Traumatic Brain Injury is a major cause of death and long-term disability. The early identification of patients at high risk of mortality is important for both management and prognosis. Although many modified scoring systems have been developed for improving the prediction accuracy in patients with trauma, few studies have focused on prediction accuracy and application in patients with traumatic brain injury. The shock index (SI) which was first introduced in the 1960s has shown to strongly correlate degree of circulatory shock with increasing SI. In this editorial we comment on a publication by Carteri et al wherein they perform a retrospective analysis studying the predictive potential of SI and its variants in populations with severe traumatic brain injury.

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UNASSIGNED: Anesthesiologists develop anesthetic plans according to the surgical procedure, patient\'s medical history, and physical exams. Patients with ischemic heart disease are predisposed to intraoperative cardiac complications from surgical blood loss. Unanticipated events can lead to intraoperative complications despite careful anesthesia planning.
UNASSIGNED: This anesthetic management simulation was developed for the anesthesiology residency curriculum during the first clinical anesthesia year (CA 1/PGY 2 residents). A total of 23 CA 1 residents participated. A 50-minute encounter focused on a 73-year-old male who presents for an elective total hip replacement and develops acute myocardial stunning in the setting of critical acute blood loss and a delay in the transportation of blood products.
UNASSIGNED: One hundred percent of the residents felt the simulation was educationally valuable in the immediate postsimulation survey (Kirkpatrick level 1). The follow-up survey showed that 100% of residents felt the simulation increased their knowledge of managing acute cardiac ischemia (Kirkpatrick level 2), and 93% felt it increased awareness and confidence in similar real-life situations that positively affected patient outcomes (Kirkpatrick level 3).
UNASSIGNED: Our simulation provides a psychologically safe environment for anesthesiology residents to develop management skills for acute critical anemia and cardiogenic shock and foster communication skills with a surgery team.

Background-Fractional flow reserve (FFR) measurements are recommended for assessing hemodynamic coronary stenosis severity. Intracoronary ECG (icECG) is easily obtainable and highly sensitive in detecting myocardial ischemia due to its close vicinity to the myocardium. We hypothesized that the remission time of myocardial ischemia on icECG after a controlled coronary occlusion accurately detects hemodynamically relevant coronary stenosis. Methods-This retrospective, observational study included patients with chronic coronary syndrome undergoing hemodynamic coronary stenosis assessment immediately following a strictly 1-minute proximal coronary artery balloon occlusion with simultaneous icECG recording. IcECG was used for a beat-to-beat analysis of the ST-segment shift during reactive hyperemia immediately following balloon deflation. The time from coronary balloon deflation until the ST-segment shift reached 37% of its maximum level, i.e., icECG ST-segment shift remission time(τ-icECG in seconds,s) was obtained by an automatic algorithm. τ-icECG was tested against the simultaneously obtained reactive hyperemia FFR at a threshold of 0.80 as reference parameter. Results-One hundred and thirty-nine icECGs from 120 patients (age 68±10 years) were analysed. Receiver operating characteristic (ROC) analysis of τ-icECG for the detection of hemodynamically relevant coronary stenosis at an FFR of ≤0.80 was performed. The area under the ROC curve was equal to 0.621(p=0.0363) at an optimal τ-icECG threshold of 8s(sensitivity 61%, specificity 67%). τ-icECG correlated inversely and linearly with FFR(p=0.0327). Conclusion-This first proof-of-concept study demonstrates that τ-icECG, a measure of icECG ST segment-shift remission after a 1-minute coronary artery balloon occlusion accurately detects hemodynamically relevant coronary artery stenosis according to FFR at a threshold of ≥8seconds.

BACKGROUND: Coronary artery thrombosis and myocardial ischemia caused by giant coronary aneurysms are the main causes of death in children with Kawasaki disease. The use of thrombolytic therapy in children with Kawasaki disease who have coronary thrombosis is a controversial topic, especially with respect to the timing of treatment.
METHODS: In this article, we report a case of a child aged two years and nine months with Kawasaki disease whose coronary arteries had no involvement in the acute phase. However, by only one week after discharge, the patient returned because we found giant coronary aneurysms complicated by thrombosis via echocardiography. Despite aggressive thrombolytic therapy, the child developed myocardial ischemia during thrombolytic therapy. Fortunately, because of timely treatment, the child\'s thrombus has dissolved, and the myocardial ischemia has resolved.
CONCLUSIONS: This case suggests that for patients at high risk of coronary artery aneurysms, echocardiography may need to be reviewed earlier. Low-molecular-weight heparin should be added to antagonize the early procoagulant effects of warfarin when warfarin therapy is initiated. In the case of first-detected coronary thrombosis, aggressive thrombolytic therapy may be justified, particularly during the acute and subacute phases of the disease course.

Subjects who have ischemia with non-obstructive coronary arteries (INOCA) experience angina pectoris with evidence of myocardial ischemia but without coronary stenosis. Few studies have investigated factors associated with its survival, especially insulin resistance. In this study, subjects with angina pectoris, without known diabetes mellites (DM), and with non-invasive tests showing myocardial ischemia were admitted for coronary angiography (CAG). Those whose CAG did not reveal stenosis and agreed to receive an oral glucose tolerance test (OGTT) 2 weeks after hospital discharge were enrolled for analysis. All-cause mortality was recorded, which served as the outcome of the study. A total of 587 subjects with INOCA, without known DM, and with OGTT data were analyzed. After OGTT and HbA1c tests, 86 subjects (14.7%) were newly diagnosed with DM and 59.8% had pre-DM. The median duration of follow-up was 7.03 years. Thirty-nine subjects died during the follow-up period. The incidence rate of mortality was 9.9 /1000 person-year. Those who died had a higher fasting glucose (101 ± 17 vs. 94 ± 13 mg/dl, p = 0.003) but a lower estimated glomerular filtration rate (eGFR) (54 ± 22 vs. 87 ± 30 ml/min, p < 0.001). In the Cox survival analysis, a higher fasting glucose (hazard ratio 1.053, p = 0.007) was associated with worse mortality for INOCA without DM (N = 501). On the contrary, a higher eGFR (hazard ratio 0.967, p = 0.012) was protective of better survival for non-diabetic INOCA (N = 501). In conclusion, for non-diabetic INOCA, higher fasting glucose was associated with worse mortality and higher eGFR was protective for better survival.

BACKGROUND: There are sex differences in left ventricular ejection fraction (LVEF) relevant to prognosis where women experience greater mortality at relatively higher LVEF compared to men, yet mechanistic understanding of this adverse prognosis is limited. Women with suspected ischemia with no obstructive coronary disease (INOCA) develop heart failure with preserved ejection fraction (HFpEF), yet contributors to LVEF remain largely unknown.
METHODS: In 370 women with suspected ischemia with no obstructive coronary disease (INOCA) who prospectively underwent cardiac magnetic resonance imaging (CMRI), we investigated the contributions of LV morphology, function, and myocardial perfusion reserve on LVEF using univariate and multiple linear regression.
RESULTS: A majority 71% of participants had high LVEF (>65%), followed by 24% having normal LVEF (55-65%), and only 5% having low EF (<55%). Baseline characteristics were comparable among the three groups, with the exception of age which was six years higher in the high LVEF group (p<0.01). Women in the high LVEF group also had the lowest LV cavity volume, greatest LV mass-volume ratio, and highest LV end-systolic elastance (all p < 0.05, adjusted for age, BMI, diabetes, and blood pressure). Myocardial perfusion reserve index was low in all groups (mean MPRI < 2.1) but was not significantly different across the spectrum of LVEF (p=0.458).
CONCLUSIONS: Taken together, these data demonstrate that the majority of women with suspected INOCA have elevated LVEF related to smaller, thicker ventricles with greater contractility. Future work is needed to better understand the specific mechanisms driving morphologic and functional changes in women with INOCA, and relations to longer-term HFpEF and mortality.
BACKGROUND: NCT02582021.

BACKGROUND: Myocardial ischemia can occur due to several causes, which result in an imbalance between the supply and demand of oxygen to cardiac muscles. One potential reason for this condition is the overwork of the heart due to hyperstimulated thyroid function.
METHODS: The patient was a 36-year-old woman who presented with left-sided chest pain, dyspnea, palpitation, and tremor. The initial evaluation showed evidence of myocardial ischemia (positive high-sensitivity troponin) caused by a hyperactive thyroid gland. The treatment for myocardial infarction, along with anti-thyroid medications, improved the patient\'s condition and subsided the symptoms. The coronary angiography revealed no pathologic finding, and the hypokinetic left ventricle, observed in the first echocardiogram, was resolved. The patient was discharged with an excellent clinical condition, and after the 4-month taking of a calcium channel blocker and tapering carbimazole, the thyroid function became normal, and her symptoms resolved completely.
CONCLUSIONS: Patients without evident risk factors for ischemic heart disease, such as non-diabetic, nonsmoker, and young individuals who presented with acute coronary syndrome, should be evaluated for a potential background reason for the imbalance between the oxygen demand and supply of the myocardium. The presence of palpitation, weight loss, tremors, insomnia, and anxiousness, along with ischemic signs, should make the physician think about the probability of the hyperthyroid-induced cardiovascular disorder.
UNASSIGNED: The initial presentation of hyperthyroidism might be accompanied by severe cardiac symptoms. When the demographic features are not aligned with usual ischemic heart disease, other probable symptoms and signs should be investigated, and thyroid function should be checked. The control of thyroid hyperactivity would result in the resolution of both cardiac and non-cardiac symptoms.

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Cardiovascular disease is the predominant cause of mortality on a global scale. Research indicates that women exhibit a greater likelihood of presenting with non-obstructive coronary artery disease (CAD) when experiencing symptoms of myocardial ischemia in comparison to men. Additionally, women tend to experience a higher burden of symptoms relative to men, and despite the presence of ischemic heart disease, they are frequently reassured erroneously due to the absence of obstructive CAD. In cases of ischemic heart disease accompanied by symptoms of myocardial ischemia but lacking obstructive CAD, it is imperative to consider coronary microvascular dysfunction as a potential underlying cause. Coronary microvascular dysfunction, characterized by impaired coronary flow reserve resulting from functional and/or structural abnormalities in the microcirculation, is linked to adverse cardiovascular outcomes. Lifestyle modifications and the use of anti-atherosclerotic and anti-anginal medications may offer potential benefits, although further clinical trials are necessary to inform treatment strategies. This review aims to explore the prevalence, underlying mechanisms, diagnostic approaches, and therapeutic interventions for coronary microvascular dysfunction.
A doença cardiovascular é a causa predominante de mortalidade em escala global. A pesquisa indica que as mulheres, em comparação aos homens, apresentam maior probabilidade de apresentar doença arterial coronariana (DAC) não obstrutiva quando têm sintomas de isquemia miocárdica. Além disso, as mulheres tendem a apresentar uma maior carga de sintomas em relação aos homens e, apesar da presença de doença cardíaca isquêmica, são frequentemente tranquilizadas erroneamente devido à ausência de DAC obstrutiva. Nos casos de cardiopatia isquêmica acompanhada de sintomas de isquemia miocárdica, mas sem DAC obstrutiva, é imperativo considerar a disfunção microvascular coronariana como uma potencial causa subjacente. A disfunção microvascular coronariana, caracterizada por reserva de fluxo coronariano prejudicada resultante de anormalidades funcionais e/ou estruturais na microcirculação, está associada a desfechos cardiovasculares adversos. Modificações no estilo de vida e o uso de medicamentos antiateroscleróticos e antianginosos podem oferecer benefícios potenciais, embora sejam necessários mais ensaios clínicos para informar estratégias de tratamento. Esta revisão tem como objetivo explorar a prevalência, mecanismos subjacentes, abordagens diagnósticas e intervenções terapêuticas para disfunção microvascular coronariana.