Background: Small vessel disease of the heart and brain share common risk factors and pathophysiological mechanisms, but imaging-based evidence of a direct link between coronary microvascular dysfunction and cerebral small vessel disease (CSVD) remains limited. This study aimed to assess whether stress myocardial blood flow (MBF) and myocardial perfusion reserve (MPR) are associated with brain magnetic resonance imaging (BMR) markers of CSVD. Methods: This retrospective study included adult patients who underwent both cardiac magnetic resonance imaging (CMR) and BMR between January 2021 and December 2025 at a tertiary center. Quantitative stress MBF and MPR were assessed using adenosine stress CMR. BMR markers included Fazekas scores for periventricular and deep white matter hyperintensities (PVWM and DWM), and the number of cerebral microbleeds identified on susceptibility-based sequences. Spearman's rank correlation coefficients and partial correlations adjusted for age and imaging interval were calculated. Subgroup analyses were performed by scanner vendor and imaging interval. Results: A total of 51 patients met inclusion criteria (33 scanned on GE Healthcare systems and 18 on Siemens Healthineers systems). Fluid-attenuated inversion recovery imaging was available in 35 patients, and susceptibility-based sequences in 42. No statistically significant associations were observed between stress MBF or MPR and PVWM, DWM, or cerebral microbleeds in either vendor group after adjustment for age and imaging interval. Findings were consistent in analyses restricted to CMR–BMR intervals ≤ 5 years. Conclusion: This exploratory study did not identify statistically significant associations between stress MBF or MPR and MRI markers of CSVD.
Ventricular premature complexes (VPCs) are common in athletes, but distinguishing benign VPCs from malignant arrhythmias remains a clinical challenge. This review summarizes current evidence on VPC evaluation and risk stratification in athletes, emphasizing electrocardiographic (ECG) features, burden, morphology, coupling interval, and exercise response. While VPC prevalence in athletes mirrors the general population, high-risk features–such as non-fascicular, non-outflow tract morphologies (e.g., superior axis or wide QRS), short coupling intervals (<300 ms), and VPC exacerbation during exercise - correlate with underlying structural heart disease (e.g.,arrhythmogenic cardiomyopathy, idiopathic left ventricular scar) and adverse outcomes. Guideline-directed assessment recommends comprehensive evaluation for athletes with high VPC burden (>10%), complex arrhythmias, or abnormal imaging. Key findings include: (1) VPC-induced cardiomyopathy risk rises with burden >5–10%, though low-burden VPCs may still indicate arrhythmogenic substrates; (2) uncommon morphologies (e.g., non-fascicular, non-outflow tract morphologies) predict cardiac pathology; and (3) exercise-induced VPCs, warrant further cardiac imaging to screen for arrhythmogenic substrate. A structured algorithm integrating clinical history, ECG, stress testing, and advanced cardiac imaging optimizes risk stratification and sports participation guidance. This review underscores the need for individualized management to mitigate sudden cardiac death risk while avoiding unnecessary sports restriction in athletes with benign VPCs.
Gastroesophageal reflux disease (GERD) and atrial fibrillation (AF) are common conditions that significantly impact gastrointestinal and cardiovascular health. Emerging evidence suggests a bidirectional relationship between these conditions, mainly driven by inflammation and vagal nerve stimulation. Shared risk factors include obesity, obstructive sleep apnea, and hiatal hernias. This review explores the underlying pathophysiological mechanisms that may link GERD and AF, focusing on the roles of autonomic dysregulation, systemic inflammation, and mechanical interactions that may cause symptoms for both diseases. Lifestyle modifications including weight management, along with pharmacological treatments like proton pump inhibitors, have shown promise in managing the symptoms of both conditions which otherwise may exacerbate one another. Despite the treatment progress, the causative link between GERD and AF is still uncertain, with various sources stating inconclusive evidence, necessitating further research. Future research should focus on therapeutic strategies for more optimized patient care, molecular pathways, and integrated care models addressing both gastrointestinal and cardiovascular health. Understanding the association between GERD and AF can help adjust clinical management and improve patient outcomes.
Background: Cardiovascular diseases (CVD) present a substantial burden on global and local healthcare systems, particularly within Hong Kong's overstretched public secondary care settings coupled with an aging population. The Personalized CARdiovascular DIsease risk Assessment for Chinese (P-CARDIAC), a locally developed and validated artificial intelligence (AI) powered cardiovascular risk assessment tool, offers a transformative opportunity for enhancing care through systematic risk prediction and a multidisciplinary care approach. Implementation strategies for its application in secondary care remain undefined. Methods: We gathered local insights from one expert meeting and thirteen semi-structured interviews with cardiologists and pharmacists, matched these with barriers and respective facilitators identified in a PRISMA-based systematic review from PubMed, EMBASE, and Scopus databases in September and October 2025. Findings were synthesised into an evidence-to-action framework. Results: We identified 1696 records from the systematic review, and included 16 primary and 6 non-primary studies. We synthesized these findings and outlined strategies in three levels. At the individual level, strategies focus mainly on building trust and promoting holistic, personalized care via effective cardiologist-pharmacist communication and targeted training led by leading specialists. The technical level requires leveraging partnerships for continuous data validation and program evaluation to demonstrate the impact of P-CARDIAC on risk stratification and service prioritization. Successful application at the organizational level hinges on seamless workflow integration, active stakeholder engagement, and institutional support through the development of evidence-based consensus and guidance. Conclusion: Promulgating these multilevel strategies is core to realizing P-CARDIAC's full potential, enabling it to overcome utilization challenges and optimize healthcare delivery through territory-wide application.
Background: Fluid responsiveness describes the capacity of the myocardium to raise stroke volume by at least 10% when ventricular filling is increased, consistent with the principle outlined by Frank and Starling. In patients with acute heart failure with reduced ejection fraction (HFrEF), elevated left ventricular filling pressure (LVFP) and impaired contractility frequently place the ventricle on the flattened segment of this relationship, resulting in a limited response to preload changes. Objectives: To investigate the relationship between LVFP and fluid responsiveness in patients with acute HFrEF. Methods: This study aimed to explore the link between LVFP and fluid responsiveness using echocardiography to track velocity–time integral (VTI) changes during a passive leg raising (PLR) maneuver. A cross-sectional observational design was applied, enrolling patients admitted with acute HFrEF from December 2024 to April 2025. LVFP was estimated through echocardiographic indices of E/A ratio, E/e' and calculated pulmonary capillary wedge pressure (PCWP). A ≥ 10% increase in VTI after PLR indicated fluid responsiveness. Results: Of 65 participants, 37 (57%) were non-responders. The non-responder group had higher LVFP values across all indices, namely: E/A, E/e', and PCWP. Fluid responsiveness correlated significantly with E velocity, E/A ratio, and E/e'. Conclusion: Higher LVFP is moderately associated with reduced fluid responsiveness in acute HFrEF, underscoring the value of echocardiographic indices in guiding individualized volume management.
Objective: To evaluate the prognostic value of proximal non-obstructive coronary plaques detected by coronary computed tomography angiography (CCTA) in predicting acute coronary syndrome (ACS) among patients with stable coronary artery disease (CAD). Methods: This retrospective cohort included patients with stable CAD who underwent CCTA at Adam Malik General Hospital, Medan, between January and December 2023. Of 458 patients with non-obstructive plaques, 416 met inclusion criteria and were followed for 18 months. Patients were classified into proximal involvement (left main, proximal left anterior descending artery, proximal left circumflex artery, or proximal right coronary artery) and non-proximal groups. The primary endpoint was occurrence of ACS (unstable angina, non-ST elevation myocardial infarction, or ST-elevation myocardial infarction). Logistic regression and Kaplan–Meier analyses were applied. Results: Among 416 patients, 208 (50 %) had proximal plaque involvement. These patients were older (58.1 vs. 51.9 years, p < 0.001), had higher rates of diabetes and dyslipidemia, and exhibited higher coronary artery calcium (CAC) scores (113.7 ± 144.1 vs. 43.5 ± 32.1, p < 0.001) and more moderate stenosis. During follow-up, ACS occurred in 20 patients (4.8 %), all from the proximal involvement group (p < 0.001). Multivariate analysis confirmed proximal plaques as an independent predictor of ACS (OR 6.51, 95 % CI 3.42–10.78, p < 0.001), along with stenosis severity, segment involvement score, and CAC score. Kaplan–Meier curves showed a significantly higher cumulative incidence of ACS in the proximal group. Conclusions: Proximal non-obstructive plaques strongly predict ACS in stable CAD. CCTA provides important prognostic information beyond stenosis severity, supporting its use for refined risk stratification and preventive strategies.
The McConnell sign is a well-recognized 2D echocardiographic feature of pulmonary embolism characterized by apparent hypokinesia of right ventricular mid and apical free wall segments. However, it is rarely described in 3D echocardiography. We report a case of high-risk pulmonary embolism with the McConnell sign demonstrated in 3D echocardiography. Comparison with other etiologies of right ventricular dysfunction regarding 3D morphology and 2D speckle tracking strain is also discussed.
Vascular closure devices (VCD) are commonly used for rapid haemostasis after femoral arterial cannulation, however, serious adverse events may rarely occur. We describe a case where use of Perclose Proglide for closure of the right femoral artery (RFA) access site led to focal arterial dissection, entrapping the footplate of a second Proglide device during staged percutaneous coronary intervention (PCI). The trapped device was eventually extracted using intravascular ultrasound (IVUS)-guided balloon angioplasty with cross-over approach. This case highlights the potential complications of VCD and possible endovascular strategies in tackling such issues.
Background: Emerging evidence suggests an association between vascular risk factors and changes in brain cortical structure and function. However, the relationship between venous thromboembolism (VTE) and brain cortical remodeling remains unclear, impeding further research on brain cortical dysfunction. Methods: Using summary statistics obtained from genome-wide association studies (GWAS), we conducted two-sample Mendelian randomization (MR) analyses to explore potential causal effects of genetically predisposed pulmonary embolism (PE, N = 361,194), deep vein thrombosis (DVT, N = 462,933) and unspecified VTE (N = 218,792) on brain cortical structure (N = 51,665). Magnetic resonance imaging (MRI)-based measures of brain cortex including surface area (SA) and thickness (TH) were collected both globally and across 34 regional gyri. All participants were of European descent. Data analysis was conducted between June 2023 and September 2023. Results: Globally, the cortical TH was consistently reduced in patients with PE, DVT and VTE (β PE: –0.344 mm, 95% CI: –0.654 mm to –0.033 mm, P = 0.030; β DVT: –0.150 mm, 95% CI: –0.298 mm to –0.002 mm, P = 0.047; β VTE: –0.003 mm, 95% CI: –0.006 mm to –0.0003 mm, P = 0.029). Regionally, DVT specifically caused a decrease in cortical TH in the paracentral gyrus (β : –0.438 mm, 95% CI: –0.647 mm to –0.229 mm, Bonferroni-corrected P = 4.02 × 10–5). This decrease persisted even after global adjustment (β : –0.281 mm, 95% CI: –0.434 mm to –0.126 mm, Bonferroni-corrected P = 3.49 × 10–4). No pleiotropy or heterogeneity was detected. Conclusion: Our study shows a causal effect of genetically proxied VTE on brain cortical thinning. This finding supports previously established epidemiological associations between VTE and brain dysfunctions and offers mechanistic insight.
Despite of advances in cardiac and surgical care, some children with complex congenital heart disease remain cyanotic in adulthood. The grown-up cyanotic congenital heart diseases are heterogeneous due to their underlying cardiac anatomy and physiology. Other than cardiovascular problems, they patients are also faced with multi-system complications in the long run. Therefore, these patients need nuanced and comprehensive assessment, regular follow-up monitoring, and multi-facet management. In this article, the types and classification of cyanotic congenital heart diseases, the multi-system complications and the approach to assessment and treatment will be presented.
Introduction: Blood pressure variability, in addition to blood pressure itself, has been used as a predictor for mortality. This study examined the predictive power of baseline/latest/mean/median blood pressure and blood pressure variability measures for all-cause mortality and adverse cardiovascular outcomes. Methods: The retrospective observational study analyzed patients who presented to family medicine clinics between 1st January, 2000 and 31st December, 2001. Blood pressure measurements were obtained over a five-year period. Standard deviation (SD), root mean square (RMS), coefficient of variation (CV) and a variability score (number of >=5 mmHg blood pressure change) were used as measures of blood pressure variability. The primary outcome was all-cause mortality and the secondary outcomes were heart failure, acute myocardial infarction, and transient ischemic attack (TIA)/stroke, with follow-up until 31 December 2019. Results:This study included 37540 patients (n=29597 patients with >=3 blood pressure measurements). A nonlinear inverse U-shaped relationship was observed between baseline/latest/maximum/minimum/mean/median/RMS measures of diastolic blood pressure and time-to-death for all-cause mortality (P Conclusion: Nonlinear inverse U-shaped relationships were observed between blood pressure and its variability measures and all-cause mortality. Higher blood pressure variability was associated with increased risk of all-cause mortality, heart failure, acute myocardial infarction and TIA/stroke.
Endovascular covered stenting is a minimally invasive option for treating iatrogenic femoral access site complications, including arteriovenous femoral fistula (AVF). Reports on AVF repair mainly concern small bore devices, but large bore devices such as leadless pacemakers post unique challenges. We present 3 cases of iatrogenic femoral AVF after large-bore, 27Fr access sheath insertion for leadless pacemaker implantation. Both underwent endovascular balloon-expandable covered stenting, with resolution of AVF and durable long-term results. As patients referred for leadless pacemaker implantations are often frail with co-morbidities, endovascular stenting is an appealing alternative to open surgical repair for AVF.
Structural heart disease (SHD) has emerged as one of the most dynamic frontiers in contemporary cardiology. Interventional echocardiography, once a niche discipline, is now central to the planning, execution, and follow-up of complex structural interventions. This comprehensive review traces the evolution of the field, anchored in both scientific literature and firsthand experience. We explore the journey from 2D to 3D imaging, the impact of mentorship and research at the Mayo Clinic, the rise of advanced interventional devices, the integration of artificial intelligence and robotics, and the importance of resilience and teamwork. Our aim is to inspire, inform, and chart a course for the next generation of pioneers in SHD imaging.
Aneurysmal dilatation is an uncommon but serious complication of directional atherectomy for heavily calcified lower extremity arterial disease. In the absence of established treatment guidelines, this case report describes the successful endovascular management of a common femoral artery aneurysm following directional atherectomy using covered stents.
We report a rare case of myocardial infarction complicated by anterolateral papillary muscle rupture and right ventricular infarction in a 49-year-old man. Initial signs suggested pulmonary embolism, but imaging revealed inferolateral infarction with right ventricular involvement. Angiography showed a thrombosed obtuse marginal branch supplying a chronically occluded right coronary artery. Despite intervention, the patient developed refractory cardiogenic shock. Surgery revealed complete papillary muscle rupture; mitral valve replacement and bypass were performed, but the patient died postoperatively. This case highlights the fatal potential of uncommon infarction patterns and the limited success of surgery, emphasizing the need for alternative transcatheter strategies in high-risk cases.
BACKGROUND: Peripheral arterial disease (PAD) is prevalent and associated with significant cardiovascular (CV) mortality. However, it remains under-recognized, particularly in Asian countries. This study aims to assess awareness of PAD, its risk factors, and perceived consequences in relation to other CV diseases to inform strategies for improving clinical care. METHODS: A total of 1,008 adults attending outpatient clinics at a university-affiliated tertiary hospital were recruited between January-August 2020 for a phone questionnaire. Differences between awareness groups were analysed by Pearson’s Chi-square test, predictors of PAD awareness were determined using multivariate logistic regression, and latent class analysis (LCA) was performed to identify subgroups. RESULTS: Only 36.7% of participants were aware of PAD, substantially lower than awareness for diabetes, hyperlipidemia, hypertension, coronary artery disease and cerebrovascular disease. Multivariate analysis identified the top predictors of PAD awareness as a prior PAD diagnosis (OR 7.94, 95% CI 3.79-17.9), history of stent or bypass procedures (OR 2.38, 95% CI 1.68-3.40), and awareness of atrial fibrillation (OR 2.22, 95% CI 1.46-3.45). Among PAD-aware patients, 84% associated the disease with walking difficulties, but only 50.0% acknowledged that PAD could be fatal. LCA identified four distinct subgroups; the largest (52.6% of the cohort) consisted of older, less-educated, and pre-atherosclerotic patients and exhibited the least awareness. CONCLUSION: Our findings underscore a critical gap in PAD awareness in Hong Kong. The identified predictors and demographic subgroups highlight populations that could benefit from targeted educational interventions. Enhancing PAD awareness is essential for improving disease management and cardiovascular health outcomes.
Background Currently there are two strategies in Percutaneous Coronary Intervention (PCI) of the true left main (LM) bifurcation lesions: provisional stenting and two-stent technique. The optimal treatment strategy for true LM bifurcation lesions is undetermined. In addition, the percentage of use of imaging-guiding in these studies was low. We would like to undertake a retrospective cohort study to compare the clinical outcomes of provisional stenting versus two-stent technique in treating the true LM bifurcation lesions with the help of intravascular imaging. Methods Data of consecutive patients undergoing PCI of true LM bifurcation lesions in Yan Chai Hospital from January, 2018 to December, 2023 was studied. All LM PCI was done using imaging-guiding. The study endpoint was the composite rate of target lesion failure (TLF): cardiac death, target vessel myocardial infarction (MI), or clinically driven target lesion revascularization. Results A total of 57 patients were included, of which 28 (49.1%) used provisional stenting and 29 (50.8%) used two-stent technique. Two-stent technique group seemed to have lower TLF rates 13.8% as compared 21.4% in provisional stenting group (P =0.41). The differences were more obvious in complex true bifurcation group, in which two-stent technique group tended to be have lower TLF rates (33% in provisional stenting group and 9% in two-stent technique group, P =0.06). Conclusions In imaging guided PCI of true LM bifurcation lesion especially complex true bifurcation, two-stent technique seemed to have lower adverse cardiac event rates compared with provisional stenting, although it was not statistically significant.
Background ST-segment elevation myocardial infarction (STEMI) carries high mortality and poor outcomes without timely treatment. Its occurrence in young patients is especially concerning due to social impact. Objectives This study examined the characteristics and outcomes of young STEMI patients in Hong Kong to identify areas for public health improvement. Methods We retrospectively reviewed STEMI patients admitted to Princess Margaret Hospital from January 2019 to January 2023 who underwent coronary angiography and reperfusion therapy. Patients were grouped as young (years) or older (≥50 years). Results Out of 818 patients treated with PCI, 102 (12.5%) were under 50 years old. Compared to older patients, young STEMI patients were more often male, chronic smokers, South-Asian, and obese, with higher rates of untreated hypertension, diabetes mellitus, and hyperlipidemia. They exhibited less multivessel and significant left main coronary disease. Complications such as acute pulmonary edema, cardiogenic shock, and highgrade atrioventricular block were less frequent in the young group. Overall, young patients had more favorable outcomes, with lower mortality and 1-year major adverse cardiac events (MACE). However, the 1-year MACE rate of 18.6% in young patients was not negligible, and out-of-hospital cardiac arrest (OHCA) was significantly associated with 1-year MACE in this group but not in older patients Conclusion Young STEMI patients in Hong Kong have distinct risk factors and better outcomes than older patients, but their risk of adverse events is still notable. Enhanced public health efforts are needed to improve primary prevention in this group.
Double Outlet Right Ventricle (DORV) is a rare cyanotic congenital heart defect often associated with polycythemia and bleeding risk. A 7-year-old boy with uncorrected DORV presented with fever, melena, and shock. He was cyanotic, tachypneic, and tachycardic, with SpO₂ of 68% and a harsh ejection systolic murmur. Labs showed anemia, thrombocytopenia, leukocytosis, and prolonged APTT. Tubex TF IgM was strongly positive. A diagnosis of typhoid fever with gastrointestinal bleeding and uncorrected DORV was made. Management included oxygen, inotropes, and fluid resuscitation. Propranolol was withheld. Severe infection with underlying cyanotic heart disease and coagulopathy presents a critical management dilemma.
Background: The association between increased rates of pneumonia and influenza and longterm exposures of angiotensin converting enzyme inhibitors (ACEIs) versus angiotensin receptor blockers (ARBs) remained unclear. Methods: This is a retrospective population-based cohort study using territory-wide healthcare data in Hong Kong. The study period was from 1st January 2000 and 31st August 2020. Patients who used ARB or ACEI were included. ARB and ACEI users were matched using a propensity score at 1:1 ratio with nearest neighbor search strategy. The follow-up started after one-year lag time after drug initiation until outcome, death or end of study. Risks of new onset adverse pneumonia outcomes of bacterial, viral and influenza infections between ARB and ACEI users were estimated using Cox proportional hazards models with competing risks consideration. Subgroup analysis was conducted by stratifying patients with different follow-up time since drug initiation. Results: In total 379201 patients (54436 ARB users and 324765 ACEI users) were initially identified. In the propensity score-matched cohort (n=108872), ARB use was associated with significantly higher risks in new onset pneumonia and influenza (HR: 5.73, 95% CI: [4.49- 7.32], P value
