total Occlusion-Angioplasty with Antegrade Approach: A two-Year Experience in “Modarres Hospital”, A Tertiary University Hospital, Tehran, Iran

Introduction: New techniques for the percutaneous treatment of coronary chronic total occlusions (CTO) have had a high success rate since a few years ago, so the interest for this treatment has been increasing these days.Methods: The current observational study was performed in Modarres hospital as a tertiary referral center. All the patients with documented stable angina who had failed to response to full guideline-mediated medical therapy, referred to our hospital, were candidates for coronary angiography. Antegrade strategy was applied for all these patients. The length of the lesion, the fluoroscopy time of the CTO angioplasty, consumed contrast volume, the number of guide wires used, whether a corsair or tornus micro-catheter was used or not, and the success rate of the angioplasty were documented for further analysis.Results: A total of 47 patients with documented stable angina were finally included. The median age was 59 (45-78) and 70.2% were male. The mean length of the lesion was 34.0 ± 1.1 .The mean fluoroscopy time and contrast volume were 57.9 ± 3.2 minutes and 525.9 ± 20.9 mL, respectively. In average, 2.2 guide wires were used. Corsair and tornus micro-catheters were applied in 30 (63.8%) and 5 (10.6%) of the cases, respectively. Seven complications (all including coronary dissection) occurred. In-hospital major adverse cardiac events (MACE) rate was 10.6%, all of which were non-Q wave myocardial infarction. The success rate was 85.1%. The higher number of used wires, use of corsair, and tornus micro-catheter were not significantly concordant with success rate (P-value > 0.05); in addition, longer lesion was not concordant with unsuccessfulness rate (P-value > 0.05).Conclusions: Patient selection for CTO-angioplasty should be performed more carefully. Patients’ quality of life and risk of probable procedural complications and future cardiac events should be assessed to decide the best treatment approach. Radiation exposure, contrast consumption and fluoroscopy time are recommended to be monitored during the procedure and thresholds should be defined to enhance safety and efficacy

Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

Background: In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries. Methods: GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution. Findings: Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990–2010 time period, with the greatest annualised rate of decline occurring in the 0–9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10–24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10–24 years were also in the top ten in the 25–49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50–74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI. Interpretation: As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and developm nt investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve. Funding: Bill & Melinda Gates Foundation. © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licens

Global, regional, and national incidence of six major immune-mediated inflammatory diseases: findings from the global burden of disease study 2019

BACKGROUND: The causes for immune-mediated inflammatory diseases (IMIDs) are diverse and the incidence trends of IMIDs from specific causes are rarely studied. The study aims to investigate the pattern and trend of IMIDs from 1990 to 2019. METHODS: We collected detailed information on six major causes of IMIDs, including asthma, inflammatory bowel disease, multiple sclerosis, rheumatoid arthritis, psoriasis, and atopic dermatitis, between 1990 and 2019, derived from the Global Burden of Disease study in 2019. The average annual percent change (AAPC) in number of incidents and age standardized incidence rate (ASR) on IMIDs, by sex, age, region, and causes, were calculated to quantify the temporal trends. FINDINGS: In 2019, rheumatoid arthritis, atopic dermatitis, asthma, multiple sclerosis, psoriasis, inflammatory bowel disease accounted 1.59%, 36.17%, 54.71%, 0.09%, 6.84%, 0.60% of overall new IMIDs cases, respectively. The ASR of IMIDs showed substantial regional and global variation with the highest in High SDI region, High-income North America, and United States of America. Throughout human lifespan, the age distribution of incident cases from six IMIDs was quite different. Globally, incident cases of IMIDs increased with an AAPC of 0.68 and the ASR decreased with an AAPC of −0.34 from 1990 to 2019. The incident cases increased across six IMIDs, the ASR of rheumatoid arthritis increased (0.21, 95% CI 0.18, 0.25), while the ASR of asthma (AAPC = −0.41), inflammatory bowel disease (AAPC = −0.72), multiple sclerosis (AAPC = −0.26), psoriasis (AAPC = −0.77), and atopic dermatitis (AAPC = −0.15) decreased. The ASR of overall and six individual IMID increased with SDI at regional and global level. Countries with higher ASR in 1990 experienced a more rapid decrease in ASR. INTERPRETATION: The incidence patterns of IMIDs varied considerably across the world. Innovative prevention and integrative management strategy are urgently needed to mitigate the increasing ASR of rheumatoid arthritis and upsurging new cases of other five IMIDs, respectively. FUNDING: The Global Burden of Disease Study is funded by the Bill and Melinda Gates Foundation. The project funded by Scientific Research Fund of Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital (2022QN38)