Background: Instantaneous wave-free ratio (IFR) represents a new vasodilator-free innovative approach which is considered as a gold standard for functional assessment of the hemodynamic significance of intermediate coronary stenoses. Although relatively safe, iFR is still an invasive procedure that has its potential hazards, complications and cost. Two-dimensional quantitative coronary analysis (2D-QCA) is a non-invasive technique that has emerged robustly as an excellent and attractive tool for delineating coronary anatomy. Aims: To assess the ability of two-dimensional quantitative coronary analysis (2D-QCA) to guide decision-making for quantification of severity of intermediate coronary stenoses (40–80% diameter stenosis) in each of the three main coronary vessels, by evaluating its accuracy in predicting true instantaneous wave-free ratio (iFR) results. Methods and results: 2D-QCA followed by iFR were performed for intermediate coronary lesions (40–80% diameter stenosis by visual assessment) discovered during coronary angiography. 2D-QCA was used to measure MLA, MLD and lesion length. This was followed by iFR measurement for the same lesion. 2D-QCA was then compared to the iFR measurements in order to assess its accuracy in prediction of true iFR result. A total of 277 intermediate lesions (155 LAD, 67 LCX, 55 RCA) in 209 vessels from 166 patients were analyzed. Males comprised ~68% of cases; mean ages were 53.3 ± 8.2 (LAD), 55.7 ± 8.9 (LCX), and 56.0 ± 8.8 years (RCA). Disagreement between modalities occurred mostly in LAD (24.5%), followed by RCA (21.8%) and LCX (14.9%). Per-vessel QCA accuracy (AUC) for predicting iFR was highest in LCX (78.5%), then RCA (72.2%), and lowest in LAD (66.6%) (all p < 0.005). Optimal QCA stenosis area cut-offs were 50.5% (LCX), 52.5% (RCA), and 53.5% (LAD), with sensitivities of 72.0%, 62.1%, and 63.2%, and specificities of 69.0%, 65.4%, and 65.8%, respectively. Conclusion: 2D-QCA can be a practical tool that bears the potential of improving angiography-based assessment of intermediate lesions regarding its prediction for functional significance without any additional costs, especially when invasive functional assessment methods are not available or contraindicated. Although, this would minimize the burden and the time of invasive procedure, 2D-QCA cannot totally replace invasive functional assessment (iFR, FFR) of intermediate coronary stenoses especially in LAD intermediate lesions.
Background: Chronic coronary syndromes (CCS) continue to impose a substantial clinical and economic burden in Saudi Arabia. Since publication of the 2022 Saudi Heart Association (SHA) CCS guidelines, important advances have emerged in diagnosis, pharmacotherapy, cardiometabolic risk reduction, antiplatelet management, and revascularization. This 2026 focused update selectively revises and clarifies key recommendations to reflect these advances within the Saudi context. Methods: A multidisciplinary SHA expert panel conducted a structured review of randomized trials, meta-analyses, and relevant international guidance published since 2022. Updates were restricted to areas with substantive new evidence or evolving clinical practice. Recommendations were formulated through expert consensus in accordance with SHA methodological standards. This document complements the 2022 guideline and does not replace it. Results and Conclusions: This focused update advances a more personalized, risk-driven approach to CCS management. Diagnostic algorithms now explicitly integrate pre-test probability, reinforce coronary computed tomography angiography as the preferred initial modality in low-to-intermediate probability, and refine the positioning of functional stress imaging. Residual risk assessment and preventive strategies are also strengthened. Importantly, this update introduces a dedicated diagnostic and management framework for angina and ischemia with non-obstructive coronary arteries (ANOCA/INOCA), emphasizing endotype-specific evaluation and targeted therapy for this historically under-recognized population. Anti-anginal therapy positions beta-blockers and calcium channel blockers as equivalent first-line agents, upgrades long-acting nitrates, and integrates ranolazine, ivabradine, and trimetazidine as evidence-based add-on options. Antiplatelet guidance emphasizes individualized dual antiplatelet therapy duration after percutaneous coronary intervention (PCI), early de-escalation strategies, and selective use of P2Y12 inhibitor monotherapy. Lipid management and cardiovascular risk reduction options are now expanded and revascularization recommendations are restructured. Collectively, these updates strengthen the delivery of contemporary, evidence-based, and patient-centered CCS care and provide a clear framework for implementation across diverse healthcare settings.
Background: Cardiovascular, kidney, metabolic, and liver diseases are closely interconnected and frequently coexist. While the cardiovascular–kidney–metabolic (CKM) framework provides a unified model, increasing evidence supports a central role for hepatic disease, particularly metabolic dysfunction–associated steatotic liver disease (MASLD), in this continuum. The Saudi Heart Association (SHA) therefore aimed to introduce the cardiovascular–kidney–liver–metabolic (CKLM) syndrome as an expanded framework and provide expert guidance on its pathophysiology, staging, screening, and management, with relevance to the Saudi population. Methods: A multidisciplinary expert panel convened under the auspices of the SHA conducted a comprehensive, non-systematic literature review and developed consensus-based recommendations through iterative discussion and critical appraisal of the evidence. Results and conclusions: CKLM syndrome is a progressive multisystem disorder driven by shared mechanisms, including insulin resistance, inflammation, and fibrosis, with bidirectional interactions across cardiovascular, kidney, metabolic, and hepatic domains. A stage-based framework is proposed to support risk stratification and guide management. Therapeutic strategies include agents with established cardiovascular, kidney and metabolic benefits, with emerging evidence supporting combination approaches. The high prevalence and coexistence of CKLM-related conditions in Saudi Arabia highlight the need for integrated care. The CKLM framework extends existing models by incorporating hepatic disease into the cardiometabolic–kidney continuum, enabling a more comprehensive approach to risk assessment and management. Multidisciplinary, stage-based strategies are recommended as they are expected to improve outcomes, although further validation is required.
Objective: To evaluate the feasibility and early outcomes of totally endoscopic non-robotic mitral valve replacement using a double-port DCT approach with posterior subvalvular preservation. Methods: In this single-center retrospective observational study, 76 consecutive patients underwent totally endoscopic non-robotic mitral valve replacement between November 2023 and December 2025. The DCT approach was defined by exclusive endoscopic visualization, no rib spreading, a camera port and prosthesis-sized working incision placed in the same intercostal space, and thoracoscopic intracardiac instrumentation. Posterior ventricular-annular continuity was preserved whenever feasible by posterior leaflet preservation, native chordal preservation, or artificial chordal reimplantation after leaflet resection. Outcomes were reported descriptively with 95% confidence intervals. Results: Mechanical prostheses were implanted in 46 patients (60.5%) and bioprostheses in 30 (39.5%). Mean skin incision length was 3.8 ± 0.5 cm. Mean cardiopulmonary bypass and aortic cross-clamp times were 148.3 ± 38.6 and 101.9 ± 32.0 minutes, respectively. There was 1 early non-cardiac death (1.3%; 95% CI, 0.03%-7.1%), no late death, and no mitral valve reoperation (0%; 95% CI, 0%-4.7%). No moderate or severe paravalvular regurgitation was observed during early echocardiographic follow-up. Mean follow-up was 9.7 ± 6.0 months. Freedom from prosthetic valve-related adverse events was 98.6% (95% CI, 90.6%-99.8%) at 6 months and 95.2% (95% CI, 80.1%-98.9%) at 12 months. The 24-month estimate was identical but was based on few patients at risk and should be interpreted cautiously. Conclusions: The double-port DCT approach was technically feasible and was associated with acceptable early clinical and echocardiographic outcomes. Because of the retrospective single-center design, small sample size, absence of a comparator group, and short follow-up, these findings should be interpreted as feasibility data rather than evidence of superiority.
Candida pericarditis is a rare, life-threatening complication of invasive candidiasis, associated with high mortality. We report this case of a young woman with 60% body surface area burn, multidrug-resistant polymicrobial sepsis, and multiorgan failure who developed Candida albicans pericarditis complicated by cardiac tamponade. Despite urgent pericardiocentesis and escalation of antifungal therapy, she ultimately progressed to refractory shock and multiorgan failure. This case illustrates the diagnostic challenge and therapeutic limitations of fungal pericarditis in critically ill host, and underscores the importance of maintaining a high index of suspicion in burn patients with multisite Candida colonization and prolonged antibiotic exposure.
Background:Heart failure with reduced ejection fraction (HFrEF) remains a major cause of morbidity, mortality, and healthcare utilization worldwide despite substantial therapeutic advances. Over the past three decades, randomized clinical trials have established four foundational pharmacologic pillars of guideline-directed medical therapy (GDMT): renin-angiotensin system inhibition or angiotensin receptor-neprilysin inhibition, evidence-based beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors. However, real-world implementation of these therapies remains suboptimal. Objectives:To provide a contemporary state-of-the-art review of current evidence supporting GDMT in HFrEF, examine unresolved challenges in sequencing and optimization, and propose a practical phenotype-based framework to support individualized treatment decisions. Methods:A structured narrative review was conducted using PubMed/MEDLINE, Embase, and Google Scholar to identify relevant publications from January 2000 to February 2026. Priority was given to randomized controlled trials, international guidelines, meta-analyses, and high-quality observational registries addressing GDMT initiation, sequencing, tolerability, and implementation. Results:Robust evidence supports early and combined use of the four foundational GDMT classes, with substantial reductions in mortality and heart failure hospitalization. Emerging data favor rapid initiation of multiple therapies followed by structured uptitration rather than prolonged sequential strategies. Nevertheless, important barriers persist, including hypotension, renal dysfunction, hyperkalemia, frailty, polypharmacy, therapeutic inertia, and inequitable access to medications. Current guidelines provide limited practical direction regarding treatment prioritization in complex clinical phenotypes. A phenotype-based decision framework may facilitate earlier, safer, and more individualized implementation of GDMT in routine practice. Conclusions:The principal challenge in modern HFrEF management is no longer the absence of effective therapies, but failure to deliver proven therapies rapidly, comprehensively, and sustainably. Future progress may depend less on development of new drug classes and more on optimizing implementation of currently available life-saving treatments through phenotype-informed and patient-centered strategies.
Objectives: To determine predictors of early mortality among pediatric patients undergoing congenital heart surgery at a tertiary care center in Saudi Arabia. Methods: This retrospective cohort study included 955 pediatric patients who underwent congenital heart surgery at King Abdulaziz University Hospital, Jeddah, between January 2017 and December 2023. Demographic, clinical, operative, and postoperative variables were collected. Results: Overall mortality was 4.9%. Mortality was higher among neonates and infants and among patients with RACHS categories 4-6. Non-survivors had longer cardiopulmonary bypass times and more frequent delayed chest closure. Postoperative complications, including the need for extracorporeal membrane oxygenation (ECMO), depressed cardiac function, acute kidney injury, central nervous system (CNS) insult, infection, and prolonged mechanical ventilation and intensive care unit (ICU) stay, were strongly associated with mortality. In multivariate analysis, independent predictors of mortality were prolonged ICU stay, longer postoperative mechanical ventilation, postoperative ECMO support, and postoperative CNS insult. Conclusion: Early mortality was comparable to international benchmarks. Postoperative physiological deterioration, particularly ECMO requirement, neurological injury, prolonged ventilation, and extended ICU stay, was independently associated with death, underscoring the importance of early detection and targeted perioperative management.
Double dorsal aorta is an extremely rare congenital embryological vascular anomaly caused by incomplete regression and fusion of the paired dorsal aortae and may be associated with complex congenital heart disease. We report a 9-year-old girl with complex congenital heart disease who underwent single-ventricle palliation, including a bidirectional Glenn at 10 months of age. During pre-Fontan cardiac catheterization a double descending dorsal aorta was incidentally discovered and later confirmed by CT angiography. Although patient was asymptomatic, recognizing this anomaly is crucial for surgical planning and catheter-based interventions, highlighting the importance of detailed preoperative imaging in single-ventricle patients.
Background:Infective endocarditis (IE) carries high morbidity and mortality, and its epidemiology in Saudi Arabia reflects a transition in which rheumatic and prosthetic valve disease coexist. Contemporary single-center data describing the clinical profile, microbiology, and in-hospital outcomes of IE in this setting remain limited. Methods:We conducted a retrospective cohort study at a tertiary cardiac center in Riyadh, Saudi Arabia, including 102 patients with IE diagnosed between October 2020 and December 2024, classified using the modified Duke criteria. Variables were analyzed descriptively. Proportions are reported with 95% confidence intervals (CI; Wilson method) against the number of patients with available data, and missing data are reported as an explicit category. The study is reported in accordance with the STROBE statement. Results:The mean age was 46.7 ± 19.2 years (median 48, IQR 34-62), and 56 patients (54.9%, 95% CI 45.2-64.2) were male. The cardiac substrate was heterogeneous: rheumatic heart disease 32.4% (95% CI 24.1-41.9), prosthetic valve disease 30.4% (95% CI 22.3-39.9), degenerative valve disease 18.6% (95% CI 12.3-27.3), and congenital heart disease 14.7% (95% CI 9.1-22.9). Blood cultures were documented in 92 patients, with positivity in 52 (56.5%, 95% CI 46.3-66.2) and a culture-negative rate of 43.5% (95% CI 33.8-53.7). All-cause in-hospital mortality was 24.5% (24/98; 95% CI 17.0-33.9). ICU admission was required in 56.3% (49/87; 95% CI 45.9-66.3) and cardiac surgery in 38.0% (30/79; 95% CI 28.1-49.0). Conclusion:IE at this center presents across a heterogeneous cardiac substrate with substantial in-hospital mortality. A high culture-negative rate and considerable missingness in this retrospective dataset limit precision; findings should be regarded as descriptive and hypothesis-generating. Prospective, protocolized data with systematic long-term follow-up are needed.
Background:The left atrial appendage (LAA) is an embryologically distinct structure with anatomical features that may mimic pathological findings on echocardiography. In Kawasaki disease, this resemblance can cause diagnostic confusion with coronary artery aneurysm or thrombus. Clinical presentation:A 7-year-old boy presented with fever lasting more than five days and cervical lymphadenopathy following a viral illness. Kawasaki disease was suspected. Transthoracic echocardiography suggested an abnormality of the left coronary artery with possible thrombus, and the patient was started on aspirin, clopidogrel, and apixaban. Coronary computed tomography angiography demonstrated normal coronary origins, course, and caliber, confirming the suspected lesion to be the LAA. Conclusion:The LAA may course adjacent to the left coronary artery and mimic a coronary aneurysm. Multimodality imaging is essential for accurate diagnosis.
Background: Spasm of ductus arteriosus is an uncommon but significant phenomenon associated with transcatheter patent ductus arteriosus (PDA) occlusion. It can lead to procedural failure, improper device sizing, or even embolization of the occluder device as the spasm subsides post-procedure. Aim of this study is to report the frequency, features, management and outcome of PDA spasm during device closure in a single Egyptian center. Patients and methods: Over about 3 years, 200 infants and children underwent percutaneous device occlusion. The echocardiographic and catheterization data of patients who developed spasm of PDA before or during or shortly after anesthesia induction or upon catheter entry into PDA were recorded and analyzed. Upon detecting the spasm, the anesthetist managed it by increasing the depth of anesthesia through a higher minimum alveolar concentration of inhaled sevoflurane and administering a secondary opioid dose (fentanyl 0.5 mcg/kg) to reduce stress level. The outcome of this treatment protocol was recorded. Results: PDA spasm occurred in 8 (4 %) of the patients between 8 months and 7 years. Complete resolution of spasm was attained after 10-45 min of anesthesia management. All 8 ducts were successfully occluded but one of them had significant residual shunt after device deployment, so larger device was used instead. No cases were referred for surgery. Conclusions: Ductal spasm at the start of anesthesia induction can be effectively managed, allowing the procedure to be safely completed, by following a straightforward anesthetic protocol.
Pulmonary hypertension associated with congenital heart disease or PH-CHD is an increasingly prevalent disorder in modern cardiology. It is characterized by progressive pulmonary vascular remodeling, chronic right ventricular (RV) pressure overload, and abnormal cardiopulmonary hemodynamic. Due to advances in congenital cardiology and treatments for pulmonary hypertension, survival rates have increased. As a result, the focus has switched to long-term functional status and quality of life. Depression and anxiety are currently recognized as prevalent and clinically significant manifestations in PH-CHD; nonetheless, they remain underdiagnosed and undertreated within cardiovascular care frameworks. More study shows the disease's severity or symptom count cannot explain PH-CHD patients' psychological distress. Instead, it shows a chronic heart disease-induced pathogenic process. The heart-brain axis underlines this idea. Chronic pulmonary vascular disease and RV failure induce neurohormonal activation, autonomic instability, systemic inflammation, hypoxia, and inadequate cerebral perfusion, which affect brain structure and emotion regulation. This brief review gathers evidence of objective cardiovascular dysfunction linked to depression and anxiety in PH-CHD, and investigates into the molecular pathways that connect the heart and brain. The ideas of psychological distress as a factor associated with chronic cardiovascular disease requires a more extensive interdisciplinary approach, which may ultimately affect favorable patient outcomes and long-term prognosis.
Objectives:Coronary artery disease (CAD) and cerebrovascular disease (CVD) share common atherosclerotic pathways. However, the clinical significance of headache absence during stress testing remains unexplored. We investigated whether the absence of headache during pharmacological stress testing reflects the presence of subtle cerebrovascular atherosclerosis detectable by transcranial Doppler ultrasonography (TCD). Methods:This cross-sectional study enrolled 225 patients with CAD undergoing pharmacological stress testing with TCD and myocardial perfusion imaging (MPI) at centers in Egypt (Cardiology Department, Fayoum University). Patients were stratified by headache status during stress testing. Multivariate logistic regression and receiver-operating characteristic (ROC) analysis identified independent predictors of abnormal TCD findings. Results:The cohort comprised 123 patients without headache (mean age 59.0 ± 6.8 years) and 102 with headache (mean age 56.5 ± 4.5 years). TCD abnormalities were significantly more prevalent in patients without headache (81.3% vs 27.5%, p < 0.0001). On univariate analysis, age (p < 0.001), hypertension (p = 0.014), and positive MPI (trend, p = 0.191) were associated with abnormal TCD. After adjustment for between-cohort heterogeneity, multivariate analysis confirmed the absence of headache as the strongest independent predictor of TCD abnormality (adjusted odds ratio [aOR] = 0.09, 95% confidence interval [CI]: 0.04-0.19; 91% risk reduction; p < 0.001). Age was the only cardiovascular risk factor that retained independent significance (aOR = 1.09 per year; 95% CI: 1.03-1.16; p = 0.005). The full predictive model achieved excellent discrimination (area under the ROC curve (AUC) = 0.833; 95% CI: 0.780-0.884), with sensitivity of 68.0%, specificity of 86.6%, and positive predictive value (PPV) of 87.0%. Conclusions:This is the first evidence of a paradoxical association in pharmacological stress testing: absence of Headache is strongly associated with advanced subclinical cerebrovascular disease. This finding challenges the conventional interpretation of stress-test symptomatology and suggests new strategies for identifying high-risk CAD patients with silent cerebrovascular atherosclerosis who warrant aggressive preventive therapy. The utility of stress-induced symptom (Headache) profiles for risk stratification warrants prospective validation.
Background and objectives:Interest in intermittent fasting regimens has expanded substantially due to its reported metabolic effects. However, whether such dietary patterns are safe for individuals living with chronic heart failure remains unclear. This issue is particularly relevant for patients who fast for religious observance, including Ramadan. We therefore performed a systematic review to evaluate the clinical safety and physiological implications of intermittent fasting regimens in stable heart failure populations. Methods:The review protocol adhered to established reporting standards for systematic reviews. Multiple electronic databases were systematically searched from inception through December 2025 to identify studies evaluating intermittent fasting regimens in adults with chronic heart failure. Both randomized and observational designs were considered eligible. Key outcomes included clinical deterioration, cardiovascular events, New York Heart Association functional status, left ventricular systolic performance, and natriuretic peptide levels. Where data allowed, pooled analyses were conducted; otherwise, findings were summarized narratively. Results:Five observational studies fulfilled inclusion criteria, three of which provided comparable data for quantitative synthesis, comprising 1345 participants. Across studies, fasting was not associated with increased rates of heart failure decompensation, major cardiovascular events, or mortality relative to non-fasting periods. Functional status remained generally stable, with a tendency toward improved symptom classification among fasting participants. Measures of systolic function and natriuretic peptides showed no clinically meaningful worsening. Conclusion:In clinically stable individuals with chronic heart failure, intermittent fasting regimens, including Ramadan fasting, were not linked to short-term adverse clinical outcomes based on currently available observational evidence.
Objective: Coronary computed tomography angiography (CCTA) is a cornerstone in the assessment of coronary artery disease. Despite technological advancements, balancing radiation does with diagnostic image quality remains a challenge. This study evaluates whether assessing preliminary non-enhanced CT scans allows for the optimization of CCTA gating protocols to enhance image quality and minimize radiation exposure. Methods: We prospectively analyzed 150 patients undergoing CCTA on a 256-slice scanner. Non-enhanced scans were used to identify motion artifacts or anatomical challenges. Based on these findings, a specific gating protocol (prospective, prospective with padding, or retrospective) was selected. This cohort was compared to a control group of 150 standard CCTAs performed without protocol pre-selection. Image quality was assessed on a four-point scale, and radiation doses were recorded. Results: The mean patient age was 49 years, with a mean heart rate (HR) of 62 +/- 14 beats per minute (bpm). Subjective image quality was significantly higher in the pre-selection group, particularly for patients with HR > 65 bpm (3.5 +/- 0.5 vs. 2.8 +/- 0.8; p = 0.06). The mean radiation dose was significantly lower in the pre-selection group (4.9 +/- 1.4 vs. 7.5 +/- 1.8 mSv; p < 0.01). Furthermore, the requirement for high-radiation protocols (padding or retrospective gating) was reduced by 50% in the pre-selection group (14/150 vs. 28/150 scans). Conclusion: Utilizing non-enhanced CT scans to tailor 256-slice CCTA protocols significantly improves image quality and reduces radiation exposure. This strategy offers a more personalized approach to cardiac imaging and should be considered for routine clinical practice.
Objectives:Inferior ST-segment elevation myocardial infarction is frequently complicated by vagally mediated bradyarrhythmias and hypotension during reperfusion, contributing to increased morbidity. The Bezold-Jarisch reflex has been implicated in this hemodynamic instability; however, evidence supporting prophylactic atropine remains limited. The study evaluated whether intravenous atropine administered immediately before reperfusion reduces clinically meaningful bradyarrhythmias, hypotension, early sustained ventricular arrhythmias, and inpatient major adverse cardiovascular events in patients undergoing primary percutaneous coronary intervention. Methods:In this prospective single-center, randomized, double-blind, placebo-controlled trial, adults presenting within 12 h of symptom onset with inferior ST-segment elevation myocardial infarction were randomized 1:1 to intravenous atropine (1 mg) or placebo immediately before guidewire crossing or balloon inflation. Of 158 patients randomized, 150 patients were included in a prespecified modified intention-to-treat analysis, excluding 8 patients with angiographic no-reflow. The primary endpoint was a composite of hypotension and symptomatic bradycardia following reperfusion. Secondary endpoints included the individual components of the primary endpoint, sustained ventricular tachycardia or ventricular fibrillation, and inpatient major adverse cardiovascular events. Results:The primary endpoint occurred in 17.3% of atropine-treated patients and 49.3% of placebo-treated patients (relative risk 0.35, 95% CI 0.20-0.61), corresponding to an absolute risk reduction of 32.0% (95% CI 17.81-46.19) and a number needed to treat of 3 (p < 0.001). Atropine significantly reduced hypotension and symptomatic bradycardia. Sustained ventricular tachycardia or ventricular fibrillation occurred in 2.7% vs 13.3% of patients. No serious atropine-related adverse events were observed. Conclusions:Prophylactic atropine significantly reduces hypotension and bradyarrhythmias and may also reduce early ventricular arrhythmias and inpatient major adverse cardiovascular events in this population. Clinical trial registration:ClinicalTrials.gov identifier NCT07268586, retrospectively registered December 2025.
