Despite increasing evidence and improvements in the care of acute coronary syndromes (ACS), sex disparities in presentation, comorbidities, access to care and invasive therapies remain, even in the most developed countries. Much of the currently available data are derived from more developed regions of the world, particularly Europe and the Americas. In contrast, in more resource-constrained settings, especially in Sub-Saharan Africa and some parts of Asia, more data are needed to identify the prevalence of sex disparities in ACS, as well as factors responsible for these disparities, particularly cultural, socioeconomic, educational and psychosocial. This review summarizes the available evidence of sex differences in ACS, including risk factors, pathophysiology and biases in care from a global perspective, with a focus on each of the six different World Health Organization (WHO) regions of the world. Regional trends and disparities, gaps in evidence and solutions to mitigate these disparities are also discussed.

Despite a growing burden of cardiovascular diseases (CVDs) in Low and Middle Income Countries (LMICs), there remain significant barriers to researchers living in these countries regarding the initiation, progression and completion of research. These obstacles are multifactorial, ranging from a lack of general incentives, national and institutional initiatives and capacity, limited opportunities for funding, and lack of mentorship and support for the presentation and publication of research. In this perspective piece, we highlight some of the challenges we have observed from our experience as early career cardiologists in LMICs and present some potential solutions to address these issues.

The pacemaker-twiddler’s syndrome is an uncommon cause of pacemaker malfunction. It occurs due to unintentional or deliberate manipulation of the pacemaker pulse generator within its skin pocket by the patient. This causes coiling of the lead and its dislodgement, resulting in failure of ventricular pacing. More commonly reported among elderly females with impaired cognition, the phenomenon usually occurs in the first year following pacemaker implantation. Treatment involves repositioning of the dislodged leads and suture fixation of the lead and pulse generator within its pocket. An 87 year old Bangladeshi lady who underwent a single chamber ventricular pacemaker (VVI mode: i.e. ventricle paced, ventricle sensed, inhibitory mode) implantation with the indication of complete heart block, and presented to us again 7 weeks later, with syncopal attacks. She admitted to repeatedly manipulating the pacemaker generator in her left pectoral region. Physical examination revealed a heart rate of 42 beats/minute, blood pressure 140/80 mmHg and bilateral crackles on lung auscultation. She had no cognitive deficit. An immediate electrocardiogram showed complete heart block with pacemaker spikes and failure to capture. Chest X-ray showed coiled and retracted right ventricular lead and rotated pulse generator. An emergent temporary pace maker was set at a rate of 60 beats per minute. Subsequently, she underwent successful lead repositioning with strong counselling to avoid further twiddling. Twiddler’s syndrome should be considered as a cause of pacemaker failure in elderly patients presenting with bradyarrythmias following pacemaker implantation. Chest X-ray and electrocardiograms are simple and easily-available first line investigations for its diagnosis. Lead repositioning is required, however proper patient education and counselling against further manipulation is paramount to long-term management.

Background: Although there is evidence of peer support in high-income countries, the use of peer support as an intervention for cardiometabolic disease management, including type 2 diabetes (T2DM), in low- and middle-income countries (LMICs), is unclear. Methods: A scoping review methodology was used to search the databases MEDLINE, Embase, Emcare, PsycINFO, LILACS, CDSR, and CENTRAL. Results: Twenty-eight studies were included in this scoping review. Of these, 67% were developed in Asia, 22% in Africa, and 11% in the Americas. The definition of peer support varied; however, peer support offered a social and emotional dimension to help individuals cope with negative emotions and barriers while promoting disease management. Conclusions: Findings from this scopingreview highlight a lack of consistency in defining peer support as a component of CMD management in LMICs. A clear definition of peer support and ongoing program evaluation is recommended for future research.

Women are under-represented among transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve repair (TMVr) operators. This review assesses the representation of women as patients and as proceduralists and trial authors in major structural interventions. Women are under-represented as proceduralists in structural interventions: only 2% of TAVR operators and 1% of TMVr operators are women. Only 1.5% of authors in landmark clinical TAVR and TMVr trials are interventional cardiologists who are women (4/260). Significant under-representation and under-enrolment of women in landmark TAVR trials is evident: the calculated participation-to-prevalence ratio (PPR) is 0.73, and in TMVr trials, the PPR is 0.69. Under-representation of women is also evident in registry data (PPR = 0.84 for TAVR registries and for TMVr registries). In structural interventional cardiology, women are under-represented as proceduralists, trial participants and patients. This under-representation has the potential to affect the recruitment of women to randomised trials, subsequent guideline recommendations, selection for treatment, patient outcomes and sex-specific data analysis.

There remains great heterogeneity in the availability of data and approaches in managing hypertension in Asia-Pacific. A narrative review was performed to better understand the epidemiology of hypertension and challenges in hypertension care provision regionally. The data obtained were discussed under five domains: epidemiology; hospitalisation and financial impact; medication prescription; national guidelines, societies and measures; and barriers and challenges in managing hypertension. Sixteen countries were included, with the prevalence of hypertension ranging between 10.6% and 48.3%. Rates of undiagnosed, untreated and uncontrolled hypertension were alarming throughout the region, with various factors from the five major domains contributing to this, such as urbanisation, gender and socioeconomic status. Data on care provision were generally sparse. Although various measures and policies exist in individual countries to help combat hypertension, challenges have also been identified: some are systemic, while others appear more granular and culturally influenced. Collaboration between stakeholders between countries is crucial to effectively tackle these issues.