Indonesian Journal of Cardiology

Optimizing Revascularization Outcomes in Chronic Coronary Syndromes

2026-09-30T03:13:56+07:00

The value of coronary revascularization in Chronic Coronary Syndromes (CCS) depends on whether it delivers the benefit that justifies intervention. Anatomical, physiological, and plaque assessment inform patient selection, but each answers a different clinical question. Applying evolving trial evidence requires attention to the populations studied, outcomes measured, and durability of treatment. Procedural optimization and complete revascularization require the same clinical judgment, with imaging and devices serving defined treatment goals. Medical therapy remains essential regardless of the revascularization strategy. Follow-up connects the procedure to sustained prevention, rehabilitation, and assessment of symptoms and clinical events. Reviewing these outcomes against the original indication, together with the patient’s priorities, provides a practical basis for improving care.

The Difference Value of Global Pulse Wave Velocity between Type 2 Diabetic and Non-diabetic Patients with Chronic Coronary Syndrome

2026-09-29T13:08:13+07:00

Background: Coronary Heart Disease (CHD) remains a major health issue in Indonesia. CHD could lead to myocardial infarction and sudden death, highlighting the necessity for cardiovascular examination and appropriate management to prevent increased morbidity and mortality rates. One non-invasive method for assessing CHD was measuring arterial stiffness using Global Pulse Wave Velocity (PWVg). This study aimed to assess the difference in PWVg among patients with Chronic Coronary Syndrome (CCS) with or without Type 2 Diabetes (T2DM).

Methods: This was an analytical cross-sectional study to evaluate the difference in PWVg values among CCS patients with or without T2DM. The study used data from medical records and elective coronary angiography at the Dr. M. Djamil Teaching Hospital’s cardiac catheterization laboratory, where PWVg was measured by Doppler echocardiography examination of CCS patients from April 2023 to 2024. Normality testing using the Shapiro-Wilk test was performed before analyzing all numerical data, followed by independent t-tests or Mann-Whitney tests to determine intergroup differences.

Results: The study comprised 36 CCS patients, with 18 samples per group (with and without T2DM). In this study, males were more prevalent in the CCS group without T2DM, smoking risk factors were more commonly found in the CCS group without T2DM, higher Random Blood Glucose (RBG) was found in the CCS group with T2DM, and higher Ankle-Brachial Index (ABI) values were observed in the CCS group without T2DM. Based on statistical analysis, there was a significant difference in PWVg values between the CCS group with T2DM and the group without T2DM (8.3 + 0.7 m/s vs. 7.7 + 0.5 m/s, p=0.009).

Conclusion: T2DM results in higher PWVg values compared to those without T2DM among patients with CCS.

SYNTAX Score 2020 Risk Estimates Between PCI and CABG in Coronary Artery Disease : A Descriptive Study

2026-09-29T13:08:14+07:00

Background:

The SYNTAX Score 2020 is a validated tool that combines anatomical and clinical parameters to estimate long-term outcomes in CAD and guide revascularization decisions between PCI and CABG. Although its components are well defined, further studies are needed to clarify how clinical variables influence risk predictions in diverse populations, including Indonesia.

Methods:

This cross-sectional study enrolled 115 patients with angiographically confirmed CAD at dr. Doris Sylvanus Regional General Hospital, Palangka Raya, Indonesia, between January and June 2025. The SYNTAX Score 2020 and anatomical SYNTAX Score I were calculated using the official application. Statistical analyses included bivariate non-parametric tests, Spearman correlations, and multivariate linear regression to identify independent clinical determinants of the SYNTAX Score 2020–predicted 10-year mortality and 5-year MACE following PCI and CABG.

Results:

PVD and DM were strongly associated with a higher SYNTAX Score 2020–predicted 5-year MACE and 10-year mortality after both PCI and CABG, with a stepwise increase in risk from no DM to insulin-treated DM. LMCAD was associated with a higher CABG-predicted risk than 3VD, whereas smoking was not associated with predicted outcomes. Age and SYNTAX Score I were positively correlated with all risk estimates, whereas CrCl and LVEF were inversely correlated. In the multivariate models, age, PVD, DM, and lower LVEF remained independent predictors for both strategies; SYNTAX Score I remained significant only for PCI, and CrCl was no longer independently associated with risk.

Conclusion:

Age was the main independent predictor of a higher SYNTAX Score 2020 that predicted long-term risk, followed by PVD and diabetes (highest in insulin-treated DM). Higher LVEF was protective, and left main disease carried a higher predicted risk than three-vessel disease.

One-Year Outcomes of Major Adverse Cardiac Events in Patients with ST-Segment Elevation Myocardial Infarction Who Received Delayed PCI in a Type-B Hospital

2026-09-29T13:08:14+07:00

Background: Delayed Percutaneous Coronary Intervention (PCI) remains common in resource-limited hospitals due to system-related delays, often resulting in prolonged ischemic time. Although early reperfusion is the standard of care for ST-segment Elevation Myocardial Infarction (STEMI), delayed PCI may still be performed in selected, clinically stable patients. This study aimed to evaluate the one-year incidence of Major Adverse Cardiac Events (MACE) among STEMI patients undergoing PCI in a Type-B hospital, where delayed PCI was the predominant treatment pattern.

Methods: This retrospective cohort study included adult STEMI patients who underwent PCI at PKU Muhammadiyah Gamping Hospital, Yogyakarta, Indonesia, between September 2018 and December 2020. Patients with incomplete medical records or loss to follow-up were excluded. Baseline clinical characteristics, comorbidities, infarct location, and door-to-wire-crossing time were collected. MACE included all-cause mortality, acute pulmonary edema, non-ST-segment elevation myocardial infarction, stroke, and rehospitalization due to reinfarction or acute heart failure within one year after PCI. Kaplan-Meier survival analysis and Mann-Whitney testing were applied.

Results: Among 130 STEMI patients who underwent PCI, 123 (94.6%) received delayed PCI, with a median door-to-wire-crossing time of 10 hours 34 minutes. During one-year follow-up, MACE occurred in 10 patients (7.7%), corresponding to a 92.3% event-free survival rate. No significant association was observed between door-to-wire-crossing time and one-year MACE (p = 0.927).

Conclusions: In this single-center study conducted at a Type-B hospital, one-year MACE occurred in 7.7% of STEMI patients undergoing PCI, most of whom received delayed PCI. No significant association was observed between door-to-wire-crossing time and MACE occurrence. Given the observational design and the limited number of events, these findings should be interpreted with caution. Delayed PCI appears feasible in selected patients, but should not be considered equivalent to guideline-recommended early PCI.

Serum Endothelin-1 Level >2.0 pg/mL associates with High-Risk Duke Treadmill Score among Chronic Coronary Syndrome Patients

2026-09-29T13:08:15+07:00

Background: Chronic coronary syndrome (CCS) contributes to morbidity and increased risk of acute coronary syndrome within 5 years. Duke Treadmill Score (DTS) is the most robust risk stratification based on cardiac exercise stress test, which predicts 5-year survival. Those with high-risk DTS (DTS ≤11) had the least favorable survival. Endothelin-1, a potent vasoconstrictor peptide, affects the 5-year survival in CCS. This study aimed to investigate the association between serum endothelin-1 level and DTS risk stratification among Indonesian patients with CCS.

Methods: This was a cross-sectional study that recruited consecutive patients with CCS after Coronary Angiography (CAG). The DTS data were collected from the previous Treadmill Test (TMT) and were classified into high-risk DTS (DTS ≤-11) and low-moderate-risk DTS (DTS >-11). A serum sample for measuring endothelin-1 was withdrawn during CAG and used in the ELISA protocol. A high endothelin-1 level was defined as > 2.0 pg/mL. An association between variables was assessed using statistical analysis (significance at p < 0.05).

Results: Eighty subjects were enrolled. Median time interval of TMT and endothelin-1 measurement was 30 days. Mean age was 58.48±8.73 years old, with males predominant (82.5%). Hypertension (71.3%) and previous Acute Coronary Syndrome (ACS) (52.5%) were dominant. The proportion of subjects with high-risk DTS was 52.5%. Median endothelin-1 level was 1.8 pg/mL (range: 0.4 - 6.8 pg/mL). Serum endothelin-1 level > 2.0 pg/mL was observed in 34 subjects (42.5%), of whom 23 (67.6%) had high-risk DTS. There was a significantly increased risk of high-risk DTS in subjects with serum endothelin-1 >2.0 pg/mL (OR 2.97; 95% CI 1.18-7.51; p=0.020). Based on bivariate analysis, two variables, namely hypertension (p=0.052) and history of ACS (p=0.036), were also significantly associated with high-risk DTS. In multivariate analysis, endothelin-1 level >2.0 pg/mL had an adjusted OR of 1.75 (95% CI: 0.60-5.13, p=0.305), indicating no statistically significant independent association with high-risk DTS. Hypertension and a history of ACS had an independent and significant association with high-risk DTS.

Conclusion: Among CCS patients, serum endothelin-1 level > 2.0 pg/mL was associated with high-risk DTS from TMT examination. However, this association was not independent, as in hypertension and history of ACS.

Prevalence and Lipid Profile Associations of Elevated Lipoprotein(a) Among Indonesian Adults: A Cross-Sectional Study

2026-09-29T13:08:15+07:00

Background: Lipoprotein(a) [Lp(a)] is a genetically determined lipoprotein and an independent risk factor for Atherosclerotic Cardiovascular Disease (ASCVD). While 20–30% of adults worldwide have elevated Lp(a), data from Indonesia remain scarce. Given reported differences by sex and metabolic profile, this cross-sectional study aimed to determine the prevalence of elevated Lp(a) and its associations with lipid parameters and Hemoglobin A1c (HbA1c) among adults undergoing routine health screening at a tertiary hospital in Indonesia.

Methods: This cross-sectional study analyzed data from 904 adults who underwent routine health screening at Siloam Hospitals Kebon Jeruk, Jakarta (2021–2024). Data on Lp(a), lipid profile, and HbA1c were extracted from the medical records. The normality of data was assessed using the Shapiro–Wilk test. Group comparisons were performed using the Mann–Whitney U test, and correlations between log-transformed Lp(a) and metabolic parameters were evaluated using Spearman correlation and simple linear regression.

Results: Among 904 participants, 18.8 % had elevated Lp(a) levels (> 30 mg/dL). Females showed significantly higher Lp(a) concentrations than males (p = 0.008). Low-Density Lipoprotein Cholesterol (LDL-C) levels were slightly higher in participants with elevated Lp(a) but did not differ significantly (p = 0.19). On linear regression, LDL-C was positively associated with log-transformed Lp(a) (B = 0.002, p < 0.001), whereas triglycerides were inversely associated (B = −0.001, p = 0.029); no significant relationships were observed for High-Density Lipoprotein Cholesterol (HDL-C) or HbA1c.

Conclusion: Nearly one in five adults undergoing routine health screening in this Indonesian cohort had elevated Lp(a) levels. Females exhibited significantly higher Lp(a) concentrations than males, and LDL-C showed a modest positive association with Lp(a). These findings reinforce the relevance of Lp(a) as an important, genetically influenced cardiovascular risk marker and support routine Lp(a) screening for improved risk stratification in clinical practice.

Correlation Between Six-Minute Walk Test and Treadmill Exercise in Post-Coronary Artery Bypass Phase II Rehabilitation Patients: A Cross-Sectional Study

2026-09-29T13:08:15+07:00

Background: Coronary Artery Bypass Grafting (CABG) improves survival in advanced Coronary Artery Disease (CAD) but is often associated with reduced functional capacity during recovery. Phase II cardiac rehabilitation improves physical performance, yet accessible and reliable tools are needed to monitor progress. Treadmill Cardiopulmonary Exercise Testing (CPET) is the gold standard for assessing aerobic capacity, but it is resource-intensive and not widely available in many settings. The Six-Minute Walk Test (6MWT) is a simple alternative, but its validity compared with treadmill testing in Indonesian post-CABG patients
remains underexplored

Methods: This cross-sectional study was conducted at the National General Hospital Dr. Cipto Mangunkusumo in Jakarta between May 2023 and October 2024. Post-CABG patients who completed an eight-week Phase II cardiac rehabilitation program, were clinically stable, and able to perform both assessments were included. Functional capacity was determined by estimated VO2Max from the 6MWT and directly measured VO2Max from a symptom-limited treadmill test using the Modified Bruce protocol. Descriptive statistics summarized baseline characteristics. Spearman correlation coefficient was used to evaluate the relationship
between the two tests, with statistical significance set at p<0.05.

Results: Fifteen post-CABG patients completed the study. Most were male (73.3%) with a mean age of 59 years. Overweight status was common (46.7%), with hypertension (80.0%), dyslipidemia (66.7%), and diabetes mellitus (53.3%) as frequent comorbidities. Mean 6MWT
distance increased from 307.8 ± 85.7 m pre-rehabilitation to 498.5 ± 140.7 m post-rehabilitation. The estimated VO2Max from the 6MWT followed a normal distribution and is reported as a mean of 18.9 mL/kg/min (SD = 4.2). In contrast, the treadmill-measured VO2
Max was nonnormally distributed and is therefore reported as a median of 21.4 mL/kg/min. A significant moderate positive correlation was found between 6MWT and treadmill VO2Max (r = 0.689, p = 0.005).

Conclusion: The 6MWT demonstrated a strong, significant correlation with treadmill-based VO2Max, supporting its use as a practical and cost-effective alternative for functional capacity assessment in post-CABG Phase II rehabilitation. Routine integration of the 6MWT may facilitate individualized exercise prescription and enhance patient monitoring, particularly in resource-limited settings.

Soluble ST2 as a Marker of Subclinical Right Ventricular Dysfunction in Pulmonary Hypertension Associated With Congenital Heart Disease

2026-09-29T13:08:15+07:00

Background: Congenital Heart Disease with Pulmonary Hypertension (CHD-PH) increases Right Ventricular (RV) afterload, which may lead to subclinical myocardial impairment before overt systolic dysfunction becomes apparent. Early detection is crucial to prevent progression to right heart failure. Global Longitudinal Strain (GLS) by echocardiography is sensitive for identifying subclinical RV dysfunction despite preserved conventional systolic parameters, but the role of molecular biomarkers remains unclear. Soluble Suppression of Tumorigenicity 2 (sST2) has been proposed as a potential biomarker for subclinical RV dysfunction. This study aims to compare sST2 levels in CHD-PH patients with and without subclinical RV dysfunction as assessed by RV-Global Longitudinal Strain (RV-GLS).

Methods: This cross-sectional study included adult CHD-PH patients (≥18 years) at the Integrated Heart Center, RSUP M. Djamil Padang, from January to June 2025. All participants underwent right heart catheterization and had preserved RV systolic function, as assessed by conventional echocardiography (Three-Dimensional Right Ventricular Ejection Fraction [3D RVEF] ≥45%). RV-GLS was assessed using Speckle-Tracking Echocardiography (STE), and serum sST2 levels were measured. Patients were categorized into subclinical RV dysfunction (GLS > –20%) and without subclinical RV dysfunction (GLS ≤ –20%) groups. Statistical analysis was performed to compare sST2 levels between groups.

Results: Thirty-four patients were included (82% female, mean age 37.8 ± 15.6 years), with secundum Atrial Septal Defect (ASD) as the most common etiology (71%). Median sST2 levels in patients with CHD-PH without subclinical RV dysfunction were 15.65 (6.05–40.90) ng/mL, with a GLS of –20.50 (–27.20 to –20.00)%. In patients with CHD-PH with subclinical RV dysfunction, median sST2 was 15.15 (5.25–47.60) ng/mL, with a GLS of –11.80 (–19.90 to –6.20)%. No statistically significant difference in sST2 levels was observed between groups (p = 0.89). In contrast, patients with CHD-PH with subclinical RV dysfunction exhibited significantly higher indexed Pulmonary Arterial Resistance (PAR) and pulmonary-to-Systemic Vascular Resistance ratio (PAR/SVR ratio), indicating increased pulmonary vascular load despite preserved conventional RV systolic function.

Conclusion: sST2 levels did not differ significantly between CHD-PH patients with subclinical RV dysfunction and those without. Subclinical RV dysfunction was associated with higher pulmonary vascular load, as reflected by increased indexed PAR and PAR/SVR ratio, despite preserved conventional RV systolic function. From this may conclude that subclinical RV myocardial impairment in CHD-PH is more closely related to hemodynamic afterload than to molecular stress biomarkers alone. These findings suggest that sST2 alone may have limited utility as a biomarker for detecting subclinical RV myocardial impairment in this population.

Predischarge Lung Ultrasound B-Lines as a Robust Predictor of 90-Day Rehospitalization in Heart Failure with Reduced Ejection Fraction (HFrEF): Evidence from Clinical and Classification and Regression Tree (CART)-Based Risk Stratification

2026-09-29T13:08:15+07:00

Background: Heart failure is a major global health burden, with high morbidity, mortality, and substantial rehospitalization rates. Residual pulmonary congestion at discharge is a key determinant of early readmission but is often underestimated using clinical assessment alone. Lung Ultrasound (LUS) offers an objective, bedside tool for detecting pulmonary congestion through B-line quantification. This study aimed to evaluate whether predischarge B-line measurements predict 90-day rehospitalization due to all cardiovascular causes in patients with Heart Failure with reduced Ejection Fraction (HFrEF).

Methods: This retrospective cohort study included 107 adults hospitalized with HFrEF at Wahidin Sudirohusodo Hospital from March to July 2023. LUS was performed prior to discharge using an eight-zone protocol, and total B-line counts were recorded. Clinical, laboratory, and echocardiographic variables were obtained from the Heart Failure Registry and electronic medical records. Patients were followed for 90 days to identify heart failure–related rehospitalization. Statistical analyses included independent t-test, Mann–Whitney U tests, chi-square test, ROC curves, multivariate logistic regression, and a Classification and Regression Tree (CART) model to identify the strongest predictors of rehospitalization.

Results: Among 107 patients (mean age 58.52 ± 12.16 years; 74.77% male), 48 (44.86%) experienced 90-day rehospitalization due to all cardiovascular causes. Rehospitalized patients had significantly higher predischarge B-line counts (25.98 ± 8.23 vs. 17.63 ± 8.03, p <0.0001). A B-line cutoff of ≥20 predicted rehospitalization with 75.7% accuracy, 77.08% sensitivity, 74.58% specificity, and an AUC of 0.754. Renal dysfunction (eGFR 58.72 ± 29.32 vs. 75.43 ± 27.49 mL/min/1.73 m², p = 0.003; creatinine 1.86 ± 2.01 vs. 1.21 ± 0.76 mg/dL, p = 0.021), lower EF (31.6 ± 8.15% vs. 36.64 ± 9.05%, p = 0.004), and higher filling pressures (PCWP, E/e′) were also significantly associated with rehospitalization. The CART model identified B-line ≥20 as the strongest primary classifier, with additional risk contributed by renal impairment and reduced EF, yielding an accuracy of 90.65% and an AUC of 0.966.

Conclusion: Predischarge B-line quantification is a strong predictor of 90-day rehospitalization in HFrEF. Integration of B-line assessment with renal function and cardiac parameters substantially improves risk stratification. LUS provides a practical, noninvasive tool for optimizing predischarge evaluation and may guide interventions to reduce early rehospitalization.

Utilization of Neuromuscular Electrical Stimulation as a Rehabilitation Treatment in Heart Failure with Reduced Ejection Fraction: A Systematic Review and Meta-Analysis

2026-09-29T13:08:13+07:00

Heart Failure with Reduced Ejection Fraction (HFrEF) is associated with substantial functional impairment, and many patients are unable to participate in conventional exercise-based cardiac rehabilitation. Neuromuscular Electrical Stimulation (NMES) has been proposed as an alternative rehabilitation treatment, but its clinical effectiveness remains uncertain. This review aims to evaluate the effectiveness of NMES in improving cardiac function and exercise capacity in patients with HFrEF. A systematic review and meta-analysis of Randomized Controlled Trials (RCTs) was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing NMES with standard medical therapy, exercise training, or no intervention in adult patients with HFrEF were identified through major electronic databases. Risk of bias was assessed using the Cochrane RoB 2.0 tool. Pooled effects were calculated as Mean Differences (MD) with 95% Confidence Intervals (CIs) using Review Manager (RevMan) version 5.4. Twelve RCTs involving 636 participants were included. NMES significantly improved peak oxygen uptake (VO2 peak) (MD 2.03 mL/kg/min; 95% CI 1.21 to 2.84; p < 0.00001), systolic blood pressure (MD −2.02; 95% CI −3.97 to −0.06; p = 0.04), Left Ventricular Ejection Fraction (LVEF) (MD −1.38%; 95% CI −2.73 to −0.03; p = 0.05), and Heart Rate (HR) (MD 2.19 beats/min; 95% CI 0.44 to 3.95; p = 0.01). A borderline significant improvement was observed in the Six-Minute Walk Test (6MWT) distance (MD −11.40 m; 95% CI −23.04 to 0.24; p = 0.05). No significant effects were found for diastolic blood pressure (MD −0.12; 95% CI −3.30 to 3.06; p = 0.94) or Minnesota Living with Heart Failure Questionnaire (MLHFQ) scores (MD 1.97; 95% CI −9.06 to 13.01; p = 0.73). NMES is associated with meaningful improvements in exercise capacity and selected parameters of cardiac function in patients with HFrEF, supporting its role as a potential adjunct rehabilitation treatment.

Coronary Vulnerable and High-Risk Plaque: Current Concepts, Selective Preventive PCI, and an ISIC Position Statement

2026-09-29T13:08:14+07:00

The concept of coronary vulnerable plaque has evolved from a histopathological concept into a potential therapeutic target for precision cardiovascular prevention. Recent evidence has expanded this paradigm beyond the traditional vulnerable-plaque construct towards the broader concept of high-risk plaque, encompassing rupture-prone plaques, erosion-prone plaques, calcified nodules, plaque burden, inflammatory activity, healing capacity, and patient-level susceptibility to thrombosis.
Advances in Coronary Computed Tomography Angiography (CCTA), Intravascular Ultrasound (IVUS), Optical Coherence Tomography (OCT), Near-Infrared Spectroscopy (NIRS), molecular imaging, and Artificial Intelligence (AI) have substantially improved the detection and characterization of high-risk plaque. Circulating lipid, inflammatory, metabolic, and renal biomarkers provide complementary information regarding patient vulnerability. Concurrently, contemporary pharmacological therapy has substantially improved the natural history of coronary atherosclerosis by promoting plaque stabilization, fibrous cap thickening, lipid core regression, and attenuation of vascular inflammation.
The emergence of preventive Percutaneous Coronary Intervention (PCI) for non-flow-limiting vulnerable plaques, particularly following the PREVENT trial, has reignited interest in focal treatment before clinical destabilization. Nevertheless, important uncertainties remain regarding patient selection, diagnostic thresholds, imaging strategies, device selection, long-term durability, cost-effectiveness, and applicability in resource-limited healthcare systems. Drug-Eluting Stents (DES) remain the most established device platform, whereas next-generation bioresorbable scaffolds and Drug-Coated Balloons (DCB) may offer future approaches to local plaque treatment without permanent metallic implantation. Although Coronary Artery Bypass Grafting (CABG) does not directly treat vulnerable plaques, it may indirectly protect selected patients with diffuse multivessel disease by bypassing plaque-bearing coronary segments.
For Indonesia and other resource-constrained healthcare systems, future implementation should emphasize pragmatic implementation rather than widespread adoption of advanced technologies. Emphasis should remain on aggressive Optimal Medical Therapy (OMT), selective use of advanced imaging, careful identification of patients at the highest absolute cardiovascular risk, structured operator training, national registries, and rigorous evaluation of cost-effectiveness. The ultimate objective is not simply to detect more vulnerable plaques but to prevent more myocardial infarctions and cardiovascular deaths through efficient use of healthcare resources.
The Indonesian Society of Interventional Cardiology (ISIC) recommends that aggressive systemic prevention, centered on OMT, should remain the foundation of care. Advanced plaque imaging and preventive PCI should be reserved for carefully selected patients with converging high-risk plaque characteristics, high patient-level risk, and a favorable benefit–risk profile.

Aerobic Exercise Only or in Combination with Resistance Exercise Provides a Significant Reduction in Blood Pressure: A Narrative Review

2026-09-29T13:08:14+07:00

Hypertension is a major global health concern and a leading risk factor for cardiovascular disease. While pharmacological therapy remains central, lifestyle interventions, particularly Aerobic Exercise (AE), offer a cost-effective, safe, and sustainable strategy for reducing Blood Pressure (BP) and improving cardiovascular health. Evidence indicates AE consistently lowers Systolic Blood Pressure (SBP) more than Diastolic Blood Pressure (DBP), with clinically meaningful reductions in both. This review aimed to synthesize current evidence on the effects of AE, alone or combined with Resistance Training (RT) or dietary interventions, on BP in individuals with hypertension, elucidate underlying mechanisms, identify moderating factors, and evaluate safety considerations. A narrative review of English-language articles published from 2015 to 2025 was conducted via PubMed, including original and review studies, as well as selected textbooks. Keywords included “aerobic exercise”, “exercise”, “hypertension”, “blood pressure”, “coronary artery disease”, and “cardiovascular disease”. Eligible studies were synthesized into themes reflecting acute and chronic exercise responses, combination interventions, mechanistic pathways, influencing factors, and safety. Thirty-four publications (26 original articles, 6 reviews, 2 textbooks) were included. AE alone or combined with RT consistently reduced SBP, with smaller reductions in DBP, whereas the combination with a hypocaloric diet primarily enhanced cardiorespiratory fitness and body composition. Mechanisms include improved endothelial function, autonomic regulation, metabolic efficiency, and anti-inflammatory effects. Effect size was influenced by age, sex, Body Mass Index (BMI), medication use, exercise timing, and vascular stiffness. Safety data indicated high tolerability, minimal adverse events, and strong adherence. AE is a safe and effective non-pharmacological intervention for hypertension, producing clinically significant BP reductions, particularly in SBP. Combining AE with RT or dietary modification offers additional cardiometabolic benefits. These findings reinforce AE as a cornerstone of hypertension management and support its integration into routine clinical practice.

Cardiac Tamponade due to Purulent Pericarditis

2026-09-29T13:08:13+07:00

Background: Purulent pericarditis, though uncommon in the antibiotic era, remains highly fatal when diagnosis or drainage is delayed. Its presentation often mimics viral hepatitis, sepsis, or parasitic infections—particularly in endemic, low-resource regions—leading to underrecognition. This case reported the development of purulent pericarditis with initial equivocal signs and symptoms, followed by progressive hemodynamic deterioration.

Case Illustration: A 40-year-old previously healthy man presented with fever, dyspnea, stabbing chest and abdominal pain, and dark urine. Examination revealed jaundice, pericardial friction rub, and hepatosplenomegaly. Laboratory tests showed leukocytosis, hyperbilirubinemia, and elevated liver enzymes. Initial echocardiography demonstrated a 2-cm circumferential effusion without signs of tamponade. Two days later, despite stable symptoms, he developed hypotension with new fibrinous effusion and right atrium collapse. Emergency pericardiocentesis drained 1.7 L of thick, purulent fluid. Hemodynamics improved rapidly after drainage. Prednisone and colchicine were initiated once infection control was achieved to limit fibro-inflammatory response and reduce the risk of constriction. Liver function normalized, and follow-up echocardiography showed minimal residual effusion. At follow-up, the patient remained asymptomatic.

Conclusion: This case highlights that purulent pericarditis can occur in immunocompetent individuals without typical risk factors, possibly from overlooked infection in low-resource settings. Hemodynamic collapse may occur even with small increases in pericardial effusion volume, owing to fibrin-induced pericardial stiffness and reduced compliance. Serial echocardiography is therefore critical when symptoms appear stable. Early pericardiocentesis is both diagnostic and therapeutic, reducing bacterial and inflammatory load, while carefully selected adjunctive anti-inflammatory therapy may prevent chronic constrictive sequelae.

Multifocal Atrial Tachycardia in a 9-Month-Old Infant: A Case Report with Therapeutic Insights

2026-09-29T13:08:14+07:00

Background: Supraventricular tachycardia is the most common arrhythmia in infants, with an estimated prevalence between 1/250 and 1/1000. Multifocal Atrial tTachycardia (MAT), a rare subtype accounting for less than 1% of supraventricular tachycardia in infants and children, is characterized by multiple atrial foci, variable P-wave morphologies, and irregular ventricular response. When incessant, MAT may lead to tachycardia-induced cardiomyopathy and congestive heart failure. This report describes a 9-month-old infant with MAT and left ventricular dysfunction, emphasizing diagnostic challenges and therapeutic strategies

Case Illustration: A previously healthy 9-month-old female infant presented for urgent evaluation due to progressive dyspnea and tiredness during breastfeeding, which had begun approximately two months earlier and worsened in the last two weeks. Her mother noted perioral cyanosis during crying and feeding. On examination, she was tachypneic (60 breaths/min), tachycardic (180 bpm), and mildly dehydrated. Transthoracic echocardiography revealed a dilated left ventricle with moderate systolic dysfunction (ejection fraction 35%). A 12-lead electrocardiogram demonstrated multifocal atrial tachycardia with at least three distinct P-wave morphologies and irregular R-R intervals, and Holter monitoring confirmed an incessant pattern (>30% of the day). Three synchronized direct current cardioversion attempts (0.5, 1.0, and 1.23 J/kg) failed to restore sinus rhythm. Intravenous amiodarone was initiated (loading dose 5 mg/kg over 1 hour, followed by 10 mcg/kg/min), later transitioned to oral therapy (5 mg/kg/day). Within 48 hours, sinus rhythm was restored, heart failure symptoms resolved, and follow-up echocardiography showed improved ejection fraction (55%). Propranolol (1 mg/kg/day) and digoxin (5 mcg/kg/day) were added for rate control. The patient was discharged asymptomatic after one week, with no relapse at 6-month follow-up.

Conclusions: MAT is a rare cause of supraventricular tachycardia in infants and may be present with congestive heart failure due to tachycardia-induced cardiomyopathy. Incessant forms are typically defined by an arrhythmia burden greater than 30% of the day on Holter monitoring. Failure of direct current cardioversion is a hallmark of MAT, reinforcing the role of pharmacological management. Early recognition and rate and rhythm control with agents such as amiodarone, propranolol, and digoxin can lead to rapid recovery of left ventricular function and an excellent prognosis in infants without structural heart disease.

Myocarditis Mimicking STEMI Complicated by Complete Atrioventricular Block: Diagnostic and Therapeutic Insights

2026-09-29T13:08:14+07:00

Background: Myocarditis, or myocardial inflammation, may share similar characteristics to Acute Coronary Syndrome (ACS), particularly ST-Elevation Myocardial Infarction (STEMI). This condition is further augmented when a Complete Atrioventricular Block (CAVB) is present. Despite being rare, this condition may pose additional diagnostic and therapeutic challenges.

Case Illustration: We report a 54-year-old woman with fatigue, dyspnea, fever, nausea, and watery diarrhea for three days. Upon admission, she experienced hypotension, pulmonary congestion, and a complete Atrioventricular (AV) block, with ST-segment elevation seen on the lateral leads. Initial laboratory results revealed markedly elevated high-sensitivity troponin T and C-reactive Protein (CRP). Bedside echocardiography showed a prominently reduced Ejection Fraction (EF) (40%) alongside the presence of regional wall motion abnormalities. Urgent coronary angiography revealed only non-obstructive coronary disease and no obstructive coronary disease. A temporary pacemaker and inotropic support were initiated. Given the presence of systemic prodromal symptoms and the absence of coronary obstruction, myocarditis was strongly suspected. High‑dose intravenous methylprednisolone was given as an anti‑inflammatory treatment in suspected fulminant myocarditis with cardiogenic shock and complete AV block. Recognizing that immunosuppressive therapy is not routinely recommended for all myocarditis cases, especially without biopsy confirmation. Cardiac magnetic resonance imaging subsequently confirmed myocarditis, demonstrating myocardial edema and subepicardial late gadolinium enhancement. The patient was discharged after receiving guideline-directed medical therapy and tapering corticosteroids, with preserved ventricular function on follow-up 1 month after discharge.

Conclusions: This report illustrates the importance of a stepwise diagnostic approach to differentiate myocarditis from STEMI, particularly when complicated by conduction disturbances such as CAVB. Early recognition and timely initiation of immunosuppressive therapy can lead to favorable outcomes.