Hayatabad Medical Complex Peshawar

Acute spontaneous spinal epidural hematoma (SSEH) is a rare but serious condition that can mimic stroke or carotid artery dissection (CAD), potentially leading to misdiagnosis and inappropriate therapy. We report the case of a 75-year-old male with atrial fibrillation on Edoxaban who awoke with neck pain and, approximately 80 minutes later, developed sudden right-sided weakness. Neurological examination showed right upper limb (RUL) weakness (3/5 proximally, 0/5 distally), right lower limb (RLL) paralysis (0/5), hypotonia, but intact sensation, with a National Institutes of Health Stroke Scale (NIHSS) score of 6 - findings that supported conservative management in the absence of progressive deterioration. Initial CT head and CT angiogram were unremarkable, ruling out intracranial hemorrhage and carotid dissection. Aortic dissection was also excluded by CT aortogram. Although uncontrolled hypertension or other acute risk factors were not identified (blood pressure (BP) 157/81 mmHg), chronic anticoagulation likely contributed to SSEH. Cervical spine magnetic resonance imaging (MRI) performed on day 6 revealed a C3-C5 epidural hematoma compressing the cord. Neurosurgical consultation recommended conservative management due to improving strength and absence of worsening symptoms. Follow-up MRI at six weeks confirmed complete hematoma resolution with residual mild myelopathy. At discharge, after a 10-day hospital stay, the patient's neurological function had improved to 4/5 strength in the RUL and 3/5 in the RLL, and he was transferred for rehabilitation. This case underscores the importance of considering SSEH in anticoagulated patients with acute neck pain and hemiparesis, even when initial imaging for stroke or CAD is negative. Timely MRI and a multidisciplinary approach are crucial to avoid misdiagnosis and optimize outcomes.

Introduction Achieving optimal low-density lipoprotein cholesterol (LDL-C) reduction in high-risk patients remains a challenge, even with combination lipid-lowering therapy. This study evaluated LDL-C target attainment (≤70 mg/dL per European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) 2019 guidelines) in high-risk patients receiving statin plus ezetimibe therapy at a single tertiary care center in Peshawar, Pakistan. Methodology A retrospective analysis of a cross-sectional dataset was conducted at Hayatabad Medical Complex (HMC) over 12 months. A total of 123 high-risk patients, as defined by ESC/EAS 2019 criteria, who had been on statin plus ezetimibe therapy for a minimum of three months (mean duration: 4.2 ± 1.1 months), were included. LDL-C levels were recorded at a single post-treatment follow-up time point. Paired t-tests were used to assess LDL-C changes, and chi-square tests along with multivariable logistic regression were employed to identify predictors of target attainment. Results Mean LDL-C decreased significantly from 156.3 ± 32.5 mg/dL to 84.7 ± 24.1 mg/dL (mean reduction: 71.6 mg/dL; 95% CI: 66.8-76.4; p < 0.001). Overall, 53 of 123 patients (43.1%; 95% CI: 34.6-51.8%) achieved the LDL-C target. Target attainment was lower among diabetic patients (24 of 71; 33.8%) and smokers (13 of 39; 33.3%). In multivariable analysis, diabetes (aOR: 0.52; 95% CI: 0.28-0.97) and smoking (aOR: 0.55; 95% CI: 0.27-0.98) were independently associated with lower target attainment. High-intensity statin use was positively associated with achieving LDL-C goals (33 of 68; 48.5%; aOR: 1.89; 95% CI: 1.02-3.49). Conclusion This single-center study highlights that despite combination therapy, more than half of high-risk patients failed to achieve LDL-C targets. The findings underscore the need for more individualized strategies, improved adherence, and possibly adjunctive therapies. Although the data are from a single center in Peshawar, the trends reflect common challenges in real-world lipid management across similar low- to middle-income healthcare settings.

Hypertension is one of the most frequent non-inherited risks to health that contributes to cardiovascular disease. Whereas the effects of reducing blood pressure are clear-cut, it is debatable what the optimal blood pressure level should be maintained. The objective of this systematic review and meta-analysis was to compare intensive blood pressure control with standard blood pressure control regarding cardiovascular outcomes, specifically focusing on major adverse cardiovascular events (MACE). We searched electronic databases comprehensively (PubMed, Embase, and Cochrane Library) from inception up to March 2025 to find randomized controlled trials comparing intensive control of systolic blood pressure with standard control. The primary outcome was MACE, a composite measure including all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, heart failure, and adverse events. Meta-analysis was performed using random effects to measure risk ratios (RRs) and 95% confidence intervals (CIs). Our analysis incorporated 37,249 subjects from 12 randomized controlled trials. Intensive blood pressure control significantly decreased the odds of MACE (RR: 0.80, 95% CI: 0.73-0.88) compared to standard management. Notable reductions were also observed in cardiovascular mortality (RR: 0.78, 95% CI: 0.67-0.90), stroke (RR: 0.78, 95% CI: 0.68-0.90), and heart failure (RR: 0.73, 95% CI: 0.61-0.88). However, intensive management was associated with higher risks of hypotension, syncope, electrolyte imbalance, and acute kidney injury. Overall, our results indicate that achieving lower blood pressure targets yields significant cardiovascular benefits, particularly in reducing MACE, cardiovascular mortality, stroke, and heart failure. However, these advantages must be weighed against the increased risk of adverse events. Treatment decisions should be individualized based on patient characteristics, risk factors, and preferences. Additionally, moderate heterogeneity was noted across studies, and the risk of bias was assessed, revealing good methodological quality overall.