Introduction: Coronary heart disease (CHD) is the leading cause of cardiovascular mortality worldwide, with the greatest burden concentrated in low- and middle-income countries (LMICs). Patient readiness-encompassing knowledge, self-efficacy, and self-care behaviour-is a critical determinant of post-discharge outcomes. Digital education interventions offer an innovative, resource-efficient approach to improving CHD patient readiness in LMICs; however, the available evidence has not been systematically mapped. Methods: This scoping review followed the Arksey and O'Malley framework and was reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR). A systematic search was conducted across four databases-PubMed, ScienceDirect, Wiley Online Library, and the Cochrane Library-for publications from 2019 to 2026. The most recent searches were run on 1 March 2026 and supplemented by manual screening of reference lists. Results: Eleven studies were included, comprising 7 full RCTs (63.6%), 1 pilot RCT (9.1%), 2 RCT protocols (18.2%), and 1 feasibility study (9.1%). Geographic distribution included China (n = 4; 36.4%), Iran (n = 4; 36.4%), Colombia (n = 1; 9.1%), Tunisia (n = 1; 9.1%), and Brazil (n = 1; 9.1%). The most frequently used primary delivery platforms were mobile applications/smartphones (n = 3; 27.3%), WeChat (n = 2; 18.2%), WhatsApp (n = 2; 18.2%), Web-based/online platforms (n = 2; 18.2%), augmented reality (n = 1; 9.1%), and digital multimedia (n = 1; 9.1%). The most commonly measured outcomes were self-efficacy (n = 4; 36.4%), quality of life (n = 3; 27.3%), disease knowledge/illness perception (n = 3; 27.3%), medication adherence/self-management (n = 3; 27.3%), and clinical events (n = 1; 9.1%). Discharge readiness was not measured as a primary outcome in any included study. Conclusion: Digital education interventions show promising potential for improving the components of CHD patient readiness in LMICs; however, the evidence remains concentrated in China and Iran. Research specifically targeting discharge readiness with validated instruments is urgently needed across diverse LMIC settings, particularly in Southeast Asia, sub-Saharan Africa, and Latin America.
Background: Atrial fibrillation is the most common cardiac arrhythmia, which has effects that goes beyond the heart, often affecting mental health. Over the years, increasing evidence has highlighted a bidirectional connection between anxiety and atrial fibrillation. However, the connection between the two in clinical practice is vague. Objective: This systematic review aims to investigate the relationship between anxiety and atrial fibrillation, including how anxiety might contribute to the onset and relapse of atrial fibrillation, how it may impact the treatment outcomes and its effects on the patient’s overall quality of life. Methods: We conducted an extensive search of PubMed, Scopus, Embase, and Cochrane to systematically identify studies between 2020 and 2025. Adult patients with atrial fibrillation diagnosis who were assessed for anxiety were included using validated scales. A total of 84 articles met the inclusion criteria, with data extracted on anxiety measures, features of atrial fibrillation, clinical impact, and treatment effects. Results: Among the reviewed studies, anxiety was both prevalent in AF patients and significantly associated with poorer clinical outcomes across the majority of included studies, though the strength and nature of associations varied across study designs and populations. Patients with higher levels of anxiety had a higher probability of recurrent atrial fibrillation, increased symptom burden, and lower health-related quality of life. Anxiety also influenced treatment outcomes and adherence, particularly regarding anticoagulation and ablation therapy. Notably, several interventions including catheter ablation and structured patient education were associated with reductions in anxiety and improvements in outcomes. Importantly, one Mendelian randomisation study found no causal relationship between anxiety and AF, while depression and panic disorder showed causal associations, underscoring the need for cautious interpretation of observational findings. Conclusion: Anxiety and atrial fibrillation appear to share a complex, predominantly bidirectional association. While most observational studies support a link between anxiety and worse AF-related outcomes, evidence from Mendelian randomisation does not confirm a causal role for anxiety in AF onset, suggesting that residual confounding may partly account for observational associations. Addressing mental health in AF care is nonetheless clinically important. Incorporating psychological assessment and support into AF management may reduce symptom burden and improve treatment adherence and quality of life. Further research, particularly longitudinal interventional studies using standardised instruments, is required to guide more comprehensive, patient-centred care.
We report the case of a 33-year-old male mountaineer, presenting with chest pain, severe headache, dyspnea, and lower extremity edema, on his first expedition to Paraw mountain located in Kermanshah Province. His condition involved a complex thrombotic presentation, including both venous and arterial events, such as a myocardial infarction due to stenosis of the left main coronary artery, which we believe to be a coincidental pathology. His neurological symptom includes headache, vomiting, and slight drowsiness associated with chest pain, which were evaluated alongside confirmatory testing for protein C-S deficiency. Physical examination revealed right lower extremity edema, respiratory distress (RR=34), and mid-drowsiness. Chest X ray showed lung congestion. A history of recurrent thrombophlebitis, along with the current myocardial infarction, raised suspicion of a thrombophilic state. The final diagnosis of these complications was confirmed to have protein C-S deficiency based on laboratory tests performed during the acute phase. However, the hereditary nature of this deficiency remains unconfirmed as no genetic testing or family screening was undertaken. The patient underwent coronary artery bypass grafting of left anterior descending artery (LAD) and LCX associated with anticoagulant therapy, and his neurologic sign and symptom and lower extremity deep vein thrombosis recovered uneventfully.
Background: Transthyretin amyloidosis (ATTR) is a progressive disease that causes a restrictive cardiomyopathy. Vutrisiran, a subcutaneous RNA interference (RNAi) therapy, is an approved treatment. This systematic review and meta-analysis evaluates its efficacy and safety with respect to transthyretin (TTR) reduction, functional capacity, quality of life, mortality, and adverse events. Methods: We identified 1,032 records, of which three randomized controlled trials-HELIOS-A, HELIOS-B, and a Phase 1 study-comprising 976 participants (508 vutrisiran; 468 comparator) met the inclusion criteria. Comparator participants received placebo, patisiran (an active reference comparator in HELIOS-A), or external placebo from the APOLLO trial. Outcomes assessed were TTR reduction, functional capacity, quality of life, mortality, and adverse events, pooled using random-effects models reporting mean differences and risk ratios. Results: Vutrisiran achieved a rapid, durable TTR reduction of up to 97% in healthy volunteers at the highest dose, and a sustained steady-state reduction in the HELIOS-A and HELIOS-B trials. QoL outcomes showed a protective effect of vutrisiran, with slowed deterioration in the intervention group. Functional outcomes (10-MWT, 6-MWT) suggested slower decline in mobility and functional capacity. Mortality showed a non-significant reduction (RR 0.51; p = 0.29; I2 = 62%), with most deaths considered unrelated to treatment. The safety analysis showed fewer falls (RR 0.62; p = 0.001; I2 = 0%) but no significant difference in overall adverse events (AEs) (RR 1.01; p = 0.76) or serious AEs (RR 0.82; p = 0.23). A sensitivity analysis supported the adverse-event findings. Conclusions: Vutrisiran consistently suppressed TTR and showed signals of benefit in quality of life, function, and mortality, though most of these outcomes did not reach statistical significance. It reduced fall risk without increasing adverse events, indicating a favourable safety profile. Larger, long-term RCTs are needed to confirm survival and functional benefits.
Oxidative stress and adipokine imbalance are important contributors to the pathogenesis of diabetic cardiovascular disease. The nuclear factor erythroid 2-related factor 2 (Nrf2) regulates antioxidant defense, while adipokines link metabolism and inflammation. Incretin-based therapies and PPARγ agonists may join on these pathways to provide cardiovascular protection beyond glycemic control. This review aims to investigate the current evidence on how incretin-based agents and PPARγ agonists regulate the adipokine-Nrf2 axis and their impact on cardiovascular outcomes in diabetes. A literature search was performed using PubMed, Google Scholar and Scopus to include reviews, experimental, clinical, and translational studies published in English until November 2025. Evidence indicates that incretin-based agents and PPARγ agonists synergistically activate Nrf2 and inhibit NF-kB signaling, leading to improved oxidative status and favorable adipokine levels. Increased adiponectin and omentin, and suppressed resistin, leptin and TNF-α contribute to reduced inflammation and enhanced vascular and myocardial protection. Collectively, combined activation of incretin and PPARγ pathways modulates the adipokine-Nrf2 axis, offering joined antioxidant and anti-inflammatory benefits that may reduce diabetic cardiovascular risk.
BACKGROUND:Atrial fibrillation (AF) is extremely common in cardiac amyloidosis (CA) due to amyloid infiltration and atrial electrical remodeling. We aim to compare ablation outcomes versus no-ablation in patients taking anti-arrhythmic drugs (AAD) in CA-associated AF. METHODS:Using TriNetX database (2019-2025), 5,562 patients with CA and AF were identified and divided into two groups: catheter ablation plus AADs (n = 893) versus medical therapy alone (n = 4,669). Baseline characteristics were adjusted and 1:1 propensity score matching was performed to account for baseline differences. Primary composite outcome included all-cause mortality, ischemic strokes, bleeding and subsequent myocardial infarction. RESULTS:870 patients were included in each cohort. At 12-month follow-up, catheter ablation was associated with a significantly lower risk of the composite outcome (8.3% vs 13.2%; HR 0.591, 95% CI [0.418-0.834], p = 0.002), and reduced all-cause mortality. There were no significant differences in all-cause hospitalization, emergency department visits, new-onset heart failure, atrioventricular block, or cardiac arrest. Repeat ablation or cardioversion, and subsequent pacemaker or ICD implantation were more frequent in the ablation group. CONCLUSION:Catheter ablation was associated with improved short-term outcomes despite higher arrhythmia recurrence. Ablation may be considered in carefully selected patients, particularly those with earlier-stage disease or significant symptoms.
Background: Hypertension is a major contributor to cardiovascular morbidity and mortality. While lifestyle modification is central to prevention, evidence on short-term blood pressure (BP) dynamics in relation to behavioural factors remains limited. Objective: To evaluate the influence of diet, physical activity, and psychological stress on systolic blood pressure (SBP) trajectories and to develop a regression-based model for short-term BP prediction. Methods: In this 12-week prospective cohort study, 75 adults attending a preventive cardiology clinic were followed, with BP measured at baseline, 6 weeks, and 12 weeks using validated oscillometric methods. Lifestyle and behavioural factors were assessed using the Food Frequency Questionnaire (sodium intake and DASH adherence), IPAQ-SF (physical activity), and PSS-10 (stress). Linear mixed-effects regression identified predictors of SBP change, and Elastic Net regression predicted 12-week SBP. Results: Sixty-seven participants (mean age 44.6 ± 10.8 years; 52.2% male) completed follow-up. Mean SBP declined from 134.2 ± 12.6 to 131.4 ± 11.5 mmHg. Higher physical activity and DASH adherence were associated with SBP reduction, whereas higher sodium intake and stress predicted SBP elevation (all p < 0.05). The Elastic Net model demonstrated strong predictive performance (R 2 = 0.78; RMSE = 5.9 mmHg). Physical activity had a stronger effect in participants <45 years, and stress amplified sodium-related SBP increases. Conclusions: Short-term SBP trajectories are strongly influenced by modifiable behavioural factors. Predictive models based on lifestyle data may support early risk stratification and personalized hypertension prevention.
Cor triatriatum dexter is a rare congenital cardiac anomaly characterized by persistence of a membranous structure that divides the right atrium into two chambers. Although often asymptomatic, cor triatriatum dexter may present in adulthood with nonspecific symptoms and atrial arrhythmias, including atrial fibrillation and atrial flutter. We present a case series of four adult patients in whom cor triatriatum dexter was incidentally diagnosed during cardiac evaluation for diverse clinical presentations. Patients ranged in age from 51 to 75 years and presented with new-onset seizures, ischemic stroke evaluation, heart failure exacerbation, and recurrent atrial arrhythmias. In all cases, diagnosis was established using echocardiographic imaging, with transesophageal echocardiography providing definitive visualization when transthoracic studies were nondiagnostic. This series highlights the diagnostic challenges of cor triatriatum dexter in adults and suggests that the condition may be underrecognized. Furthermore, altered right atrial anatomy may be associated withatrial arrhythmia maintenance through structural and conduction alterations of the right atrium.
Introduction: Infective endocarditis (IE) remains a significant cause of mortality, and neurological complications-particularly stroke-are associated with worsened outcomes. However, temporal trends in mortality when both conditions co-occur remain underexplored. Aims: To analyze mortality trends in infective endocarditis with stroke as a contributing cause of death using the CDC Multiple Cause of Death (MCD) database from 1999 to 2020. Methods: A retrospective observational study was conducted using the CDC MCD database to assess mortality trends among individuals aged ≥25 years in the United States from 1999 to 2020. Deaths in which infective endocarditis (ICD-10: I33.0) was listed as the underlying cause and cerebral infarction (ICD-10: I63) as a contributing cause were analyzed. Data were stratified by age, sex, race, geographic region, and place of death. Age-adjusted mortality rates (AAMR) and annual percentage change (APC) were calculated. Results: Between 1999 and 2020, 1,761 deaths met the inclusion criteria. The AAMR for IE with stroke demonstrated an initial decline followed by a subsequent increase (APC: 8.30%; 95% CI: 0.74-16.42). Mortality was highest among males, White adults, and those dying in metropolitan areas and medical facilities. Disparities were observed across demographic and geographic subgroups. Conclusions:IE-associated stroke mortality shows a concerning upward trend, with significant disparities by sex, race, and location. These findings underscore the need for targeted prevention strategies and equitable healthcare access for high-risk populations.
We report a rare case of fulminant myocarditis caused by Rickettsia conorii infection in a 31-year-old previously healthy male from rural Greece. The patient presented with acute chest pain, fever, and an insect bite eschar. Initial electrocardiography (ECG) demonstrated inferior ST-segment elevation, and coronary angiography excluded obstructive coronary artery disease. Within 24 h, the patient deteriorated to hemodynamic collapse, with left ventricular ejection fraction (LVEF) declining to 20-25%. Management included doxycycline, empirical broad-spectrum antibiotics, intravenous corticosteroids, and aggressive diuresis. Serological confirmation of R. conorii infection (IgM titer 1:64) directed targeted antibiotic monotherapy. Cardiac magnetic resonance (CMR) imaging performed two days post-discharge confirmed acute myocarditis per the 2018 Updated Lake Louise Criteria, with extensive late gadolinium enhancement (LGE) involving 28% of LV mass. LVEF recovered to 56% within weeks. This case highlights the potential for R. conorii to precipitate fulminant myocarditis even in immunocompetent young patients, underscoring the importance of clinical suspicion in endemic regions.
Objective:To evaluate the prognostic value of mean platelet volume (MPV) for cardiovascular risk stratification in settings with limited resources. Methods: We conducted a comprehensive systematic review in accordance with the PRISMA 2020 guidelines (PROSPERO registration number: CRD420251156089). From January 2019 to December 2024, we searched five databases (PubMed, Scopus, Web of Science, SciELO and LILACS) for observational studies linking MPV to cardiovascular outcomes. The methodological quality of the studies was assessed using the STROBE criteria, and the certainty of the evidence was assessed using the GRADE approach. Results: Thirteen studies involving 3,085 participants were included. Of these, 12 (92.3%) reported statistically significant associations between elevated mean platelet volume (MPV) and an increased risk of acute myocardial infarction, stroke, and thromboembolism. MPV values in patients experiencing acute events (8.4-10.7 fL) were consistently higher than in the control group. Derived indices, particularly the MPV-to-lymphocyte ratio, demonstrated superior predictive utility compared to MPV alone. However, critical limitations included substantial heterogeneity in the cut-off point (7.45-12 fL), pre-analytical variability and the complete absence of Latin American populations. The overall certainty of the evidence was classified as VERY LOW. Conclusions: Although there is a consistent predictive signal across worldwide cohorts, its current application in clinical practice is prohibited by the VERY LOW certainty of evidence, which is caused by high pre-analytical heterogeneity and a total lack of Latin American data. These results show that MPV should be prioritized for standardized validation studies rather than being used right away in clinical settings.
Background: The coronary no-reflow phenomenon remains a major obstacle to optimal outcomes after primary percutaneous coronary intervention. Its mechanisms are multifactorial and not fully clarified, with genetic components increasingly recognized as important contributors. This study aims to identify key genes, characterize their biological functions, and explore in silico-based therapeutic options targeting genes implicated in this condition. Methods:Genes related to the coronary no-reflow phenomenon were retrieved from the GeneCards database. A protein-protein interaction network was constructed using STRING, and top-ranked genes were identified via the maximal cliques centrality and maximum neighborhood component algorithms in Cytoscape. Gene ontology enrichment analysis was performed using WebGestaltR. Three-dimensional protein structures were generated with SWISS-Model and validated using ERRAT and PROCHECK. Results: Seventy-nine genes with significant relevance were identified. Network analysis yielded 55 nodes, from which eight hub genes were identified: IL6, TNF, ICAM1, MPO, ALB, MMP9, CXCL8, and CRP. Enrichment analysis highlighted blood vessel diameter maintenance and coagulation as key biological processes, with antioxidant activity as the leading molecular function. MPO, CRP, CXCL8, and ALB demonstrated favorable structural characteristics, supporting their prioritization. Conclusion: MPO, CRP, CXCL8, and ALB are central genes in the coronary no-reflow phenomenon and warrant further experimental validation for therapeutic development.
Background: Cardiopulmonary bypass (CPB) is integral to open-heart surgery but carries significant risks of systemic inflammatory response and organ-specific complications. In low-resource settings, limited local data can impede targeted prevention. This study assessed the frequency and predictors of CPB-related complications at the Jakaya Kikwete Cardiac Institute, Tanzania. Methods: A retrospective review examined 195 pediatric and adult patients who underwent open-heart surgery in 2020. Data from perfusion records and ICU charts were analyzed using descriptive statistics and univariate logistic regression. Results: Of the cohort, 55.4% were male and 52.3% were under 16 years. Valvular heart disease was the most common diagnosis (42.1%). At least one major complication occurred in 31.3% of patients, with cardiovascular (10.8%) and bleeding (9.2%) events predominating. Prolonged ICU stay affected 52.8% of cases and in-hospital mortality was 4.1%. Key predictors of complications included younger age, diagnosis type, procedure type, CPB duration, and cross-clamp time. CPB time exceeding 120 min significantly increased the likelihood of prolonged ICU stay. Conclusions: CPB-related complications represent a substantial burden in this setting. Minimising CPB and cross-clamp durations may improve outcomes. Prospective locally driven research is needed to refine management strategies.
Introduction: LVOT obstruction after surgical bioprosthetic MVP placement is uncommon and the influence of the MVP strut width has seldom been examined. Case presentation: A 74-year-old female presented with palpitations, chest pain, and shortness of breath. She had MVR with 31-mm bioprosthetic valve 2 years prior. TEE confirmed LVOT obstruction secondary to a MVP strut, causing a peak gradient of 55 mmHg. The redo operation was complicated by iatrogenic Type A aortic dissection. The patient was immediately cooled for DHCA with RCP and ascending aortic replacement was performed. MVR was then performed with a prosthesis with narrower strut width. Recovery after surgery was uneventful and post-bypass TEE confirmed absence of LVOT obstruction (gradient of 4 mmHg). Discussion: This case is of interest for two reasons. Primarily, the overall profile of the valve, including the width of the struts may play a significant role in the development of LVOT obstruction after MVR. Additionally, the patient had an ITAAD requiring prompt and thoughtful management. Conclusions: This case underscores the importance of evaluating MVP profile in relation to patient anatomy. Furthermore, intraoperative Type A aortic dissection is a rare but lethal phenomenon requiring swift decision-making and technical ability, and both are important considerations for trainees.
Infective endocarditis is a life-threatening condition with high morbidity and mortality, particularly in low- and middle-income countries. Amongst causes, enterococcal IE accounts for a substantial proportion of cases, with E. faecalis as the predominant species (90%). We report a 59-year-old man with arterial hypertension and type 2 diabetes mellitus who presented with asthenia, low-grade fever, and osteoarticular pain. Laboratory evaluation revealed severe anemia, leukocytosis, and thrombocytopenia. A new holosystolic mitral murmur prompted echocardiography, which identified vegetation, aneurysm, and perforation of the anterior mitral leaflet with severe regurgitation. Blood cultures confirmed E. faecalis, and appropriate antibiotic therapy was initiated. Despite rapid intervention and intensive care, the patient developed acute heart failure and died within 23 days of admission. This case illustrates the fulminant potential of E. faecalis IE complicated by complex mitral valve destruction, and underscores the importance of early recognition, real-time 3D echocardiography, and prompt multidisciplinary intervention in high-risk presentations.
Late saphenous vein graft (SVG) pseudoaneurysm is a rare but life-threatening complication of coronary artery bypass graft surgery. An 80-year-old man presented with dyspnea and chest pain two decades after CABG (LIMA-LAD, SVG-RCA). Coronary angiography revealed SVG occlusion with contrast extravasation and mass formation adjacent to the right heart chambers. CT angiography confirmed a 39 mm mediastinal pseudoaneurysm from proximal SVG rupture, compressing the right heart chambers and lung, with consequent left ventricular dysfunction (EF 45%), elevated pulmonary pressures, and orthostatic hypotension. Following Heart Team discussion, the patient underwent successful pseudoaneurysm resection with right coronary artery revascularization using a left radial artery graft. Symptoms and cardiac function improved at one-month follow-up. This case highlights the importance of clinical suspicion for SVG pseudoaneurysm in patients with prior CABG, and the central role of CT angiography and multidisciplinary decision-making in management.
To the Editor, We read with considerable interest the recent meta-analysis by Al Hennawi et al., which synthesizes data from more than 240,000 individuals to evaluate the prognostic implications of coronary artery calcium (CAC) and its association with preventive therapies. The authors should be commended for addressing an important and timely topic. However, several key limitations warrant further discussion, particularly regarding the interpretation and global extrapolation of the findings.
Introduction: Hypertension contributes to cardiovascular mortality, yet its role as an underlying cause with intracerebral hemorrhage (ICH) as a contributing cause is underexplored. Understanding demographic and geographic patterns can guide prevention. Aim: To analyze mortality trends and demographic disparities in deaths with hypertension as the underlying cause and ICH as a contributing cause, using the CDC Multiple Cause of Death (MCD) database from 1999-2020. Methods: Retrospective observational analysis of the CDC MCD database for adults aged ≥25 years in the United States from 1999-2020. Deaths were included if hypertension (I10-I15) was the underlying cause and intracerebral hemorrhage (ICH I61) a contributing cause. Data were stratified by gender, race, geographic region, and place of death. Crude and age-adjusted mortality rates per 1,000,000 and annual percentage change (APC) were calculated. Temporal trends were assessed using Joinpoint software. Results: Among 14,613 deaths (crude rate 3.3 per million), most decedents were male (56.5%) and White (62.8%); Black/African American individuals accounted for 31.2%, Asian/Pacific Islander 5.3%, and American Indian/Alaska Native 0.7%. Most deaths occurred in metropolitan areas (89.4%) and in medical facilities (61.0%), while 25.2% occurred at home. Age-adjusted rates were stable from 1999-2007, declined 2007-2013, then rose 2013-2020. Females showed larger early declines followed by a modest rise, whereas males experienced a later sharper increase. Black/African American decedents had early declines with a subsequent plateau, while White decedents showed smaller early change, followed by decline and later increase. Conclusion: Deaths with hypertension as the underlying cause and ICH as a contributing cause were concentrated among males, White and Black populations, and metropolitan residents, with most deaths in medical facilities. Notably, after a period of decline, mortality rates increased again after 2013, particularly among males and White individuals, underscoring the urgency of renewed prevention efforts.
Background: Cardiogenic shock (CS) is a life-threatening condition requiring timely pharmacological support. Dobutamine and milrinone are commonly used inotropes, yet their comparative efficacy and safety in CS management remain uncertain. This systematic review and meta-analysis aims to evaluate the outcomes associated with dobutamine versus milrinone in CS patients. Methods: A thorough literature search was conducted across databases including MEDLINE (via PubMed), CENTRAL (Cochrane Central Register of Controlled Trials), and Scopus, spanning publications up to February 2025. Randomized controlled trials and observational studies comparing dobutamine and milrinone in adult patients diagnosed with CS were incorporated. Statistical analyses were performed employing a random-effects model. Effect measures comprised odds ratios (OR) for binary outcomes and standardized mean differences (SMD) for continuous outcomes, accompanied by 95% confidence intervals (CI), with heterogeneity evaluated using I 2 statistics. Results: Dobutamine was associated with higher in-hospital mortality (OR 1.56, 95% CI 1.01-2.39; I 2 = 93%; p = 0.04), which was non-significant in RCTs (OR 1.24, 95% CI 0.70-2.19; I 2 = 0%; p = 0.46; moderate certainty) but significant in observational studies (OR 1.63, 95% CI 1.02-2.59; I 2 = 94%; p = 0.04; very low certainty). Mortality was markedly increased in ICU settings (OR 2.85, 95% CI 1.42-5.69; I 2 = 93%; p < 0.001; moderate certainty), whereas non-ICU settings showed no significant difference (OR 0.68, 95% CI 0.32-1.45; I 2 = 84%; low certainty). Overall all-cause mortality was also higher with dobutamine (OR 1.54, 95% CI 1.07-2.21; I 2 = 87%; p = 0.02), remaining non-significant in RCT data (OR 1.30, 95% CI 0.73-2.32; moderate certainty) but significant in observational data (OR 1.58, 95% CI 1.06-2.35; I 2 = 89%; low certainty). No significant differences were observed in ICU length of stay (SMD -0.13, 95% CI -0.99 to 0.73; I 2 = 93%) or hospital length of stay (SMD -0.69, 95% CI -4.49 to 3.11; I 2 = 98%), and significant arrhythmias were comparable (OR 0.88, 95% CI 0.40-1.93; I 2 = 76%). However, acute renal failure was significantly more frequent with dobutamine (OR 1.22, 95% CI 1.01-1.47; I 2 = 0%; p = 0.03). Conclusion: Dobutamine is associated with increased mortality particularly in ICU patients and a higher risk of acute renal failure compared with milrinone, with evidence certainty ranging from moderate to very low and substantial heterogeneity across mortality outcomes.
Acute pulmonary embolism and acute myocardial infarction are critical conditions with overlapping presentations, and their coexistence can be catastrophic. We report a 45-year-old man with prior mid LAD stent who presented with chest pain and ventricular fibrillation arrest, diagnosed with inferior/posterior STEMI. Emergent PCI to the mid RCA restored stability. The patient developed persistent hypoxia over the next two days requiring intubation and mechanical ventilation. Worsening hypoxia and shock prompted urgent transesophageal echocardiography to evaluate for mechanical complications, instead revealing a mobile echo density spanning the right and left main pulmonary arteries, consistent with acute saddle pulmonary embolism, and right ventricular dilation and hypokinesis. Due to rapidly progressive hypoxia and shock, he was placed on VA-ECMO and started on anticoagulation, improving without the need for urgent interventional or surgical embolectomy. This case underscores the importance of considering acute pulmonary embolism in post-myocardial infarction patients with unexplained hypoxia or shock, where overlapping features may delay diagnosis. Early VA-ECMO initiation can provide a bridge to recovery in such critically ill patients.
