Special Issue. (Special Issue.)

This special issue contains 13 articles that discuss public health articles such as public perception, knowledge and factors influencing COVID-19 vaccine acceptability, determinants of enrolment in health insurance scheme among HIV patients, hypertension and associated factors among patients attending HIV clinic, determinants of visit-to-visit systolic blood pressure variability among Ghanaians with hypertension and diabetes mellitus, short-term outcomes among patients with subclinical hypothyroidism, association of erectile dysfunction with coronary artery disease, psychological correlates of COVID safety protocol adherence, ophthalmic services utilisation and associated factors, safe duration of silicon catheter replacement in urological patients, and leadership in health and medical education.

Observational study of imaging findings in COVID -19 related rhino-orbito-cerebral mucormycosis - a tertiary care center study

Background: There has been a tremendous increase in number of cases of rhino-orbitocerebral involvement with mucor in the COVID era, as reported from India. It is well established that management of ROCM involves early clinical and radiological diagnosis, reversal of underlying risk factors, prompt antifungal therapy and surgical debridement when indicated. Materials &Methods: Multiplanar MR imaging and CT scan were performed for brain, orbit and paranasal sinuses. All the cases were assessed for involvement of the paranasal sinuses, nasal cavities, orbits and brain. Results: 25 cases with ROCM were identified over 8 months. The mean age of the cases was 56.1 years. 18 of the 25 cases had a positive RT-PCR test result at the time of diagnosis with ROCM. 20 cases had poorly controlled diabetes mellitus, 2 had a hematological malignancy, 2 had chronic kidney disease and 1 had ischemic heart disease. There was involvement of the paranasal sinuses, nasal cavities, orbits and brain inclusing necrosis in most of the cases. The number of cases identified during the interval is much higher than the numbers presenting in the prior 2 years during equivalent intervals than those reported in the literature in different settings in the pre-pandemic era. Conclusions: Rhino-orbito mucormycosis can have aggressive necrosis of the involved paranasal sinuses and orbits with or without cerebral extension. Hence, the correct diagnosis is imperative as prompt antifungal drugs and surgical debridement can significantly reduce mortality and morbidity.

Effect of Austrian COVID-19 lockdowns on acute myocardial infarction frequency and long-term mortality: a multicentre observational study.

OBJECTIVES: The aim of this study was to find out if the decrease in acute myocardial infarction (AMI) admissions during the first COVID-19 lockdowns (LD), which was described by previous studies, occurred equally in all LD periods (LD1, LD2, LD2021), which had identical restrictions. Further, we wanted to analyse if the decrease of AMI admission had any association with the 1-year mortality rate. DESIGN AND SETTING: This study is a prospective observational study of two centres that are participating in the Vienna ST-elevation myocardial infarction network. PARTICIPANTS: A total of 1732 patients who presented with AMI according to the 4th universal definition of myocardial infarction in 2019, 2020 and the LD period of 2021 were included in our study. Patients with myocardial infarction with non-obstructive coronary arteries were excluded from our study. MAIN OUTCOME MEASURES: The primary outcome of this study was the frequency of AMI during the LD periods and the all-cause and cardiac-cause 1-year mortality rate of 2019 (pre-COVID-19) and 2020. RESULTS: Out of 1732 patients, 70% (n=1205) were male and median age was 64 years. There was a decrease in AMI admissions of 55% in LD1, 28% in LD2 and 17% in LD2021 compared with 2019.There were no differences in all-cause 1-year mortality between the year 2019 (11%; n=110) and 2020 (11%; n=79; p=0.92) or death by cardiac causes [10% (n=97) 2019 vs 10% (n=71) 2020; p=0.983]. CONCLUSION: All LDs showed a decrease in AMI admissions, though not to the same extent, even though the regulatory measures were equal. Admission in an LD period was not associated with cardiac or all-cause 1-year mortality rate in AMI patients in our study.

Fixed dose combination drugs for cardiovascular disease in a prolonged humanitarian crisis in Lebanon: an implementation study.

OBJECTIVES: This pre-post implementation study evaluated the introduction of fixed dose combination (FDC) medications for atherosclerotic cardiovascular disease (ASCVD) secondary prevention into routine care in a humanitarian setting. SETTING: Two Médecins sans Frontières (MSF) primary care clinics serving Syrian refugee and host populations in north Lebanon. PARTICIPANTS: Consenting patients ≥18 years with existing ASCVD requiring secondary prevention medication were eligible for study enrolment. Those with FDC contraindication(s) or planning to move were excluded. Of 521 enrolled patients, 460 (88.3%) were retained at 6 months, and 418 (80.2%) switched to FDC. Of these, 84% remained on FDC (n=351), 8.1% (n=34) discontinued and 7.9% (n=33) were lost to follow-up by month 12. INTERVENTIONS: Eligible patients, enrolled February-May 2019, were switched to Trinomia FDC (atorvastatin 20 mg, aspirin 100 mg, ramipril 2.5/5/10 mg) after 6 months' usual care. During the study, the COVID-19 pandemic, an economic crisis and clinic closures occurred. OUTCOME MEASURES: Descriptive and regression analyses compared key outcomes at 6 and 12 months: medication adherence, non-high density lipoprotein cholesterol (non-HDL-C) and systolic blood pressure (SBP) control. We performed per-protocol, intention-to-treat and secondary analyses of non-switchers. RESULTS: Among 385 switchers remaining at 12 months, total adherence improved 23%, from 63% (95% CI 58 to 68) at month 6, to 86% (95% CI 82 to 90) at month 12; mean non-HDL-C levels dropped 0.28 mmol/L (95% CI -0.38 to -0.18; p<0.0001), from 2.39 (95% CI 2.26 to 2.51) to 2.11 mmol/L (95% CI 2.00 to 2.22); mean SBP dropped 2.89 mm Hg (95% CI -4.49 to -1.28; p=0.0005) from 132.7 (95% CI 130.8 to 134.6) to 129.7 mm Hg (95% CI 127.9 to 131.5). Non-switchers had smaller improvements in adherence and clinical outcomes. CONCLUSION: Implementing an ASCVD secondary prevention FDC improved adherence and CVD risk factors in MSF clinics in Lebanon, with potential for wider implementation by humanitarian actors and host health systems.

Changes in clinical features and outcomes in three major critical diseases after COVID-19 pandemic: acute myocardial infarction, stroke, and cardiac arrest. (Special Issue: COVID-19 in the emergency department: epidemiology and changes throughout the pandemic.)

A few months after the onset of the coronavirus Disease 2019 (COVID-19) pandemic, the worse prognoses of acute myocardial infarction, ischemic and hemorrhagic stroke, and cardiac arrest were reported. This study aimed to investigate the changes in the characteristics and prognoses of these diseases in the emergency department (ED) over a year after pandemic's onset. This was a retrospective observational study. The year 2019 was defined as the pre-period, while the year from February 2020 to January 2021 was defined as the post-period. Adult patients diagnosed with acute myocardial infarction, ischemic stroke, hemorrhagic stroke, or cardiac arrest during the study period were included. The primary outcome was in-hospital mortality. Time series analyses using autoregressive integrated moving average (ARIMA)(p,d,q) model were performed to evaluate the changes between periods. A multivariable logistic regression analysis of factors affecting in-hospital mortality was performed. The proportions of patients with acute myocardial infarction (0.8% vs. 1.1%, p < 0.001), hemorrhagic stroke (1.0%vs. 1.2%, p = 0.011), and cardiac arrest (0.9% vs. 1.1%, p = 0.012) increased in the post-period. The post-period was independently associated with in-hospital mortality in acute myocardial infarction (adjusted odds ratio (aOR) 2.54, 95% confidence interval (95% CI) 1.06-6.08, p = 0.037) and hemorrhagic stroke (aOR 1.74, 95% CI 1.11-2.73, p = 0.016), but not for ischemic stroke or cardiac arrest. Over a year after onset of the COVID-19 pandemic in Korea, the number of patients with acute myocardial infarction, hemorrhagic stroke, and cardiac arrest in the ED increased. An independent association between the post-period and mortality was observed for acute myocardial infarction, and hemorrhagic stroke. This study provides important information for future studies and policies.

Global, regional and national trends in statin utilisation in high-income and low/middle-income countries, 2015-2020.

OBJECTIVE: Prior studies have reported inequitable global access to essential medicines for cardiovascular disease (CVD) prevention, especially statins. Here we examine recent trends and disparities in statin utilisation at the income group, regional and country levels. DESIGN: Ecological study. Pharmaceutical sales data were used to examine statin utilisation in high-income counties (HICs) and low/middle-income countries (LMICs) from 2015 to 2020. Population estimates were obtained from the Global Burden of Disease. Fixed-effects panel regression analysis was used to examine associations between statin utilisation and country-level factors. SETTING: Global, including 41 HICs and 50 LMICs. PARTICIPANTS: Population older than 40 years of age. PRIMARY AND SECONDARY OUTCOME MEASURES: Statin utilisation was measured using defined daily doses (DDDs) per 1000 population ≥40 years per day (TPD). RESULTS: Globally, statin utilisation increased 24.7% from 54.7 DDDs/TPD in 2015 to 68.3 DDDs/TPD in 2020. However, regional and income group disparities persisted during this period. In 2020, statin utilisation was more than six times higher in HICs than LMICs (192.4 vs 28.4 DDDs/TPD, p<0.01). Substantial disparities were also observed between LMICs, ranging from 3.1 DDDs/TPD in West African nations to 225.0 DDDs/TPD in Lebanon in 2020. While statin utilisation increased in most LMICs between 2015 and 2020, several experienced declines in utilisation, most notably Venezuela (-85.1%, from 92.3 to 14.0 DDDs/TPD). In LMICs, every $100 increase in per capita health spending was associated with a 17% increase in statin utilisation, while every 10% increase in out-of-pocket health spending was associated with a 11% decline (both p<0.05). CONCLUSIONS: Despite global increases in statin utilisation, there are substantial regional and country-level disparities between HICs and LMICs. To address global CVD disparities, policymakers should promote increased and equitable access to statins in LMICs.

Risk factors for COVID-19 from interculturality and the preservation of ancestral knowledge

In December 2019, an outbreak of pneumonia cases emerged in Wuhan, China, which evolved into the COVID-19 pandemic. The purpose of the work is to design a community prevention strategy in the indigenous population of zone 3 at the starting point of the epidemiological characterization carried out. A longitudinal and prospective experimental explanatory study was conducted with deliberate intervention, descriptive and inferential statistical methods were used. It was identified that the age of 60 years or more pre- dominated in the subjects surveyed, which represented 9,7%, and the other risk group located at ages under 18 years, were located 17 for 4,5% of the sample, although the figure of both age groups of risk is not high, it is necessary to work with the indigenous population at the community level, ischemic heart disease, high blood pressure, diabetes mellitus and bronchial asthma were also identified as a risk. As social factors, extreme poverty, living alone, overcrowding and poor accessibility to health services. The community prevention strategy of Covid-19 in the indigenous population will favor the epidemiological control of the pandemic with probable economic and social impact added, which will guarantee a rational use of resources focused on the most vulnerable population.

Minimally invasive treatment of left main coronary artery thrombosis in a young patient with COVID-19.

COVID-19 has been associated with cardiovascular events. This case demonstrates severe left main coronary artery thrombosis with distal embolisation in a young male patient admitted with COVID-19 who developed ST-elevation myocardial infarction. The patient was treated with thrombus aspiration combined with aggressive anticoagulant treatment, which yielded complete resolution of the thrombus. Left main thrombus represents a life-threatening coronary event and is most often associated with atherosclerotic plaque rupture. In this case, however, we suspect that COVID-19-related intimal inflammation and hypercoagulopathy might be the causal mechanism of thrombus formation. Revascularisation with coronary artery bypass grafting or percutaneous coronary intervention is the standard treatment of left main thrombosis. However, due to the patient's young age and lack of significant atherosclerotic disease burden, we used a conservative medical treatment strategy using potent antithrombotic therapy.

Very early invasive angiography versus standard of care in higher-risk non-ST elevation myocardial infarction: study protocol for the prospective multicentre randomised controlled RAPID N-STEMI trial.

BACKGROUND: There are a paucity of randomised data on the optimal timing of invasive coronary angiography (ICA) in higher-risk patients with non-ST elevation myocardial infarction (N-STEMI). International guideline recommendations for early ICA are primarily based on retrospective subgroup analyses of neutral trials. AIMS: The RAPID N-STEMI trial aims to determine whether very early percutaneous revascularisation improves clinical outcomes as compared with a standard of care strategy in higher-risk N-STEMI patients. METHODS AND ANALYSIS: RAPID N-STEMI is a prospective, multicentre, open-label, randomised-controlled, pragmatic strategy trial. Higher-risk N-STEMI patients, as defined by Global Registry of Acute Coronary Events 2.0 score ≥118, or >90 with at least one additional high-risk feature, were randomised to either: very early ICA±revascularisation or standard of care timing of ICA±revascularisation. The primary outcome is the proportion of participants with at least one of the following events (all-cause mortality, non-fatal myocardial infarction and hospital admission for heart failure) at 12 months. Key secondary outcomes include major bleeding and stroke. A hypothesis generating cardiac magnetic resonance (CMR) substudy will provide mechanistic data on infarct size, myocardial salvage and residual ischaemia post percutaneous coronary intervention. On 7 April 2021, the sponsor discontinued enrolment due to the impact of the COVID-19 pandemic and lower than expected event rates. 425 patients were enrolled, and 61 patients underwent CMR. ETHICS AND DISSEMINATION: The trial has been reviewed and approved by the East of England Cambridge East Research Ethics Committee (18/EE/0222). The study results will be submitted for publication within 6 months of completion. TRIAL REGISTRATION NUMBER: NCT03707314; Pre-results.

Quantifying the Excess Risk of Adverse COVID-19 Outcomes in Unvaccinated Individuals With Diabetes Mellitus, Hypertension, Ischaemic Heart Disease or Myocardial Injury: A Meta-Analysis.

Background: More than 80% of individuals in low and middle-income countries (LMICs) are unvaccinated against coronavirus disease 2019 (COVID-19). In contrast, the greatest burden of cardiovascular disease is seen in LMIC populations. Hypertension (HTN), diabetes mellitus (DM), ischaemic heart disease (IHD) and myocardial injury have been variably associated with adverse COVID-19 outcomes. A systematic comparison of their impact on specific COVID-19 outcomes is lacking. We quantified the impact of DM, HTN, IHD and myocardial injury on six adverse COVID-19 outcomes: death, acute respiratory distress syndrome (ARDS), invasive mechanical ventilation (IMV), admission to intensive care (ITUadm), acute kidney injury (AKI) and severe COVID-19 disease (SCov), in an unvaccinated population. Methodology: We included studies published between 1st December 2019 and 16th July 2020 with extractable data on patients ≥18 years of age with suspected or confirmed SARS-CoV-2 infection. Odds ratios (OR) for the association between DM, HTN, IHD and myocardial injury with each of six COVID-19 outcomes were measured. Results: We included 110 studies comprising 48,809 COVID-19 patients. Myocardial injury had the strongest association for all six adverse COVID-19 outcomes [death: OR 8.85 95% CI (8.08-9.68), ARDS: 5.70 (4.48-7.24), IMV: 3.42 (2.92-4.01), ITUadm: 4.85 (3.94-6.05), AKI: 10.49 (6.55-16.78), SCov: 5.10 (4.26-6.05)]. HTN and DM were also significantly associated with death, ARDS, ITUadm, AKI and SCov. There was substantial heterogeneity in the results, partly explained by differences in age, gender, geographical region and recruitment period. Conclusion: COVID-19 patients with myocardial injury are at substantially greater risk of death, severe disease and other adverse outcomes. Weaker, yet significant associations are present in patients with HTN, DM and IHD. Quantifying these associations is important for risk stratification, resource allocation and urgency in vaccinating these populations. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, registration no: CRD42020201435 and CRD42020201443.

A multi-centre prospective cohort study of patients on the elective waiting list for cardiac surgery during the COVID-19 pandemic.

OBJECTIVES: During the worldwide COVID-19 pandemic, elective cardiac surgery was suspended to provide ICU beds for COVID-19 patients and those requiring urgent cardiac surgery. The aim of this study is to assess the effect of the pandemic on outcomes of patients awaiting elective cardiac surgery. DESIGN: A multi-centre prospective cohort study. SETTING: The elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. PARTICIPANTS: Patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. MAIN OUTCOME MEASURES: Primary outcome was surgery, percutaneous therapy or death at one year. METHODS: Data were collected prospectively on patients on the elective adult cardiac surgery waiting list as of 1 March 2020 across seven UK cardiac surgical centres. Primary outcome was surgery, percutaneous therapy or death at one year. Demographic data and outcomes were obtained from local electronic records, anonymised and submitted securely to the lead centre for analysis. RESULTS: On 1 March 2020, there were 1099 patients on the elective waiting list for cardiac surgery. On 1 March 2021, 83% (n = 916) had met a primary outcome. Of these, 840 (92%) had surgery after a median of 195 (118-262) days on waiting list, 34 (3%) declined an offer of surgery, 23 (3%) had percutaneous intervention, 12 (1%) died, 7 (0.6%) were removed from the waiting list. The remainder of patients, 183 (17%) remained on the elective waiting list. CONCLUSIONS: This study has shown, for the first time, significant delays to treatment of patients awaiting elective cardiac surgery. Although there was a low risk of mortality or urgent intervention, important unmeasured adverse outcomes such as quality of life or increased perioperative risk may be associated with prolonged waiting times.

Clinical and radiological characteristics of adult hospitalized Coronavirus disease-2019 patients of Dhaka, Bangladesh

The severity of Coronavirus disease-2019 (COVID-19) varies among individuals and some influential factors leads to critical infections and death. This study aimed to assess various clinical data of hospitalized patients and identify the determinants of critical COVID-19 infection. This was a cross-sectional study among hospitalized COVID-19 patients confirmed by reverse transcription polymerase chain reaction (RT-PCR). Data was collected from a single Centre between January to April 2021 by experienced physicians of Ad-din Medical College Hospital. All of the laboratory tests were performed by technical experts and the data was analyzed by Statistical package for the social sciences software. Among the study participants 25% were Intensive care unit (ICU) patients and the mean age of them were higher (59 years) than non-ICU (55 years) patients. Our analysis has identified diabetes mellitus (AOR=2.5, 95%CI: 1.1-5.4) and ischemic heart disease (AOR=3.1, 95%CI: 1.1-8.9) as significant predictor of critical outcome (ICU admission). Anemia (AOR=3.3, 95%CI: 1.5-7.4), lymphopenia (AOR=2.9, 95%CI: 1.2-7.1), and thrombocytopenia (AOR=4.2, 95%CI: 2.7-12.9) was also associated critical outcome. Biomarkers of kidney injury (creatinine, blood urea nitrogen), liver damage (alanine transaminase, aspartate aminotransferase, fibrinogen) and electrolyte imbalance (sodium and potassium level) were also significantly associated with critical infection. A higher d-dimer level (2.5) was the most important predictor (AOR=11.5, 95%CI: 5.4-24.6) of critical COVID 19 infections. The study has revealed socio-demographic, comorbidity, and radiological risk factors of critical COVID-19 infections. The identified risk factors would be considered for decision making during the treatment process.

Fear of COVID-19 leading to late presenting myocardial infarction complicated by cardiogenic shock due to ventricular septal rupture.

Post myocardial ventricular septal rupture (VSR) is one of the most fatal complications of acute myocardial infarction (AMI) in spite of percutaneous and surgical closure. With the advancement of percutaneous coronary interventions in a timely manner, incidence of post MI VSR has declined remarkably. However, the COVID-19) pandemic-related late hospital presentations with AMI increases the possibilities of a potential upward shift in the incidence of post MI VSR. This case report aimed to increase awareness of negative contributions of the current pandemic to AMI and its fatal complications.

Outcome, severity, and risk of mortality in patients with COVID-19 and chronic underlying diseases: a prospective study

Background: The novel coronavirus pandemic, severe acute respiratory syndrome CoV-2 (SARS COV-2), has become a global threat and rapidly spread worldwide. The COVID-19 pandemic has posed a number of challenges, the most notable of which is the management of patients with chronic underlying diseases. Objectives: The present study aimed to evaluate the risk of COVID-19 severity and mortality in patients with chronic underlying diseases.

Differences in outcomes of patients with in-hospital versus out-of-hospital ST-elevation myocardial infarction: a registry analysis.

OBJECTIVES: Patients with ST-elevation myocardial infarction (STEMI) that occur while already in hospital ('in-hospital STEMI') face high mortality. However, data about this patient population are scarce. We sought to investigate differences in reperfusion and outcomes of in-hospital versus out-of-hospital STEMI. DESIGN, SETTING AND PARTICIPANTS: Consecutive patients with STEMI all treated with percutaneous coronary intervention (PCI) across 30 centres were prospectively recruited into the Victorian Cardiac Outcomes Registry (2013-2018). PRIMARY AND SECONDARY OUTCOMES: Patients with in-hospital STEMI were compared with patients with out-of-hospital STEMI with a primary endpoint of 30-day major adverse cardiovascular events (MACE). Secondary endpoints included ischaemic times, all-cause mortality and major bleeding. RESULTS: Of 7493 patients with PCI-treated STEMI, 494 (6.6%) occurred in-hospital. Patients with in-hospital STEMI were older (67.1 vs 62.4 years, p<0.001), more often women (32% vs 19.9%, p<0.001), with more comorbidities. Patients with in-hospital STEMI had higher 30-day MACE (20.4% vs 9.8%, p<0.001), mortality (12.1% vs 6.9%, p<0.001) and major bleeding (4.9% vs 2.3%, p<0.001), than patients with out-of-hospital STEMI. According to guideline criteria, patients with in-hospital STEMI achieved symptom-to-device times of ≤70 min and ≤90 min in 29% and 47%, respectively. Patients with out-of-hospital STEMI achieved door-to-device times of ≤90 min in 71%. Occurrence of STEMI while in hospital independently predicted higher MACE (adjusted OR 1.77, 95% CI 1.33 to 2.36, p<0.001) and 12-month mortality (adjusted OR 1.49, 95% CI 1.08 to 2.07, p<0.001). CONCLUSIONS: Patients with in-hospital STEMI experience delays to reperfusion with significantly higher MACE and mortality, compared with patients with out-of-hospital STEMI, after adjustment for confounders. Focused strategies are needed to improve recognition and outcomes in this high-risk and understudied population.

The year in cardiovascular medicine 2021: imaging.

This article reviews the most relevant literature published in 2021 on the role of cardiovascular imaging in cardiovascular medicine. Coronavirus disease 2019 (COVID-19) continued to impact the healthcare landscape, resulting in reduced access to hospital-based cardiovascular care including reduced routine diagnostic cardiovascular testing. However, imaging has also facilitated the understanding of the presence and extent of myocardial damage caused by the coronavirus infection. What has dominated the imaging literature beyond the pandemic are novel data on valvular heart disease, the increasing use of artificial intelligence (AI) applied to imaging, and the use of advanced imaging modalities in both ischaemic heart disease and cardiac amyloidosis.

Ischemic stroke in COVID 19 - management dilemmas

This article presents some points concerning management dilemmas that the authors would like to highlight, which were not specifically addressed in the published guidelines, "Consensus statement - suggested recommendations for acute stroke management during the COVID-19 pandemic: Expert group on behalf of the Indian Stroke Association" which was published recently. The authors emphasize that importance of recognizing that there are treatment dilemmas in COVID-19-related ischaemic stroke management, owing to its variable presentation, even while acknowledging that no definite guidelines are presently available on these.

Anti-ischemic therapy in patients with COVID-19 and acute coronary syndrome

Introduction. Since the end of 2019, the pandemic caused by SARS-CoV2 has affected hundreds of millions of people, and the number of indirectly affected is many times higher. In addition to directly affecting lung tissue, the coronavirus infection predisposes patients to thrombotic events responsible for the occurrence of cardiovascular complications. The aim of our study was to observe patients with COVID-19 and acute coronary syndrome (ACS) and to evaluate the efficacy of anti-ischemic therapy with beta-blockers, molsidomine and trimetazidine.

Focus issue on epidemiology and prevention. (Focus issue on epidemiology and prevention.)

This issue contains 18 articles that discuss COVID-19 and cardiovascular health. Topics include The Jessa Hospital experience for cardiac rehabilitation, cardiology training using technology, the value of sotagliflozin in patients with diabetes and heart failure detracted by an unexpected ending, Taking a stand against air pollution as a joint opinion from the World Heart Federation, American College of Cardiology, American Heart Association, and the European Society of Cardiology, a call to action for new global approaches to cardiovascular disease drug solutions, validation of risk scores for ischaemic stroke in atrial fibrillation across the spectrum of kidney function, the risk of atrial fibrillation in a Swedish nationwide cohort study, the physical activity paradox in cardiovascular disease and all-cause mortality, among others.