Nonspecific electrocardiographic (ECG) abnormalities are common in patients presenting with syncope, but their presence does not necessarily establish the mechanism of transient loss of consciousness. The frontal QRS-T angle has recently been proposed as a marker for identifying cardiac syncope in the emergency department. However, it may reflect structural and electrical abnormalities and coexist with syncope without being mechanistically related to the event. In the reported cohort, most patients classified as having cardiac syncope had structural cardiac conditions, while only a minority were assigned an arrhythmic etiology; among the latter, atrial fibrillation with rapid ventricular response predominated, with no ventricular tachyarrhythmias reported. These findings highlight a broader limitation in the interpretation of nonspecific ECG abnormalities in syncope: association with cardiac disease or cardiovascular risk does not establish causation of the syncopal event. Distinguishing ECG findings that are incidental to the event from those that identify a plausible mechanism of transient cerebral hypoperfusion is essential for etiological diagnosis of syncope.

Recurrent syncope and behavioral changes in the older population may suggest several disease entities associated with aging. Hypoglycemia is an often-missed potentially correctable underlying cause that should also be considered in the differential diagnosis. We present a case of a 62-year-old Filipino female who presented with recurrent syncopal attacks, behavioral changes and unintentional weight gain, associated with endogenous hyperinsulinemic hypoglycemia with no pancreatic mass seen on abdominal CT scan. A pancreatic head tumor was visualized through endoscopic ultrasound. Surgical removal of the mass resulted in resolution of her symptoms and restoration of her physical and functional wellbeing. This case is being reported to highlight that surgery cured her of the disease and she remains asymptomatic and well 13 years after her surgery.

State Ceremonial and Public Duties (SCPD) expose soldiers to extreme physiological stressors, predisposing to syncope. Despite a high incidence of syncope in military personnel, physiological responses during SCPD are unknown. Data were collected across three ceremonial parades (n = 41; 3 female, age = 24 ± 1 years, duration = 2.5 h). Parades had alternating phases of motionless standing and marching. Pre-parades, baseline cardiovascular parameters (systolic arterial pressure [SAP] and heart rate [HR]), anthropometric measures, urinary sodium, anxiety and parade perspectives were collected. Salivary steroid analyses were performed pre- and post-parade. In thirty participants (n = 10/parade; 2 female) continuous SAP, HR, respiration, postural sway and skin temperature were collected using discrete wearable technology (Astroskin) worn underneath the traditional uniform. During parades, HR and minute ventilation were elevated, with maximum HR reflecting 71 ± 1.5% of age-predicted max. Parade SAPmin was 107 ± 1.8 mmHg (range 88-125 mmHg). During prolonged motionless standing (Stand 2; 63 ± 1mins), 50% of participants experienced reduced SAP that exceeded clinical criteria for orthostatic hypotension. Lower Stand 2 SAPmin was associated with larger leg mass (r = 0.484, p = 0.012), and lower percent body fat (r = 0.523, p = 0.006). Post-parade, salivary cortisol decreased (p < 0.001) while aldosterone increased (p < 0.001). Maximum estimated core temperature was 38.6 ± 0.03 °C, indicating considerable thermal stress, with a "high" physiological stress index of 7.2 ± 0.2. Participants did not fear repercussions for fainting during SCPD, but associated it with profound stigma. This work highlights the utility of wearables in field environments. SCPD represent considerable physiological stress, with marked cardiovascular instability, and substantial thermal, orthostatic, and exercise stress. Use of evidence-based prevention measures could improve syncope outcomes during SCPD.

Vagal-mediated cardiovascular responses can occur following carbon dioxide pneumoperitoneum during laparoscopic surgery. In rare cases, an exaggerated vagal reflex may result in profound bradycardia or asystole. We report the case of a 44-year-old woman (American Society of Anesthesiologists physical status II) who developed abrupt bradycardia progressing to asystolic cardiac arrest immediately after abdominal insufflation during an elective minimally invasive gynecologic procedure. The planned operation included hysteroscopy with MyoSure (Hologic, Inc., Marlborough, MA, US) resection, NovaSure (Hologic) endometrial ablation, Acessa (Hologic) radiofrequency fibroid ablation, diagnostic laparoscopy, and salpingectomy for symptomatic uterine fibroids refractory to conservative management. Her past medical history was notable only for uterine fibroids and recently diagnosed hypertension. Preoperative laboratory testing and vital signs were within normal limits, and electrocardiography demonstrated normal sinus rhythm without clinically significant rhythm abnormalities. Immediately following the bradycardia, one milligram of atropine was administered intravenously. The patient then became asystolic, pneumoperitoneum was evacuated, and cardiopulmonary resuscitation was initiated. Return of spontaneous circulation was achieved after a single round of compressions, with restoration of normal sinus rhythm. The intra-abdominal portion of the procedure was subsequently aborted, and the patient remained hemodynamically stable postoperatively. At cardiology follow-up nine days postoperatively, the patient reported prior vasovagal-type episodes, including syncope following influenza vaccination and near-syncope during magnetic resonance imaging with intravenous contrast. This case highlights the importance of rapid recognition and management of vagally mediated cardiac events in the operating room. It also raises the question of whether targeted preoperative assessment for prior syncope or vasovagal episodes may help identify patients at increased risk for exaggerated vagal responses during procedures involving pneumoperitoneum, a potential area for future investigation.

Babesiosis is a tick-borne infection caused by intraerythrocytic Babesia parasites and may result in severe hemolytic anemia and systemic complications. Coinfection with other Ixodes-borne pathogens may further complicate diagnosis and management. We report a 45-year-old immunocompetent man working as a landscaper in Connecticut who presented with syncope following two weeks of fever, fatigue, diaphoresis, arthralgias, jaundice, and dark urine. Laboratory evaluation revealed profound hemolytic anemia with a hemoglobin of 6.8 g/dL, elevated lactate dehydrogenase (LDH), undetectable haptoglobin, reticulocytosis, and stage 1 acute kidney injury. Peripheral blood smear demonstrated characteristic Maltese cross formations, with approximately 0.6% parasitemia, and polymerase chain reaction (PCR) testing confirmed Babesia microti and Borrelia burgdorferi coinfection. Direct antiglobulin testing for immunoglobulin G (IgG) was negative. The patient required intensive care monitoring and transfusion and improved following treatment with atovaquone, azithromycin, and doxycycline. Subsequent outpatient evaluation identified asymptomatic Strongyloides stercoralis infection, which was treated with ivermectin. This finding was clinically significant because warm autoimmune hemolytic anemia is a recognized complication of babesiosis and may require corticosteroid therapy, which can precipitate potentially life-threatening Strongyloides hyperinfection in patients with occult infection. This case highlights that severe babesiosis may occur despite low-level parasitemia and emphasizes the importance of recognizing coinfections and obtaining a detailed occupational and environmental exposure history, particularly when future immunosuppressive therapy may be considered.

Angiolipomas are uncommon benign mesenchymal neoplasms composed of mature adipocytes and proliferating vascular channels. In dogs, infiltrative angiolipomas are rarely reported and have primarily been described as localized soft-tissue masses. An 11-year-old, 10.8 kg, castrated male Japanese Spitz was referred for evaluation of regenerative anemia, mild thrombocytopenia, recurrent syncopal episodes, and a 5-year history of a slowly enlarging ventral thoracic mass. Preoperative hematological evaluation demonstrated anemia with a hematocrit of 25.4% and an increased absolute reticulocyte count of 122.7 K/µL, supporting a regenerative erythropoietic response. The platelet count was mildly decreased at 109 × 10[3]/µL. D-dimer concentration was increased (737.61 ng/mL; reference interval, 0-250 ng/mL), whereas prothrombin time (9.5 s; reference interval, 5-15 s) and activated partial thromboplastin time (15.6 s; reference interval, 15-45 s) were within their reference intervals. Referral history indicated that previous infectious and immune-mediated evaluations had not identified a definitive cause, although the original external testing records were unavailable for verification. Computed tomography revealed a heterogeneous subcutaneous mass with mixed fat- and soft-tissue-attenuating components, suspected infiltration of the superficial pectoral muscle, and focal rather than diffuse contrast enhancement. Surgical cytoreduction, including partial myectomy, was performed because complete excision was not considered feasible owing to deep muscular infiltration. Histopathological examination confirmed an infiltrative angiolipoma characterized by mature adipocytes, numerous vascular channels, skeletal muscle infiltration, and frequent intravascular fibrin thrombi. Following surgery, the hematological abnormalities progressively improved without blood transfusion or long-term immunosuppressive therapy. The platelet count increased from 109 × 10[3]/µL preoperatively to 153 × 10[3]/µL by postoperative day 16 and 202 × 10[3]/µL by postoperative day 56. During the same period, the hematocrit increased from 25.4% to 45.0%, and the absolute reticulocyte count subsequently returned to the reference interval. The syncopal episodes ceased after surgery and did not recur during the available 12-month follow-up. Fibrinogen concentration and peripheral blood smear evaluation were unavailable, and serial postoperative coagulation testing was not performed. Accordingly, the temporal association between tumor cytoreduction and hematological improvement raises the possibility of a tumor-associated process, but neither the underlying mechanism nor a causal relationship could be established.

Background and Objectives: Pediatric chest pain is usually benign, but identifying children who require admission or have a cardiac diagnosis remains challenging. We aimed to identify factors associated with these outcomes, with a focus on recurrent presentation and the combined value of C-reactive protein (CRP) and predefined red-flag findings. Materials and Methods: This retrospective cohort included children aged 0-18 years presenting with chest pain to a tertiary pediatric emergency department between January 2021 and January 2026; visits with insufficient documentation were excluded. Red-flag findings were predefined as effort-related chest pain, syncope, palpitations, dyspnea, fever, or a family history of sudden cardiac death. Independent predictors were assessed using multivariable Firth logistic regression, and cluster-robust standard errors were used in a sensitivity analysis to account for recurrent visits. Results: Of 1703 visits (1435 patients), 452 (26.5%) were recurrent presentations. Admission occurred in 64 visits (3.8%), and 91 (5.3%) had a cardiac diagnosis. Red-flag findings (OR, 5.15), abnormal ECG (OR, 4.00), CRP > 5 mg/L (OR, 3.71), male sex (OR, 2.13), and recurrent presentation (OR, 2.51) were independently associated with admission (all p ≤ 0.009). Recurrent presentation was not associated with a cardiac or psychogenic diagnosis. Admission and cardiac diagnosis rates increased from 1.4%/2.2% in children with neither elevated CRP nor red-flag findings to 22.2%/24.8% in those with both. Routine ECG, troponin, and chest radiography had low diagnostic yields (2.1-6.0%), whereas echocardiography performed selectively yielded abnormal findings in 79.7%. Conclusions: Red-flag findings, abnormal ECG, elevated CRP, and recurrence were associated with admission, whereas recurrence was not associated with diagnosis. Combining CRP with red flags may improve risk stratification, though prospective validation is needed.

Background: Pulmonary embolism (PE) has classically been divided, on the basis of symptom duration, into acute (<2 weeks), subacute (2-12 weeks) and chronic (>12 weeks) forms. Subacute PE remains poorly characterised, is frequently underdiagnosed, and is largely absent from randomised trials and dedicated guideline recommendations. Whether the efficacy and safety of catheter-directed therapy (CDT) extend to subacute presentations, in which the thrombus is older, more organised and potentially more adherent, is unknown. We aimed to describe the clinical profile, management and early outcomes of patients with subacute PE selected for CDT within a national interventional registry. Methods: We analysed the National Registry of Catheter-Directed Interventions for the Management of Acute PE (NCT06348459), an investigator-initiated, multicentre registry promoted by the Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC). Subacute PE was defined as a symptom duration >14 days and <12 weeks. Baseline characteristics, echocardiographic variables, biomarkers, invasive pulmonary artery pressures, procedural data and early outcomes were described for the subacute group and set alongside the acute presentations treated in the same cohort. All between-group comparisons are descriptive and exploratory and are not intended to characterise subacute PE beyond this selected population. Continuous variables are median [interquartile range]. Results: Among 447 PE cases treated with catheter-directed therapy, 11 (2.5%) met the criteria for subacute PE and 436 (97.5%) for acute PE. Subacute patients presented with progressive dyspnoea (73%) over a median symptom duration of 21 [18-28] days and infrequent syncope (9%); two patients (18%) fulfilled ESC criteria for high-risk PE and three (27%) required vasoactive amines. Subacute patients showed a right ventricular (RV) basal diameter of 50 [48-52] mm (echocardiographic data available in 7 of 11) and an echocardiographic pulmonary artery systolic pressure of 60 [46-60] mmHg, with a high-sensitivity troponin I of 455 [85-767] ng/L and an NT-proBNP of 1433 [256-1970] pg/mL; corresponding values in acute PE were 47 [44-50] mm, 50 [43-60] mmHg, 237 [97-853] ng/L and 2200 [626-5535] pg/mL. None of the between-group differences reached statistical significance. Catheter-directed therapy achieved 100% procedural success in the subacute group, with invasive systolic pulmonary artery pressure falling from 58 [53-60] to 48 [39-51] mmHg and peripheral oxygen saturation improving from 92% [89-95] to 95% [92-98], with no major periprocedural complications, no circulatory support and no in-hospital deaths. Conclusions: Subacute PE was an infrequent but clinically recognisable presentation among patients treated with catheter-directed therapy, accounting for 2.5% of the cohort and characterised by weeks of progressive symptoms before referral and by a substantial right ventricular and pulmonary pressure load at presentation. Mechanical thrombectomy was safe and effective in this subgroup, with favourable early outcomes comparable to those of acute PE. These hypothesis-generating findings support dedicated study of the diagnosis, risk stratification and interventional management of subacute PE.

This article summarizes the top 20 research studies of 2025 identified as POEMs (patient-oriented evidence that matters). Treating male sex partners of female patients with oral and topical medication reduces recurrence of bacterial vaginosis. Anti-influenza drugs do not reduce hospitalizations or mortality. COVID-19 vaccines still improve mortality and reduce hospitalizations. Influenza vaccines are safe in pregnancy. Vaginal estrogen appears to be safe in breast cancer survivors. Women with normal bone density given zoledronic acid every 5 years have fewer fractures. Early post-partum insertion of a long-acting reversible contraceptive is associated with fewer pregnancies vs delayed insertion. Early medication abortion before pregnancy confirmation is safe and effective. After stent placement in patients with atherosclerotic coronary vascular disease who are taking an anticoagulant, adding aspirin worsens outcomes. After catheter ablation for atrial fibrillation, discontinuing anticoagulants after 1 year is safe if atrial arrhythmia does not recur, whereas left atrial appendage closure is superior to oral anticoagulation. For patients with provoked venous thromboembolism and at least one ongoing risk factor, 12 months of apixaban is better than 3 months. Clopidogrel is slightly more effective than aspirin for the secondary prevention of myocardial infarction and stroke over 3 years. Intensive blood pressure lowering decreases cardiovascular events but increases rates of hypotension and syncope, and there are concerns about the applicability of the data to the United States. Duloxetine, milnacipran, and pregabalin provide meaningful pain reduction in adults with fibromyalgia. Amyloid-directed monoclonal antibodies do not provide clinically meaningful cognitive benefits and may cause harms. Bright light therapy is effective for nonseasonal depression. Water exposure 6 hours after cutaneous surgery does not increase the risk of complications. A meta-analysis of platelet-rich plasma injections for knee osteoarthritis concluded that high-quality studies found no meaningful pain improvement. Using an oral challenge to rule out sulfonamide allergy is safe when used with a risk assessment tool.

Aortic stenosis is the most common valvular heart disease in the United States, and it affects up to 3.7% of the general population. Atherosclerosis results in progressive calcification of the aortic valve, leading to valve narrowing. Aortic stenosis is more common in older adults and men and in those with bicuspid aortic valves or cardiovascular risk factors. Classic symptoms of aortic stenosis include exertional angina, dyspnea, syncope, presyncope, and symptoms of heart failure. Patients may present with atypical symptoms (eg, fatigue, exercise intolerance), which may be mistaken for other cardiopulmonary conditions or attributed to aging. Transthoracic echocardiography is the preferred test for diagnosis because it can classify the severity of aortic stenosis. Asymptomatic patients with aortic stenosis may be monitored with echocardiography every 3 to 5 years for mild stenosis, 1 to 2 years for moderate stenosis, and 6 to 12 months for severe stenosis. No specific treatment prevents the need for aortic valve replacement or reverses aortic stenosis. Aortic valve replacement is indicated in patients with symptomatic severe aortic stenosis and in a subset of those with asymptomatic severe stenosis. There is no difference in mortality between transcatheter aortic valve replacement and surgical valve replacement.