European Journal of Cardiovascular Medicine

Current surgical palliation for neonates with single ventricle physiology includes Norwood-based and Hybrid-based surgical strategies. When transplantation is not available, clinicians must choose between these two strategies with distinctly different learning curves and risk profiles. The Norwood strategy has evolved over several decades while the rising popularity of the Hybrid strategy is a much more recent addition to our therapeutic options. Based upon the premise that avoiding cardio pulmonary bypass in the neonatal period and deferral of aortic arch reconstruction until a second stage procedure have an important influence on outcomes, the Hybrid strategy has compelling theoretical advantages and disadvantages in comparison to the Norwood strategy. The purpose of this review is to summarise the currently available data to support – or refute – the theoretical advantages of the Hybrid strategy within the context of the Norwood strategy.

Platelets are pivotal in the pathophysiology of acute coronary syndromes; the leading cause of death worldwide. The use of antiplatelet agents in the treatment of acute coronary syndromes has reduced morbidity and mortality substantially. Thus, aspirin has been a cornerstone in the treatment of acute coronary syndromes for years. However, during the last decade the P2Y12 inhibitor clopidogrel has accompanied aspirin to further improve clinical outcomes. P2Y12 inhibitors are antiplatelet agents preventing the binding of adenosine diphosphate to P2Y12 receptors on the platelet surface thus inhibiting platelet aggregation. Recently, the emergence of two new P2Y12 inhibitors, prasugrel and ticagrelor, has challenged the role of clopidogrel. Similar to clopidogrel, prasugrel is a prodrug that needs hepatic conversion to its active metabolite to provide irreversible P2Y12 inhibition. In contrast, ticagrelor is a direct-acting allosteric P2Y12 antagonist inhibiting the P2Y12 receptor reversibly. Both drugs provide a better pro- tection against cardiovascular outcomes than clopidogrel as evidenced by large clinical trials. This benefit might partly reflect the rapid onset of action and the pronounced antiplatelet effect of these drugs compared to clopidogrel. So far, no direct comparison of prasugrel and ticagrelor has been performed, but ongoing trials will provide data to clarify the clinical role of these drugs. The present review outlines the key milestones of the history of P2Y12 inhibitors and provides an up- to-date overview and comparison of the clinical applicability of these drugs.

Atherosclerosis is the leading cause of death in the developed world1.In Pakistan; the disease seems to follow an accelerated course with ischaemic events occurring a decade earlier than those reported worldwide2. While many risk factors of cardiovascular diseases are well established, many are still under evaluation; like homocysteine, which is now being considered an independent risk factor for cardiovascular diseases3. Homocysteine is a sulfur containing amino acid which is not our dietary constituent but is formed by metabolism of methionine, another amino acid present in our daily protein diet. In case of excess formation of homocysteine as compared to its consumption, it appears in urine if levels are too high3. Normal plasma homocysteine concentration ranges from 5 to 15µmol/litre. Of this, almost 75% is bound to proteins, especially albumin, through disulfide bond. Classification of hyperhomo- cysteinemia described by Kang SS 4 is followed widely. Moderate hyperhomocysteinemia (15 to 30 µmol/litre) Intermediate hyperhomocysteinemia (30 to 100µmol/litre) Severe hyperhomocysteinemia (>100 µmol/litre)

The head-up tilt (HUT) test is a standard diagnostic test that is widely accepted in the evaluation of patients with recurrent syncope of unknown etiology. Prolonged asystole during the HUT test is rarely encountered in patients with neurocardiogenic syncope. The incidence of prolonged asystole in patients with neurocar- diogenic syncope is 18% (>3 seconds) and 9.1% (>5 seconds) (1-3). According to our knowledge, there have been few reports related to prolonged asystole longer than 30 seconds during the HUT test (4-8). Asystole lasting for approximately 30 seconds during a HUT test was observed in the present case, which was pre-during HUT.