Kleindorfer et al2021 Guideline for the Secondary Prevention of Ischemic Stroke AdherenceA key component of secondary stroke prevention is assessing and addressing barriers to adherence to medications and a healthy lifestyle. If a patient has a recurrent stroke while on secondary stroke prevention medications, it is vital to assess whether they were taking the medications that they were prescribed and, if possible, to explore and address factors that contributed to nonadherence before assuming that the medications were ineffective. Antithrombotic DosingUnless stated otherwise in the recommendations herein, the international normalized ratio (INR) goal for warfarin is 2.0 to 3.0 and the dose of aspirin is 81 to 325 mg. Application Across PopulationsUnless otherwise indicated, the recommendations in this guideline apply across race/ethnicity, sex, and age groups. Special considerations to address health equity are delineated in section 6.3, Health Equity. DIAGNOSTIC EVALUATION FOR SECONDARY STROKE PREVENTION Recommendations for Diagnostic EvaluationReferenced studies that support recommendations are summarized in online Data Supplements 1 and 2. CORLOE Recommendations 1 B-R Recommendations for Diagnostic Evaluation (Continued) COR LOE Recommendations

Transfemoral percutaneous transvenous mitral valve implantation in high-risk patients with degenerated bioprosthesis is safe, effective, and associated with rapid improvement in hemodynamics, short length of stays, and improved functional status. Percutaneous mitral valve implantation in patients with failed annuloplasty rings and severe MAC is a promising therapy with significant short-term morbidity and mortality that requires further study.

One-year outcomes following successful transseptal balloon-expandable transcatheter heart valve implantation in high-risk patients with degenerated mitral bioprostheses are excellent, characterized by durable symptom relief and prosthesis function. Although mitral valve in ring and valve in MAC have higher operative morbidity and mortality, 1-year outcomes after an initially successful procedure are favorable in carefully selected patients.

The article contains sections titled: 1. Introduction 2. Aliphatic Nitriles 2.1. Physical Properties 2.2. Chemical Properties 2.3. General Production Processes 2.4. Selected Aliphatic Nitriles 2.4.1. Saturated Mono‐ and Dinitriles 2.4.2. Unsaturated Mono‐ and Dinitriles 2.4.3. Substituted Nitriles 2.4.4. β‐Iminonitriles 2.4.5. β‐Ketonitriles 2.5. Toxicology and Occupational Health 3. Aromatic and Araliphatic Nitriles 3.1. Properties 3.2. General Production Methods 3.3. Selected Araliphatic and Aromatic Nitriles 3.3.1. Araliphatic Nitriles 3.3.2. Aromatic Nitriles 3.3.2.1. Cyanobenzenes 3.3.2.2. Cyanonaphthalenes (Naphthalene Carboxylic Acid Nitriles) 3.4. Toxicology

In most cases of acute ST-segment elevation myocardial infarction, only 1 epicardial artery contains an occluding thrombus, commonly referred to as the "culprit" artery. Rarely, however, patients present with >1 acutely thrombosed coronary artery (i.e., "multiple culprits"). The investigators present their experience with 18 patients presenting with ST-segment elevation myocardial infarctions and angiographically documented multiple culprit arteries, provide a detailed review of an additional 29 patients previously reported, and summarize baseline characteristics, pertinent electrocardiographic and angiographic findings, laboratory values, and clinical outcomes for all 47 patients. In this case series, most patients were men (85%) with histories of tobacco use (49%). Although nearly 1/3 of the patients had isolated inferior ST-segment elevation on initial 12-lead electrocardiography, 50% of them had simultaneous thrombotic occlusions of the right coronary and the left anterior descending coronary arteries documented on coronary angiography. These patients were hemodynamically unstable on presentation, with >1/3 in cardiogenic shock. In most cases, no other potential predisposing factors were identified. In conclusion, patients with multiple culprit arteries in the setting of ST-segment elevation myocardial infarctions represent a unique population with high rates of cardiogenic shock and no clear cause.We present our own case series of 18 patients with ST-segment elevation myocardial infarctions (STEMIs) who were referred for primary percutaneous coronary intervention (PCI) in whom multiple culprit arteries were identified angiographically. In addition, we provide a detailed review of an additional 29 patients previously reported, report summary data for all 47 patients, and discuss possible causative factors. MethodsWith investigational review board approval, we searched the primary PCI database at the University of Texas South-western Medical Center and the University of Virginia for all patients presenting with STEMIs referred for primary PCI who had evidence of ST-segment elevation on admission 12-lead electrocardiography and >1 acutely occluded coronary artery documented on coronary angiography. All angiograms were reviewed by an interventional