Nishanth Thiagarajan

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized non-atherosclerotic cause of acute coronary syndrome (ACS), particularly affecting young women in the peripartum or postpartum period. We report the case of a 39-year-old woman, 3 months postpartum and breastfeeding, who presented with acute central chest pain radiating to the left arm and associated dyspnea. She had no cardiovascular risk factors. Her electrocardiogram showed dynamic T-wave inversions in the anterolateral leads, and high-sensitivity troponin-T was elevated at 454 ng/L. Transthoracic echocardiography demonstrated a left ventricular ejection fraction of 45% with apical hypokinesis. Coronary angiography demonstrated a 99% stenosis in the mid-left anterior descending artery, consistent with type 2 SCAD. The patient was hemodynamically stable and managed conservatively with beta-blocker, ACE inhibitor, and dual antiplatelet therapy. Breastfeeding was discontinued following shared decision-making due to concerns over medication safety. Screening for fibromuscular dysplasia with CT angiography of the carotid and renal arteries was unremarkable. At 6 months, CT coronary angiography showed complete resolution of the dissection and normal coronary anatomy, allowing cessation of antiplatelet therapy in line with the patient’s preference to resume breastfeeding. Interval echocardiography also demonstrated recovery of left ventricular ejection fraction to 62%. This case highlights the importance of considering SCAD in young postpartum women presenting with ACS. Prompt diagnosis and tailored conservative management can result in excellent outcomes. Longitudinal imaging, medication review, and reproductive counselling are essential in the follow-up of such patients with the need for patient-centered care in the context of breastfeeding and future pregnancies.

Background: Self-monitoring of blood glucose (SMBG) using web-based diabetes management platforms has demonstrated promise in managing type 2 diabetes (T2D). However, the effectiveness of such systems incorporating algorithm-guided insulin titration has not been extensively studied in Asian populations. Objective: This study evaluates the efficacy and safety of the ALRT telehealth solution—a US Food and Drug Administration–cleared, web-based platform that integrates SMBG with algorithm-driven insulin dose adjustments—in improving glycemia in insulin-treated T2D. Methods: This 24-week, pre-post intervention study enrolled 25 adults with T2D (mean age 58.9, SD 7.0 y; n=14, 56% male) on twice-daily premixed insulin. Inclusion criteria included a baseline hemoglobin A_1c (HbA_1c) level between 7.5% to 9.9% (58‐86 mmol/mol), a BMI ≤40 kg/m², and experience with SMBG. Participants uploaded twice-daily SMBG data weekly via a mobile app, which generated insulin titration recommendations based on a predefined algorithm. Physicians reviewed and approved the recommendations, which were then communicated back to participants via the app. The primary outcome was the change in HbA_1c level from baseline to 24 weeks. Secondary outcomes included changes in fasting plasma glucose, insulin dose, hypoglycemia incidence, and SMBG adherence. Results: Participants achieved significant reductions in HbA_1c level from 8.6% (70 mmol/mol) at baseline to 7.4% (57 mmol/mol) at 24 weeks (P<.001), with reductions of 0.8% and 0.4% in the first and second 12 weeks, respectively. Fasting plasma glucose decreased from 8.7 (SD 2.0) mmol/L to 7.1 (SD 1.4) mmol/L (P<.001). Mean total daily insulin dose increased modestly from 0.73 (SD 0.31) units/kg/day to 0.79 (SD 0.34) units/kg/day (P=.007). Participants demonstrated high adherence, completing 97.3% (327/336) of prescribed SMBG measurements. During the study, 48% (12/25) of participants experienced at least 1 hypoglycemia episode, predominantly mild hypoglycemia (85/96, 88.5%; glucose 3.0‐3.9 mmol/L). Hypoglycemia episodes increased from 24 during weeks 0‐12 to 72 during weeks 13‐24. There were no episodes of severe hypoglycemia requiring external assistance. BMI increased slightly from 29.0 (SD 3.6) kg/m² to 29.5 (SD 3.6) kg/m² (P=.03), reflecting a modest weight gain associated with improved glycemia. Conclusions: In conclusion, patients with insulin-treated T2D initiated on a web-based glucose monitoring system with algorithm-guided dosing recommendations showed significant improvement in glycemic control compared to baseline. High adherence rates underscore the feasibility of integrating algorithm-guided insulin titration into routine care. While hypoglycemia incidence rose slightly, episodes were predominantly mild, and no severe events occurred. This intervention shows promise for broader adoption in T2D management, particularly in resource-constrained settings.

BACKGROUND Self-monitoring of blood glucose (SMBG) using online diabetes management platforms has shown promise in type 2 diabetes (T2D) management. OBJECTIVE This study aimed to assess the effect of the ALRT Telehealth Solution, an FDA-cleared online platform incorporating SMBG with algorithm-guided insulin titration recommendations, on the hemoglobin A1c (HbA1c) in insulin-treated T2D. METHODS Adults with T2D on twice-daily premixed insulin, HbA1c ≥7.5% (58 mmol/mol) and <10% (86 mmol/mol), and BMI ≤40 kg/m² were enrolled. They measured blood glucose twice-daily and uploaded glucometer data weekly using the ALRT mobile-phone application, which then alerted physicians with algorithm-guided insulin titration recommendations. These were communicated back to participants via the app weekly. HbA1c and fasting plasma glucose (FPG) were measured at baseline, weeks 12 and 24. RESULTS We enrolled 25 adults (44.0% female, 52.0% Chinese), mean age 58.9 years. Adherence to twice-daily SMBG regimen was 97.4%. Over 24 weeks, mean total daily insulin dose increased from 0.73 to 0.79 units/kg/day. This led to a significant reduction in HbA1c from an average of 8.6% (70 mmol/mol) to 7.4% (57 mmol/mol) and FPG from an average of 8.7 to 7.1 mmol/L (both p<0.01). Most hypoglycemia events were mild (88.5%) (3.0-3.9 mmol/L), and the prevalence of hypoglycemia (<4.0 mmol/L) at 48.0% was similar to the self-reported baseline of 44.9%. There were more hypoglycemia episodes during the final 12 weeks of the study (72) than the first 12 weeks (25). CONCLUSIONS An internet-based glucose monitoring system with structured SMBG and algorithm-guided insulin titrations significantly improved glycemia in individuals with insulin-treated T2D without increasing hypoglycemia.

BACKGROUND: Electrocardiography (ECG) may be performed as part of preparticipation sports screening. Recommendations on screening of athletes to identify individuals with previously unrecognized cardiac disease are robust; however, data guiding the preparticipation screening of unselected populations are scarce. T wave inversion (TWI) on ECG may suggest an undiagnosed cardiomyopathy. This study aims to describe the prevalence of abnormal TWI in an unselected young male cohort and the outcomes of an echocardiography‐guided approach to investigating these individuals for structural heart diseases, focusing on the yield for cardiomyopathies. METHODS AND RESULTS: Consecutive young male individuals undergoing a national preparticipation cardiac screening program for 39 months were studied. All underwent resting supine 12‐lead ECG. Those manifesting abnormal TWI, defined as negatively deflected T waves of at least 0.1 mV amplitude in any 2 contiguous leads, underwent echocardiography. A total of 69 714 male individuals with a mean age of 17.9±1.1 years were studied. Of the individuals, 562 (0.8%) displayed abnormal TWI. This was most frequently observed in the anterior territory and least so in the lateral territory. A total of 12 individuals (2.1%) were diagnosed with a cardiomyopathy. Cardiomyopathy diagnoses were significantly associated with deeper maximum TWI depth and the presence of abnormal TWI in the lateral territory, but not with abnormal TWI in the anterior and inferior territories. No individual presenting with TWI restricted to solely leads V ₁ to V ₂ , 2 inferior leads or both was diagnosed with a cardiomyopathy. CONCLUSIONS: Cardiomyopathy diagnoses were more strongly associated with certain patterns of abnormal TWI. Our findings may support decisions to prioritize echocardiography in these individuals.