Shyla Gupta

Electrocardiography (ECG) is a critical diagnostic tool for identifying cardiac conditions. While standard lead positions are widely used to ensure diagnostic accuracy, alternative lead placements have been developed to address specific clinical scenarios. These alternative configurations can overcome physical or technical challenges, enhance rhythm assessment, improve signal quality, and provide greater specificity for certain conditions, ultimately enabling more personalized diagnostic strategies. This paper examines the clinical significance of alternative ECG lead positions, highlighting their advantages, limitations, and potential applications in various clinical settings.

The current guidelines contraindicate intravenous amiodarone in patients with Wolff-Parkinson-White syndrome presenting with preexcited atrial fibrillation (AF) due to the risk of degeneration into ventricular fibrillation (VF). However, these recommendations are based predominantly on isolated case reports, which is concerning given the drug’s widespread global use as a first-line antiarrhythmic in resource-limited settings. To evaluate the safety of intravenous amiodarone in this context, we conducted a systematic review of (1) studies enrolling patients with electrocardiographically confirmed preexcited AF who received intravenous amiodarone and (2) studies quantifying antegrade accessory-pathway effective refractory period during intravenous amiodarone administration. All observational and interventional studies assessing patients with preexcited AF were pooled under a conjugate β–binomial model with prespecified weak priors to estimate the risk of VF during or following infusion. Concomitantly, to assess real-world access to alternative class IIa/IIb European Society of Cardiology-recommended antiarrhythmic agents for preexcited AF, we performed a multinational survey of Latin American emergency departments. Twelve studies comprising 177 patients were included in the review (7 case reports, 2 cohorts, 3 before-and-after interventional studies). Four case reports described transient ventricular rate acceleration or VF following intravenous amiodarone. However, across the observational and interventional cohorts assessing patients with preexcited AF (n=146), no acceleration or VF was observed. The posterior mean estimates of VF risk ranged 0.12% to 0.68% over priors. Across 3 interventional before-and-after studies, there was a significant increase in the anterograde effective refractory period of the atrioventricular node and AP following amiodarone administration. The survey responses from 10 emergency centers indicated that none had access to class IIa/IIb indicated agents, while all had intravenous amiodarone available. Taken together, population-level evidence suggests that the risk of VF in preexcited AF following intravenous amiodarone administration is rare. In settings where guideline-recommended drugs are inaccessible, intravenous amiodarone may represent a clinically reasonable alternative for rhythm or rate control.

Background and Aims: Perianal fistulising Crohn's disease (pfCD) is a heterogeneous phenotype of Crohn's disease with marked variability in anatomical complexity, symptomatology, and disease trajectory. This often creates uncertainty in the optimal approach to management, particularly the surgical aspects of when to perform examination under anaesthesia (EUA) and when to insert or remove setons. Methods: We conducted a systematic review following PRISMA guidelines. Multiple databases were searched from inception through December 2025. Eligible publications included clinical guidelines on pfCD and/or rectovaginal fistulas that reported indications for EUA, seton insertion, and/or seton removal. We stratified recommendations by fistula complexity, the presence of abscesses, and clinical symptoms. Risk of bias was assessed using the AGREE II Instrument. Results: Twenty‐four guidelines met inclusion criteria. EUA (and often seton placement) was universally recommended for perianal abscesses and frequently for symptomatic complex pfCD. For asymptomatic complex or symptomatic simple fistulas, recommendations were variable and often conditional on the presence of proctitis or plans for biologic therapy. In contrast, EUA and setons were not broadly endorsed for asymptomatic simple fistulas. Recommendations for seton removal varied widely, ranging from predefined intervals after anti‐TNF therapy initiation to individualised criteria based on clinical or radiologic response. Most guidelines did not consider symptom type/severity, prior surgery, suitability for surgical closure, and asymptomatic abscesses detected by imaging. Conclusion: Substantial heterogeneity and limitations exist across guidelines on the surgical management of pfCD. This underscores the need for international consensus informed by multidisciplinary expertise to standardise care in this complex population.

Introduction: Immunization rates against influenza and pneumococcus in Latin America remain lower than expected, particularly in Andean region, Central America, Mexico, and Caribbean region. An incremental correlation between economic strata and educational level and vaccines uptake has been observed. This highlights the need for more comprehensive data to accurately characterize the current health landscape and develop strategies for improvement. Methods and Design: The Inter-American Registry of Influenza and Pneumococcal Vaccination (CorVacc Study) is a cross-sectional survey of the general population conducted across 19 Latin American countries. Adults aged 18 years and older completed a 34-question online survey. The pool was validated within the first 1000 responses. Data were grouped into seven categories: demographics, socioeconomic and educational level, cardiometabolic profile, cardiovascular interventions, medical follow-up and treatments, and COVID-19 vaccination status. Results: A total of 21,389 responses were obtained, distributed as follows: 8915 from the North, Central, and Caribbean region; 7492 from the Andean region; and 4801 from the Southern Cone region. Influenza vaccination rates were lower in the Andean region (OR: 0.62; 95% CI: 0.50–0.78), the Caribbean (OR: 0.30; 95% CI: 0.23–0.39), and Central America (OR: 0.59; 95% CI: 0.46–0.76) compared with the Southern Cone. Residing in Central America (OR: 3.06; 95% CI: 1.62–5.77) was associated with greater pneumococcal vaccination. The probability of being vaccinated against influenza was higher in men (OR: 1.3; 95% CI: 1.1–1.6) and in individuals with obesity (OR: 1.26; 95% CI: 1.13–1.40). COPD was associated with a lower probability of pneumococcal vaccination (OR: 0.51; 95% CI: 0.33–0.79). Conclusions: This study highlights the importance of targeted vaccination campaigns to improve coverage, particularly in regions with lower rates. It also underscores the need for enhanced education and awareness of the benefits of vaccination. Tackling barriers such as vaccine hesitancy and misinformation will be essential for raising vaccination rates and, ultimately, for reducing the burden of cardiovascular disease.

Review Article A narrative review of electrocardiogram manifestation of myocardial infarction with non-obstructive coronary arteries (MINOCA) Arshdeep Raul, Shyla Gupta, Annie Hung, Hasan Alturki, Amin Meghdadi, Sebastian Garcia-Zamora, Sanoj Chacko, Norberto Bornancini, Martha Gulati, Adrian Baranchuk

Introduction: Among professional athletes, high altitude training is a popular technique due to its documented success on improving cardiovascular health and athletic performance. Nevertheless, there is little consensus on the guidelines for high altitude training and competition. This review sought to summarize existing literature for acclimatization recommendations for competing at high altitudes and suggests a blueprint that could be followed by athletes and trainers. Methods: This paper is part of the Altitude Nondifferentiated ECG Study (ANDES) project. A non-systematic search was conducted using Pubmed, EMBASE and MEDLINE databases. Results: Six studies were included, all of which recommended a gradual ascent before competition. The duration of acclimatization ranged from 4 days to 2 weeks depending on the magnitude of ascent. Athletes are encouraged to have pre-ascent assessments of ferritin, transferrin, hemoglobin mass, ECG, and weight with close monitoring of adverse altitude-induced complications. Conclusion: This study provides insight on key recommendations for athletes and trainers to consider when training and competing at high altitudes. These strategies can optimize athletic performance and mitigate deleterious altitude effects that can hinder functionality and training.