Heart rate variability (HRV) is one of the promising emerging noninvasive modalities that are extensively used nowadays in research and risk stratification of several diseases. Reduced HRV has been linked to several cardiovascular risk factors such as hypertension (HTN) and diabetes mellitus (DM) also; it has been linked and used for years now in the risk stratification of congestive heart failure, coronary artery disease (CAD), and acute myocardial infarction (AMI). Controversial data are present about the effect of coronary artery bypass graft (CABG) on HRV and the use of HRV for risk stratification in post-CABG patients while percutaneous coronary intervention was linked to a dramatic improvement in HRV and improved survival of CAD patients. Although experimental data are present correlating reduced HRV with increased risk for cardiovascular morbidity and mortality, extensive research is required for further implementation in daily clinical use. In this review, we will discuss the current cardiovascular clinical implications and highlight the limitations of usage and future perspective of HRV.

Introduction: Stroke was the second-leading global cause of death accounting for 11.8% of total deaths worldwide and a leading cause of disability. Stroke was the leading cause of death in Indonesia accounting for 21.1% of them. Knowledge is essential for the prevention of stroke and minimizing delay in receiving proper treatment. Methods: This was a cross-sectional observational study using a questionnaire consisting of questions about signs, symptoms, and risk factors for stroke in the Indonesian Language with a minimal amount of technical jargon. There were 113 respondents, 49 has a medical background (11 was medical doctors) and 64 was from a nonmedical background. Results: Majority of the nonmedical personnel knew that hemiparesis is a symptom of stroke, but only a third knew that hemihypesthesia is one of the symptoms. Approximately half knew that dysarthria and uneven face is a symptom of stroke. Only a few knew that sudden loss of vision is a symptom of stroke. Hypertension and hypercholesterolemia were the two most popular risk factors among nonmedical personnel, other risk factors were only known to <40% of the respondents. After comparing the results between medical and nonmedical personnel, medical personnel was more confident about their knowledge (P < 0.001). The difference was also statistically significant in hemihypesthesia (P = 0.029) and sudden loss of vision (P = 0.032). The difference was statistically significant when assessing several risk factors such as arrhythmia (P = 0.004), smoking (P = 0.004), hypertension (P = 0.001), diabetes (P < 0.001), and atrial fibrillation (P < 0.001). Disappointingly, both groups performed poorly in recognizing menopause as a risk factor. Conclusion: The knowledge about the symptoms and signs of stroke other than hemiparesis was poor in nonmedical personnel. Medical personnel was only slightly better than nonmedical personnel. This is a wake-up call to emphasize the importance of stroke, its prevention and early recognition.

Aim: Red blood cell distribution width (RDW) and epicardial fat tissue (EFT) are considered as a novel risk factor for cardiovascular disease. However, their relationship in patients with type II diabetes mellitus (DM) has never investigated before. Materials and Methods: Our study was a single-center prospective study which included 159 diabetic patients and 153 healthy controls. Two-dimensional and M-mode echocardiographic examination was performed using standard apical, parasternal, and subcostal views in all the study participants. Results: EFT thickness and RDW were found to be significantly higher in diabetic patients compared to controls (4.3 ± 1.1 mm vs. 3.7 ± 1.0 mm P = 0.001 and 13.5 ± 0.7 vs. 13.2 ± 0.9 P = 0.044, respectively). EFT thickness and RDW were positively correlated. RDW value of 13.55 predicted EFT thickness >5 mm with a sensitivity of 61.7% and specificity of 58.8% (area under the curve [AUC]: 0.649 and P = 0.001). HgA1C value of >7 predicted EFT thickness ≥4.15 mm with a sensitivity of 60.7% and specificity of 60.4% (AUC: 0.651 and P < 0.001). No correlation found between RDW and HgA1C (AUC: 0.554 and P: 0.169). Conclusion: EFT thickness increased in diabetic patients, independent of age, gender, waist circumference, body mass index, and it was correlated with RDW and HgA1C.

Background: T wave inversion in leads with ST-segment elevation after reperfusion therapy is considered a sign of reperfusion. However, the significance of T wave inversion on presentation before the initiation of reperfusion therapy is unclear. Aim of the Work: The current study aimed to assess whether the initial T wave morphology in the electrocardiographic (ECG) at presentation can predict patency of the left anterior descending artery (LAD) in patients with acute anterior ST segment elevation myocardial infarction (STEMI) before undergoing primary percutaneous coronary interventions (PCIs). Methods: This study included ninety patients who presented to the emergency department with acute anterior ST-elevation MI. We excluded patients with bundle branch block, postcoronary artery bypass grafting patients, patients with paced rhythm, and patients who received thrombolytic therapy. The T wave morphology in the 2 leads with maximal ST-segment elevation on the presenting ECG was identified as one of the three morphologies, positive T waves (T+; initial positive deflection ≥0.5 mm above the isoelectric line), biphasic T waves (T+/−; where the T wave initially showed a positive deflection above the ST segment afterward followed by a negative deflection ≥0.5 mm below the isoelectric line), and negative T waves (T−; where the T wave initially showed a negative deflection ≥0.5 mm below the isoelectric line without showing any initial positive deflection). Then, according to the results of the initial angiography, patients were classified into spontaneous reperfusion (SR) (those with thrombolysis in MI [TIMI] II or TIMI III flow in the infarct-related artery [IRA] prior to intervention) or non-SR (those with TIMI 0 or TIMI I flow in the IRA prior to intervention). Results: Ninety consecutive patients (77 males and 13 females) presented by STEMI and treated by primary PCI at cath lab of Ainshams University Hospitals (a 24/7 tertiary referral center for primary PCI) between January 2015 and March 2016 were included in this study, of which 40 patients (44.4%) had positive T waves (T+), 34 patients (37.8%) had negative T waves (T−), and 16 patients (17.8%) had biphasic T waves (T+/−). Initial angiogram showed that 18 patients had SR and 72 patients had no SR. With regard to T wave morphology, negative T waves were significantly present in SR group (66.7% vs. 30.6%, P = 0.004), whereas positive T waves were predominantly present in non-SR (50% vs. 22.2%, P = 0.033). Conclusions: For SR of LAD in anterior STEMI patients, prior to primary PCI, T wave inversion had a good sensitivity of 66.7%, a specificity of 69.4%, and a good negative predictive value of 89.29%.

Aim: Previous data reflected confusions about classification and management of atrial fibrillation (AF) among physicians. Although relatively clear suggestions of dedicated guidelines, poor adaptation of them to routine clinical practice may result with suboptimal prevention and treatment measures. As a main stakeholder of management, physicians' perceptions about the disease have major role. The study aimed to assess confusions and concordances of physicians about the definition and management of the disease. Methods and Results: We developed a web-based survey about AF consisting of 27 questions regarding valvular or non-valvular AF perception, using thromboembolic and bleeding risk scores, antithrombotic management and rate/rhythm control strategies. Two hundred and thirty two physicians participated and 224(97%) of them completed the survey. Although only cardiologists were invited to the survey, 27 physicians from different specialties also responded the survey. Half of the physicians reported that ≥40% of their patients had valvular AF. Dramatically, the survey responses revealed that nearly one-third of physicians classified the AF patients with mitral regurgitation as valvular AF. Most of the physicians denoted that they were using bleeding and stroke risk scores before deciding oral anticoagulation therapy and also preferring long term rhythm-control strategy in AF patients with systolic heart failure. However, results exposed evident disparities among physicians at specific aspects of the disease management. Conclusion: The survey-based study demonstrated a great heterogeneity in classification and management of AF among physicians because of guideline confusions/failures, inadequate evidence about some specific conditions and not being able to dominate the guidelines by physicians.

The great majority of atrial fibrillation cases originate from pulmonary vein (PV) triggers; however, non-PV triggers may be the drivers of the arrhythmia, especially in the patients with a persistent left superior vena cava (PLSVC). The presence of a PLSVC may be suggested with a dilated coronary sinus on transesophageal echocardiography during the procedure and may be confirmed with an atrial angiogram, if not known beforehand. Detection and elimination of true trigger site are the most important step for clinical success in such cases.

40 years old female with prosthesis aortic valve had developed shortness of breath and consulted to our clinic on the first postpartum day. Her dyspnea was worsened at the last week. She had a history of Bentall operation before 16 years ago, and had a bi-leaflet mechanical prosthetic valve. After detection of pregnancy, her warfarin treatment had switched to enoxaparine 6000 IU subcutaneously for twice a day, continued throughout the pregnancy. Her weight was 62 kg. She did not have any blood test for factor Xa. On physical examination, she has orthopnea, tachypnea (24/min), tachycardia (128 bpm) and hypotension (85/55 mmHg). Electrocardiogram was uneventful with sinus tachycardia of 128 bpm with normal axis. Echocardiography revealed normal left ventricle size with left ventricle hypertrophy, ejection fraction of 60%, reduced motion of prosthetic-valve leaflets and an obstructing mass between the struts. Doppler ultrasonography showed that prosthetic aortic valve has a pressure gradient of 104/59 mmHg. These findings were consistent with prosthetic thrombosis. Moderate aortic regurgitation into the left ventricle was also detected. Transesophageal echocardiography showed 1.4 × 2.3 cm thrombotic material located over leaflets and adjacent to the posterior aortic wall. It was restricting the valve motion. The patient underwent emergency operation immediately. The thrombotic material over mechanical valve was extracted and there was no pathology seen on mechanical valve, graft repaired primarily. Postoperative recovery was fine. No bacteria were detected both direct microscopy and culture.