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PURPOSE OF REVIEW: A significant proportion of patients evaluated for chest pain have ischemia with non-obstructive coronary artery disease (INOCA). Studies have shown INOCA is associated with increased risk of major adverse cardiac events and significant burden on the health care system. RECENT FINDINGS: While there is scarce scientific evidence on management of INOCA, the CorMicA trial showed that stratified medical therapy based on the type of INOCA improved patients’ symptoms and quality of life. There are multiple ongoing trials, including Women’s IschemiA Trial to Reduce Events in Non-ObstRuctIve CORonary Artery Disease (WARRIOR trial), assessing the benefit of intensive medical therapy versus usual care for this increasingly recognized clinical entity. SUMMARY: In this review, we discuss the definition of INOCA, epidemiology and risk factors, pathophysiology, and management as well as the current knowledge gaps and ongoing clinical trials in this arena.

Transcatheter edge-to-edge repair (TEER) with MitraClip improves outcomes among select patients with moderate-to-severe and severe mitral regurgitation; however, data regarding sex-specific differences in the outcomes among patients undergoing TEER are limited.An electronic search of the PubMed, Embase, Central, and Web of Science databases for studies comparing sex differences in outcomes among patients undergoing TEER was performed. Summary estimates were primarily conducted using a random-effects model.Eleven studies with a total of 24,905 patients (45.6% women) were included. Women were older and had a lower prevalence of comorbidities, including diabetes, chronic kidney disease, and coronary artery disease. There was no difference in procedural success (odds ratio [OR]: 0.75, 95% confidence interval [CI]: 0.55-1.05) and short-term mortality (i.e., up to 30 days) between women and men (OR: 1.16, 95% CI: 0.97-1.39). Women had a higher incidence of periprocedural bleeding and stroke (OR: 1.34, 95% CI: 1.15-1.56) and (OR: 1.57, 95% CI: 1.10-2.25), respectively. At a median follow-up of 12 months, there was no difference in mortality (OR: 0.98, 95% CI: 0.89-1.09) and heart failure hospitalizations (OR: 1.07, 95% CI: 0.68-1.67). An analysis of adjusted long-term mortality showed a lower incidence of mortality among women (hazards ratio: 0.77, 95% CI: 0.67-0.88).Despite a lower prevalence of baseline comorbidities, women undergoing TEER with MitraClip had higher unadjusted rates of periprocedural stroke and bleeding as compared with men. There was no difference in unadjusted procedural success, short-term or long-term mortality. However, women had lower adjusted mortality on long-term follow-up. Future high-quality studies assessing sex differences in outcomes after TEER are needed to confirm these findings.

Mechanical circulatory support devices are increasingly used for the treatment of acute myocardial infarction complicated by cardiogenic shock. These devices provide different levels of univentricular and biventricular support, have different mechanisms of actions, and provide different physiologic effects. Institutions require expert teams to safely implant and manage these devices. This article reviews the mechanism of action, physiologic effects, and data as they relate to the utilization of these devices.

Background This study sought to assess the contemporary outcomes of patients transferred after receiving fibrinolytic therapy (‘drip-and-ship’) for ST-segment elevation myocardial infarction (STEMI) in the United States. Methods During 2009–2016, adults (>18 years) with STEMI (>18 years) without cardiac arrest and cardiogenic shock that received fibrinolytic therapy and were subsequently transferred were identified using the National Inpatient Sample (NIS). These admissions were divided into those undergoing fibrinolysis alone, subsequent coronary angiography (CA) without revascularization and subsequent CA with revascularization. Outcomes of interest included in-hospital mortality, resource utilization, and discharge disposition. Results A total of 27,454 STEMI admissions receiving a ‘drip-and-ship strategy’, 96.3% and 85.8% received subsequent coronary angiography and revascularization Admissions receiving CA and revascularization were younger, male, and with lower comorbidity. The fibrinolysis alone cohort had higher rates of organ failure, hemorrhagic sequelae, and intracranial hemorrhage. Compared to the fibrinolysis cohort, CA with revascularization (adjusted odds ratio [aOR] 0.17 [95% confidence interval {CI} 0.11–0.27]; p Conclusion Fibrinolysis with subsequent revascularization is associated with excellent outcomes in STEMI. Admissions receiving fibrinolysis alone were systematically different, sicker and had poorer outcomes.

The management of left main coronary artery (LMCA) disease has evolved over the past two decades. Historically, coronary artery bypass grafting (CABG) surgery has been the gold standard for the treatment of LMCA disease. However, with the advancements in percutaneous coronary interventions (PCIs) and stent technology, PCI in select patients has achieved comparable outcomes to CABG. As such, this has led to changes in the American College of Cardiology and European Society of Cardiology guidelines, which recommend that PCI might be an alternative to CABG in select patients. In this review article, we describe the historical perspective and early experience with coronary interventions of LMCA disease, landmark clinical trials and their effect on guidelines, and the role of intravascular imaging in the management of LMCA lesions.

There has been increasing interest in open artery syndrome, also known as ischemia with non-obstructive coronary arteries (INOCA). INOCA has been increasingly recognized as a heterogeneous clinical entity. Diagnostic evaluation of this heterogeneous entity, including invasive assessment, remains key to diagnose this clinical condition and provide the appropriate treatment. Importantly, medical stratification based on the type of INOCA has shown benefit in improving the symptoms in these patients, as illustrated in the CorMicA trial. The Women's IschemiA Trial to Reduce Events in Non-ObstRuctIve CORonary Artery Disease (WARRIOR) is another promising landmark trial that is currently enrolling patients and will address some of the unanswered questions for management of women with INOCA. In this review, we discuss the pathophysiology, management options, knowledge gaps, and future directions while highlighting the rationale and design of the ongoing WARRIOR trial.

We will review transcatheter mitral valve replacement (TMVR) and discuss this evolving cutting edge procedure in terms of types (valve in valve, valve in ring and valve in mitral annular calcification MAC), clinical indications, pre-procedural planning and value of pre-procedural imaging including computed tomography role, technical challenges encountered in these procedures, potential complications for each type of TMVR, and potential strategies to mitigate and avoid such complications, We will review the currently available devices dedicated for mitral valve replacement, with a summary of their preliminary data and early outcome results. We will also discuss knowledge gaps and ideas for future research.

The influence of weight on in-hospital events of acute myocardial infarction complicated with cardiac arrest (AMI-CA) is understudied. To address this, we utilized the National Inpatient Sample database (2008-2017) to identify adult AMI-CA admissions and categorized them by BMI into underweight, normal weight, and overweight/obese groups. The outcomes of interest included differences in in-hospital mortality, use of invasive therapies, hospitalization costs, and hospital length of stay across the three weight categories. Of the 314,609 AMI-CA admissions during the study period, 268,764 (85.4%) were normal weight, 1,791 (0.6%) were underweight, and 44,053 (14.0%) were overweight/obese. Compared to 2008, in 2017, adjusted temporal trends revealed significant increase in prevalence of AMI-CA in underweight (adjusted OR {aOR} 3.88 [95% CI 3.04-4.94], P

Syndromes of cardiac ischemia with nonobstructive coronary arteries have been increasingly recognized as a clinical entity with heterogeneous clinical presentations, commonly encountered in women. Knowledge of pathophysiology and clinical risk factors is key to ensuring appropriate diagnostic evaluation and management for these often-neglected patients. In this review, we discuss the epidemiology, risk factors, and clinical presentations of these syndromes. We provide algorithms for diagnosis and management of these entities based on current scientific knowledge and highlight some of the key knowledge gaps and ongoing trials in this emerging field.

Spontaneous Coronary Artery Dissection (SCAD) is an important cause of Acute Coronary Syndrome (ACS), especially in pregnant women. SCAD has angiographic appearance that might mimic atherosclerotic coronary artery disease (CAD). SCAD in pregnancy can be associated with both maternal and fetal complications. The best management approach of such cases may be achieved by a multi-disciplinary team, including an obstetrician, an interventional cardiologist and a cardiothoracic surgeon. We present a very interesting case of SCAD involving the left anterior descending (LAD) artery with two different angiographic appearances in a pregnant woman which was associated with fetal heart deceleration requiring urgent cesarean section and later coronary artery bypass graft (CABG) surgery.

Aims To evaluate sex‐specific disparities in acute kidney injury (AKI) complicating acute myocardial infarction‐related cardiogenic shock (AMI‐CS) in the United States. Methods and results This was a retrospective cohort study from 2000 to 2014 from the National Inpatient Sample (20% sample of all hospitals in the United States). Patients >18 years admitted with a primary diagnosis of AMI and concomitant CS that developed AKI were included. The endpoints of interest were the prevalence, trends, and outcomes of men and women with AKI in AMI‐CS. Multivariable hierarchical logistic regression was used to control for confounding, and a two‐sided P

Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome, especially in young women. Recurrent SCAD can be due…, Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome, especially in young women. Recurrent SCAD can be due to extension of dissection or de novo dissection of unrelated vessel. The authors present a case of acute de novo recurrent SCAD treated conservatively and with coronary intervention. (Level of Difficulty: Intermediate.), Graphical abstract

The aim of this study was to evaluate the combined impact of race, ethnicity, and sex on in-hospital outcomes using data from the National Inpatient Sample.Cardiogenic shock (CS) is a major cause of mortality following ST-segment elevation myocardial infarction (STEMI). Early revascularization reduces mortality in such patients. Mechanical circulatory support (MCS) devices are increasingly used to hemodynamically support patients during revascularization. Little is known about racial, ethnic, and sex disparities in patients with STEMI and CS.The National Inpatient Sample was queried from January 2006 to September 2015 for hospitalizations with STEMI and CS. The associations between sex, race, ethnicity, and outcomes were examined using complex-samples multivariate logistic or generalized linear model regressions.Of 159,339 patients with STEMI and CS, 57,839 (36.3%) were women. In-hospital mortality was higher for all women (range 40% to 45.4%) compared with men (range 30.4% to 34.7%). Women (adjusted odds ratio [aOR]: 1.11; 95% confidence interval [CI]: 1.06 to 1.16; p 0.001) as well as Black (aOR: 1.18; 95% CI: 1.04 to 1.34; p = 0.011) and Hispanic (aOR: 1.19; 95% CI: 1.06 to 1.33; p = 0.003) men had higher odds of in-hospital mortality compared with White men, with Hispanic women having the highest odds of in-hospital mortality (aOR: 1.46; 95% CI: 1.26 to 1.70; p 0.001). Women were older (age: 69.8 years vs. 63.2 years), had more comorbidities, and underwent fewer invasive cardiac procedures, including revascularization, right heart catheterization, and MCS.There are significant racial, ethnic, and sex differences in procedural utilization and clinical outcomes in patients with STEMI and CS. Women are less likely to undergo invasive cardiac procedures, including revascularization and MCS. Women as well as Black and Hispanic patients have a higher likelihood of death compared with White men.

Background: There are limited data on acute myocardial infarction with cardiogenic shock (AMI-CS) stratified by chronic kidney disease (CKD) stages. Objective: To assess clinical outcomes in AMI-CS stratified by CKD stages. Methods: A retrospective cohort of AMI-CS during 2005&ndash, 2016 from the National Inpatient Sample was categorized as no CKD, CKD stage-III (CKD-III), CKD stage-IV (CKD-IV) and end-stage renal disease (ESRD). CKD-I/II were excluded. Outcomes included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI) and mechanical circulatory support (MCS). We also evaluated acute kidney injury (AKI) and acute hemodialysis in non-ESRD admissions. Results: Of 372,412 AMI-CS admissions, CKD-III, CKD-IV and ESRD comprised 20,380 (5.5%), 7367 (2.0%) and 18,109 (4.9%), respectively. Admissions with CKD were, on average, older, of the White race, bearing Medicare insurance, of a lower socioeconomic stratum, with higher comorbidities, and higher rates of acute organ failure. Compared to the cohort without CKD, CKD-III, CKD-IV and ESRD had lower use of coronary angiography (72.7%, 67.1%, 56.9%, 61.1%), PCI (53.7%, 43.8%, 38.4%, 37.6%) and MCS (47.9%, 38.3%, 33.3%, 34.2%), respectively (all p &lt, 0.001). AKI and acute hemodialysis use increased with increase in CKD stage (no CKD&ndash, 38.5%, 2.6%, CKD-III&ndash, 79.1%, 6.5%, CKD-IV&ndash, 84.3%, 12.3%, p &lt, 0.001). ESRD (adjusted odds ratio [OR] 1.25 [95% confidence interval {CI} 1.21&ndash, 1.31], 0.001), but not CKD-III (OR 0.72 [95% CI 0.69&ndash, 0.75), 0.001) or CKD-IV (OR 0.82 [95 CI 0.77&ndash, 0.87] was predictive of in-hospital mortality. Conclusions: CKD/ESRD is associated with lower use of evidence-based therapies. ESRD was an independent predictor of higher in-hospital mortality in AMI-CS.

Background: There are limited data on how sex influences the outcomes of acute myocardial infarction-cardiogenic shock (AMI-CS) in young adults. Methods: A retrospective cohort of AMI-CS admissions aged 18 to 55 years, during 2000 to 2017, was identified using the National Inpatient Sample. Use of coronary angiography, percutaneous coronary intervention, mechanical circulatory support and noncardiac interventions was identified. Outcomes of interest included in-hospital mortality, use of cardiac interventions, hospitalization costs, and length of stay. Results: A total 90 648 AMI-CS admissions ≤55 years of age were included, of which 26% were women. Higher rates of CS were noted in men (2.2% in 2000 to 4.8% in 2017) compared with women (2.6% in 2000 to 4.0% in 2017; P P P P P Conclusions: In young AMI-CS admissions, women are treated less aggressively and experience higher in-hospital mortality than men.

BACKGROUND Randomized trials have confirmed that intravascular ultrasound (IVUS) guidance for percutaneous coronary interventions (PCI) improves long-term clinical outcomes. However, data on real-world utilization of IVUS in ST-elevation myocardial infarction (STEMI) and the impact on short to mid-term outcomes are scarce. We sought to evaluate the utilization and the readmission rates for IVUS-guided PCI in the setting of STEMI. METHODS Hospitalizations with a primary diagnosis of STEMI undergoing PCI were included from the Nationwide Readmissions Database (NRD) during 2012-2017. RESULTS Among 809,601 hospitalizations with STEMI undergoing PCI, 33,644 (4.2%) underwent IVUS-guided PCI. IVUS use increased from 4.2% in 2012 to 5.6% in 2017 (p

Aims Anticoagulants are the mainstay treatment for stroke prevention in patients with non-valvular atrial fibrillation (NVAF), and the CHA2DS2-VASc score is widely used to guide anticoagulation therapy in this cohort. However, utility of CHA2DS2-VASc in NVAF patients is debated, primarily because it is a vascular scoring system, which does not incorporate atrial fibrillation related parameters. Therefore, we conducted a meta-analysis to estimate the discrimination ability of CHA2DS2-VASc in predicting ischaemic stroke overall, and in subgroups of patients with or without NVAF. Methods and results PubMed and Embase databases were searched till June 2020 for published articles that assessed the discrimination ability of CHA2DS2-VASc, as measured by C-statistics, during mid-term (2–5 years) and long-term (>5 years) follow-up. Summary estimates were reported as random effects C-statistics with 95% confidence intervals (CIs). Seventeen articles were included in the analysis. Nine studies (n = 453 747 patients) reported the discrimination ability of CHA2DS2-VASc in NVAF patients, and 10 studies (n = 138 262 patients) in patients without NVAF. During mid-term follow-up, CHA2DS2-VASc predicted stroke with modest discrimination in the overall cohort [0.67 (0.65–0.69)], with similar discrimination ability in patients with NVAF [0.65 (0.63–0.68)] and in those without NVAF [0.69 (0.68–0.71)] (P-interaction = 0.08). Similarly, at long-term follow-up, CHA2DS2-VASc had modest discrimination [0.66 (0.63–0.69)], which was consistent among patients with NVAF [0.63 (0.54–0.71)] and those without NVAF [0.67 (0.64–0.70)] (P-interaction = 0.39). Conclusion This meta-analysis suggests that the discrimination power of the CHA2DS2-VASc score in predicting ischaemic stroke is modest, and is similar in the presence or absence of NVAF. More accurate stroke prediction models are thus needed for the NVAF population.

The influence of environmental factors on the structure and composition of plant communities in the Caatinga is complex and poorly explored. Spatial variation of biodiversity in Caatinga is poorly know and strictly attributed to climatic conditions. We investigated the influence of slags on floristic composition and structure of a shrubby-arboreal community in one of the driest region in Brazil. Chemical and physical analyses of soils were performed in samples of seven plots from savannic formations and from forest formations. Vegetation was characterized floristically and structurally in all plots. Habitats were structurally distinct, and diversity differed between peripheral and non-peripheral areas of slags. Nine of the ninety-seven species identified are reported to (sub)humid biomes. Soils are dominantly shallow, eutrophic and sandy loam. However, soils in the periphery of slags are more developed once paludization, melanization and bioturbation were verified. Our results suggest that soil fertility did not influence vegetable cover in Caatinga. The cover of plant species considered exclusive of (sub)humid biomes in Brazil extends beyond highlands in the semiarid, associated with high soil organic carbon content and water retention capacity of more developed soils than the typical of the Caatinga.

There are limited data on arrhythmias in acute myocardial infarction with cardiogenic shock (AMI-CS). Using a 17-year AMI-CS population from the National Inpatient Sample, we identified common arrhythmias - atrial fibrillation (AF), atrial flutter, supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, and atrioventricular blocks (AVB). Admissions with concomitant cardiac surgery were excluded. Outcomes of interest included temporal trends, predictors, in-hospital mortality, and resource utilization in cohorts with and without arrhythmias. Of the 420,319 admissions with AMI-CS during 2000 to 2016, arrhythmias were noted in 213,718 (51%). AF (45%), ventricular tachycardia (35%) and ventricular fibrillation (30%) were the most common arrhythmias. Compared with those without, the cohort w`ith arrhythmias was more often male, of white race, with ST-segment elevation AMI-CS presentation, and had higher rates of cardiac arrest and acute organ failure (all p0.001). Temporal trends of prevalence revealed a stable trend of atrial and ventricular arrhythmias and declining trend in AVB. The cohort with arrhythmias had higher unadjusted (42% vs 41%; odds ratio [OR] 1.03 [95% confidence interval 1.02 to 1.05]; p0.001), but not adjusted (OR 1.01 [95% CI 0.99 to 1.03]; p = 0.22) in-hospital mortality compared with those without. The cohort with arrhythmias had longer hospital stay (9 ± 10 vs 7 ± 9 days; p0.001) and higher hospitalization costs ($124,000 ± 146,000 vs $91,000 ± 115,000; p0.001). In the cohort with arrhythmias, older age, female sex, non-white race, higher co-morbidity, presence of acute organ failure, and cardiac arrest, predicted higher in-hospital mortality. In conclusion, cardiac arrhythmias in AMI-CS are a marker of higher illness severity and are associated with greater resource utilization.

Objectives To examine national-level differences in management strategies and outcomes in patients with autoimmune rheumatic disease (AIRD) with acute myocardial infarction (AMI) from 2004 through 2014. Methods All AMI hospitalizations were analyzed from the National Inpatient Sample, stratified according to AIRD diagnosis into 4 groups: no AIRD, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and systemic sclerosis (SSC). The associations between AIRD subtypes and (1) receipt of coronary angiography and percutaneous coronary intervention (PCI) and (2) clinical outcomes were examined compared with patients without AIRD. Results Of 6,747,797 AMI hospitalizations, 109,983 patients (1.6%) had an AIRD diagnosis (RA: 1.3%, SLE: 0.3%, and SSC: 0.1%). The prevalence of RA rose from 1.0% (2004) to 1.5% (2014), and SLE and SSC remained stable. Patients with SLE were less likely to receive invasive management (odds ratio [OR] [95% CI]: coronary angiography—0.87; 0.84 to 0.91; PCI—0.93; 0.90 to 0.96), whereas no statistically significant differences were found in the RA and SSC groups. Subsequently, the ORs (95% CIs) of mortality (1.15; 1.07 to 1.23) and bleeding (1.24; 1.16 to 1.31) were increased in patients with SLE; SSC was associated with increased ORs (95% CIs) of major adverse cardiovascular and cerebrovascular events (1.52; 1.38 to 1.68) and mortality (1.81; 1.62 to 2.02) but not bleeding or stroke; the RA group was at no increased risk for any complication. Conclusion In a nationwide cohort of AMI hospitalizations we found lower use of invasive management in patients with SLE and worse outcomes after AMI in patients with SLE and SSC compared with those without AIRD.

Multiple imaging modalities play an important role in the identification and quantification of right-to-left shunts, which determine the management pathway of patients with patent foramen ovale (PFO). The most commonly used screening modalities are transthoracic echocardiography and transcranial Doppler bubble studies. Following the initial screening study, transesophageal echocardiography, intracardiac echocardiography, or angiography and catheter probing are used for further confirmation of the presence of an intracardiac shunt and quantification of its severity. In rare occasions, other imaging modalities such as computed tomography or magnetic resonance imaging could be used. This chapter discusses the techniques, advantages, and limitations of each modality for the detection of an intracardiac right-to-left shunt due to a PFO, with reference to the available evidence supporting each test.

BackgroundThere are limited data on the complications with a percutaneous left ventricular assist device (pLVAD) vs. intra-aortic balloon pump (IABP) in acute myocardial infarction-cardiogenic shock (AMI-CS).ObjectiveTo assess the trends, rates and predictors of complications.MethodsUsing a 17-year AMI-CS population from the National Inpatient Sample, AMI-CS admissions receiving pLVAD and IABP support were evaluated for vascular, lower limb amputation, hematologic, neurologic and acute kidney injury (AKI) complications. In-hospital mortality, hospitalization costs and length of stay in pLVAD and IABP cohorts with complications was studied.ResultsOf 168,645 admissions, 7,855 (4.7%) receiving pLVAD support. The pLVAD cohort had higher comorbidity, cardiac arrest (36.1% vs. 29.7%) and non-cardiac organ failure (74.7% vs. 56.9%) rates. Complications were higher in pLVAD compared to IABP cohort-overall 69.0% vs. 54.7%; vascular 3.8% vs. 2.1%; lower limb amputation 0.3% vs. 0.3%; hematologic 36.0% vs. 27.7%; neurologic 4.9% vs. 3.5% and AKI 55.4% vs. 39.1% (all pConclusionsAMI-CS admissions receiving pLVAD had higher rates of complications compared to the IABP, with worse in-hospital outcomes in the cohort with complications.

There are limited data on the outcomes of acute myocardial infarction with cardiogenic shock (AMI-CS) in patients with prior coronary artery bypass grafting (CABG).A retrospective cohort of AMI-CS admissions during 2000-2016 from the National Inpatient Sample was created and prior CABG status was identified. Outcomes of interest included in-hospital mortality and resource utilization in the two cohorts. Temporal trends of prevalence, in-hospital mortality, and cardiac procedures were evaluated.In 513,288 AMI-CS admissions, prior CABG was performed in 22,832 (4.4%). Adjusted temporal trends showed a 2-fold increase in CS in both cohorts. There was a temporal increase in coronary angiography and percutaneous coronary intervention (PCI) across both cohorts. The cohort with prior CABG was on average older, of male sex, of white race, and with higher comorbidity. The cohort with prior CABG received coronary angiography (50% vs. 75%), PCI (32% vs. 49%), right heart catheterization/pulmonary artery catheterization (15% vs. 20%), mechanical circulatory support (26% vs. 46%) less frequently compared to those without (all p 0.001). The cohort with CABG had higher in-hospital mortality (53% vs. 37%; adjusted odds ratio 1.41 [95% confidence interval 1.36-1.46]), greater use of do not resuscitate status (13% vs. 6%), shorter lengths of hospital stay (7 ± 8 vs. 10 ± 12 days), lower hospitalization costs ($92,346 ± 139,565 vs. 138,508 ± 172,895) and fewer discharges to home (39% vs. 43%) (all p 0.001).In AMI-CS, admission with prior CABG was older and had lower use of cardiac procedures and higher in-hospital mortality compared to those without prior CABG.

The heart is a destination for metastases of various types of primary tumors, with lung, breast, melanoma, and mesothelioma being the most common types. Recurrent isolated cardiac metastasis presenting as a cavitary mass is rare. We present a case of recurrent isolated cavitary metastatic mass to the right atrium in a patient with the history of breast cancer who presented with new-onset atrial fibrillation. The patient successfully received radiation therapy with the resolution of the mass confirmed on repeat echocardiography.

Purpose of reviewIn recent years, there have been advances in the prevention, management, and control of peripheral vascular disease (PVD). There is a trend towards aggressive risk factor modification, noninvasive screening, and endovascular revascularization with surgical approaches reserved only for select cases. This article reviews the different management strategies ranging from pharmacotherapy, revascularization, and rehabilitation with an emphasis on the response of women to these therapies.Recent findingsOverall, the representation of women in the majority of the published data in this arena remains poor. Studies examining medical therapy and endovascular and surgical revascularization were not designed to address sex disparities. Nevertheless, we dissect these therapies and their relevant randomized trials.SummaryThe paucity of data investigating the response of women to the different management options makes it difficult to make any evidence-based recommendations. This not only applies to the type of intervention, but also the appropriate timing and risks entailed.

OBJECTIVE With the increasing number of aneurysms treated with endovascular coiling, more recurrences are being encountered. The aim of this study was to evaluate the efficacy and safety of microsurgical clipping in the treatment of recurrent, previously coiled cerebral aneurysms and to identify risk factors that can affect the outcomes of this procedure. METHODS One hundred eleven patients with recurrent aneurysms whose lesions were managed by surgical clipping between January 2002 and October 2014 were identified. The rates of aneurysm occlusion, retreatment, complications, and good clinical outcome were retrospectively determined. Univariate and multivariate logistic regressions were performed to identify factors associated with these outcomes. RESULTS The mean patient age was 50.5 years, the mean aneurysm size was 7 mm, and 97.3% of aneurysms were located in the anterior circulation. The mean follow-up was 22 months. Complete aneurysm occlusion, as assessed by intraoperative angiography, was achieved in 97.3% of aneurysms (108 of 111 patients). Among patients, 1.8% (2 of 111 patients) had a recurrence after clipping. Retreatment was required in 4.5% of patients (5 of 111) after clipping. Major complications were observed in 8% of patients and mortality in 2.7%. Ninety percent of patients had a good clinical outcome. Aneurysm size (OR 1.4, 95% CI 1.08–1.7; p = 0.009) and location in the posterior circulation were significantly associated with higher complications. All 3 patients who had coil extraction experienced a postoperative stroke. Aneurysm size (OR 1.2, 95% CI 1.02–1.45; p = 0.025) and higher number of interventions prior to clipping (OR 5.3, 95% CI 1.3–21.4; p = 0.019) were significant predictors of poor outcome. An aneurysm size > 7 mm was a significant predictor of incomplete obliteration and retreatment (p = 0.018). CONCLUSIONS Surgical clipping is safe and effective in treating recurrent, previously coiled cerebral aneurysms. Aneurysm size, location, and number of previous coiling procedures are important factors to consider in the management of these aneurysms.

Radiation recall dermatitis (RRD) is a rare and poorly understood phenomenon, constituting an inflammatory skin reaction to a previously irradiated area of skin following the administration of certain agents, usually chemotherapy. Our patient developed RRD 66 years after receiving radiation therapy; to the best of our knowledge, this is the longest reported period in the literature. The mainstay of therapy is to withhold the agent that elicited the adverse reaction, followed by symptomatic management. Subjecting patients to further chemotherapy can provoke another episode of RRD. Therefore, clinical judgment in this regard is usually recommended.

The COVID-19 pandemic has affected millions of patients across the globe. Multiple studies, national and international governmental data have shown important sex and gender differences in the incidence and outcomes of patients with COVID-19. These differences are not only attributed to the differences in age and comorbid conditions but likely a combination of factors, including hormonal differences, immune response, inflammatory markers and behavioral attitudes, among others. In this review, we discuss the studies addressing sex- and gender-specific differences in COVID-19 infections with discussion on the potential pathophysiological mechanisms of these differences.

Vasospasm is a significant cause of morbidity and mortality among those with aneurysmal subarachnoid hemorrhage (aSAH). Treating increased intracranial pressure by drainage of cerebral spinal fluid through an external ventriculostomy is routine practice. The objective of this study is to evaluate the trends of CSF output in patients who experience vasospasm.Electronic medical charts were reviewed to identify two groups of patients with aSAH, 75 consecutive patients who developed vasospasm and 75 matched patients who did not develop vasospasm. CSF output was recorded within 3 days before and 3 days after the occurrence of vasospasm. CSF output was recorded for the same days after SAH in matched patients with no vasospasm.Total CSF output was lower in patients with vasospasm as compared to patients without vasospasm matched for the same day (p0.001). In patients with vasospasm, CSF output recordings were significantly higher prior to the occurrence of vasospasm (438ml/day) than the period following vasospasm (325.7ml/day), with a consistent decrease in CSF drainage from day 3 before vasospasm to day 3 after vasospasm (p=0.012). Decreasing CSF output was significantly associated with the occurrence of vasospasm (p=0.017). Youden indices demonstrated that daily CSF drainage160ml was significantly associated with the occurrence of vasospasm. The sensitivity of this test was 64.79% and the specificity was 55.38%.In addition to clinical exam findings, observation of a CSF output decline to less than 160ml/day may be used as additional support for the diagnosis of vasospasm.