Armin Attar

Pseudoaneurysm of the mitral‐aortic intervalvular fibrosa (P‐MAIVF) is a rare condition resulting from dehiscence of the mitral‐aortic intervalvular fibrosa (MAIVF), leading to the formation of a sac communicating with the left ventricular outflow tract (LVOT). P‐MAVIF is caused mainly by infective endocarditis (IE) or trauma during medical procedures. Only six cases of blunt chest wall trauma‐induced P‐MAIVF have been reported, and our case is the first to report its long‐term complications. A 32‐year‐old man is reported with a history of a motorcycle accident that was referred due to a to‐and‐fro murmur. The echocardiographic evaluation one year after the accident revealed P‐MAIVF, and the patient was advised to undergo an operation, but he refused. Three years later, he returned with New York Heart Association (NYHA) class III dyspnea associated with orthopnea. A new transesophageal echocardiogram (TEE) confirmed a large P‐MAIVF with a dilated, dysfunctional left ventricle (LV). At this time, the patient underwent surgical intervention, and six months after the operation, he became asymptomatic, and cardiac function returned to normal. Our case is the first to report a long‐term complication of a blunt chest wall trauma‐induced P‐MAIVF, and our findings once again confirm the fact that early surgery and repair are a wise and appropriate decision for such patients.

Clopidogrel is the guideline-recommended P2Y12 inhibitor for dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) in Chronic Coronary Syndrome (CCS). Recent evidence suggests potential benefits of more potent P2Y12 inhibitors, primarily Ticagrelor, though their role in CCS remains less defined than in acute settings. To compare the efficacy and safety of Ticagrelor or Prasugrel with Clopidogrel in DAPT following PCI in CCS patients. A systematic approach was used to identify eligible randomized controlled trials (RCTs) and observational studies comparing the safety and efficacy of Ticagrelor or Prasugrel versus Clopidogrel. A meta-analysis using a random-effects model evaluated major adverse cardiovascular events (MACE), its individual components, and bleeding outcomes. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed by study design, P2Y12 inhibitor type, follow-up duration, and geographical region. Twelve studies (6 RCTs, 6 observational) were included, comprising 10,048 patients receiving potent P2Y12 inhibitors (Ticagrelor: 10 studies; Prasugrel: 3 studies) and 45,103 receiving Clopidogrel. Potent P2Y12 inhibitors were associated with a significantly reduced risk of MACE (OR = 0.69, 95% CI: 0.55–0.88) and all-cause mortality (OR = 0.63, 95% CI: 0.46–0.88). These benefits were primarily driven by the Ticagrelor subgroup, observational data, follow-up > 6 months, and Asian studies. While no significant differences were found for myocardial infarction, stroke, or overall stent thrombosis, the Ticagrelor subgroup showed a significantly lower risk of revascularization (OR = 0.67, 95%CI: 0.52–0.86). Regarding safety, while major bleeding showed a non-significant trend toward increase (OR = 1.41, 95% CI: 0.92–2.17), minor bleeding was significantly higher in the potent P2Y12 group (OR = 1.56, 95% CI: 1.26–1.95). This meta-analysis suggests that intensified DAPT, primarily Ticagrelor-based, may offer superior clinical benefit to Clopidogrel-based DAPT in patients with CCS undergoing PCI, particularly by reducing MACE, all-cause mortality, and revascularization. However, these benefits are accompanied by an increased risk of minor bleeding and a potential signal toward higher major bleeding. Considering the scarcity of large-scale RCTs, heterogeneous MACE definitions, limited data on Prasugrel, and ethnic/racial influence on bleeding risk and thrombotic events, these findings emphasize the need for individualized post-PCI antiplatelet regimens and support further long-term RCTs to better define the role of potent P2Y12 inhibitors in this population. The online version contains supplementary material available at 10.1186/s12872-026-05781-1.

Background and Aims: Electrocardiographic (ECG) markers may provide incremental prognostic value for cardiovascular disease (CVD) events beyond traditional ASCVD risk scores. This study aimed to evaluate the association between baseline ECG parameters and the incidence of cardiovascular events over 5 years in a nested case‐control cohort. Methods: We analyzed 442 participants from the Shiraz Heart Study, including 221 individuals who experienced CVD events and 221 ASCVD risk‐matched event‐free controls. Detailed ECG parameters and clinical variables were evaluated. Multivariable logistic regression, including a prespecified 22‐variable model and LASSO penalized regression, was used to identify independent ECG predictors. Model performance was assessed using bootstrap‐corrected area under the curve (AUC). Results: In multivariable analyses, ST‐segment coving (OR 7.57, 95% CI 2.09–27.4, p = 0.002) and shorter PR interval (OR 0.98 per ms decrease, 95% CI 0.95–1.00, p = 0.036) remained independent predictors of incident CVD events in the prespecified 22‐variable model, which was constructed based on clinical relevance and supported by univariable analyses. This model demonstrated excellent discrimination (bootstrap‐corrected AUC 0.97, 95% CI 0.96–0.98). In the parsimonious four‐variable LASSO model, ST‐segment coving (OR 4.31, 95% CI 1.38–13.0) and PR interval (OR 0.977, 95% CI 0.961–0.992) remained independent predictors, and model performance remained robust (bootstrap‐corrected AUC 0.96, 95% CI 0.94–0.98). Other ECG features, including prolonged QTc, abnormal R‐wave progression, left ventricular hypertrophy, and T‐wave inversions, were significant in univariable analyses but did not remain independent predictors in multivariable models. Conclusion: Baseline ECG parameters provide independent prognostic information for cardiovascular events beyond traditional ASCVD risk factors. These findings highlight the potential of ECG markers to enhance risk stratification, although external validation in larger and diverse populations is warranted before clinical implementation.

Background and Aims: This systematic review and meta‐analysis aimed to compare the clinical outcomes of antihypertensive medication administration at bedtime versus morning, focusing on major adverse cardiovascular events (MACE), mortality, and secondary cardiovascular outcomes in hypertensive patients. Methods: We conducted a systematic search across multiple databases to identify randomized controlled trials (RCTs) comparing bedtime versus morning antihypertensive dosing. Studies were included if they evaluated MACE, all‐cause mortality, or cardiovascular mortality. Myocardial infarction, stroke, and heart failure were considered secondary outcomes. Data were extracted, and statistical analysis was performed using hazard ratios and mean differences with 95% confidence intervals. A random‐effects model with Hartung–Knapp correction was used to account for between‐study heterogeneity. Sensitivity analyses were conducted to assess the robustness of the results. Results: Five studies with 36,477 patients (42.30% male) were included. No significant differences were found between bedtime and morning dosing for MACE (HR: 0.71, 95% CI: 0.43–1.15, p = 0.11) and mortality outcomes (all‐cause HR: 0.76, 95% CI: 0.50–1.16, p = 0.14; cardiovascular HR: 0.54, 95% CI: 0.08–3.86, p = 0.31). These findings, which showed substantial heterogeneity (I² > 90%), were consistent in sensitivity analyses. Also, for secondary outcomes, there were no significant differences observed in myocardial infarction (HR: 0.79, 95% CI: 0.49–1.29, p = 0.26), stroke (HR: 0.61, 95% CI: 0.32–1.17, p = 0.10), or heart failure (HR: 0.64, 95% CI: 0.37–1.08, p = 0.07). Conclusion: This meta‐analysis found no significant difference in cardiovascular outcomes between bedtime and morning antihypertensive dosing. Within the limitations of the available evidence, a universal chronotherapy strategy does not appear to provide additional cardiovascular benefit. Once‐daily antihypertensive medications can be taken at a time that aligns with the patient's lifestyle, with adherence being the most critical factor in ensuring treatment effectiveness.

Background: Beta‐blockers are regarded as one of the primary treatment options for acute coronary syndrome (ACS) patients with reduced left ventricular ejection fraction (LVEF). However, there is ongoing debate about their therapeutic efficacy in patients with non‐reduced LVEF (≥ 40%). Objective: To determine the impact of long‐term beta‐blocker administration on major adverse cardiovascular events (MACE) in ACS patients with LVEF ≥ 40 % . Methods: A thorough literature search across four databases was conducted to identify eligible studies comparing beta‐blocker therapy with placebo or no medication in addition to standard ACS pharmacotherapy. The outcomes of interest included all‐cause mortality and MACE (comprising cardiovascular mortality, recurrent myocardial infarction [Re‐MI], stroke, rehospitalization for heart failure, and revascularization). Based on LVEF values, patients were divided into three groups: (1) LVEF > 40 % , (2) 40 % < LVEF < 50 % , and (3) LVEF ≥ 50 % , and the random‐effects meta‐analysis estimated the risk ratios (RRs), hazard ratios (HRs), and 95% confidence intervals (CIs). Results: Five randomized controlled trials (RCTs) and 19 observational studies met the inclusion criteria. Within the RCTs, beta‐blocker use was associated with a non‐significant 6% reduction in MACE (RR = 0.94, 95 % CI = 0.87–1.02, I ² = 19.1 % ). The pooled analyses of observational studies showed no significant overall impact of beta‐blocker use on endpoint outcomes. Subgroup analyses revealed a reduction in MACE (HR = 0.75, 95 % CI = 0.59–0.95, I ² = 0 % ) and Re‐MI (HR = 0.45, 95 % CI = 0.23–0.89) in patients with LVEF 40%–49%; however, these findings were derived primarily from observational data. Patients with LVEF ≥ 50 % did not appear to benefit from long‐term beta‐blocker use. Conclusion: Long‐term beta‐blocker use did not show a significant benefit in patients with preserved ejection fraction (LVEF ≥ 50 % ). Observational data suggested a possible reduction in MACE and Re‐MI in the LVEF 40%–49% subgroup; however, this finding requires confirmation in dedicated RCTs. Future larger RCTs are needed to clarify the role of beta‐blockers in this borderline population.

Mirhosseini SA, et al. Clin Hypertens. 2026 Jan;32:e4. https://doi.org/10.5646/ch.2026.32.e4

Stem cell therapy has emerged as a potential regenerative approach for Acute myocardial infarction (AMI). Despite decades of research and advancement in ac

An Erratum to this paper has been published: https://doi.org/10.1134/S0026893325070015

Perforation of the right internal mammary artery (RIMA) is an extremely rare vascular complication associated with the transradial approach (TRA) to coronary angiography. A 75‐year‐old woman presented with weakness. ECG revealed atrial fibrillation with long pauses. Echocardiography showed severe left ventricular (LV) systolic dysfunction (LVEF: 20%). During coronary angiography, an unintended passage of a hydrophilic wire into the RIMA caused tissue staining indicative of severe spasm without perforation. The patient was initially managed conservatively, but then she experienced a significant drop in hemoglobin. Subsequent CT angiography revealed a mediastinal hematoma. The patient was emergently transferred to the catheterization laboratory, where angiography confirmed RIMA perforation with dye extravasation. Despite the unsuccessful balloon tamponade, a 2.5 × 21 mm covered stent was deployed, successfully sealing the perforation. This case is distinctive as one of the very few reported RIMA perforations complicating TRA coronary angiography. It emphasizes the importance of vigilance even when early angiography shows no clear perforation and highlights covered stenting as a life‐saving option when balloon tamponade is unsuccessful. Knowing the possible complications of the TRA, specifically during hydrophilic guidewire maneuvers, empowers us to recognize and manage these complications promptly.