AUCTORES
Globalize your Research
Review Article | DOI: https://doi.org/10.31579/2690-4861/140
*Corresponding Author: Mohammed H Habib, Department of Cardiology and Cardiac Catheterization, Al-Shifa Hospital, Gaza, Palestine.
Citation: M Habib. (2021) Cardio-Cerebral Infarction Syndrome: An Overview. International Journal of Clinical Case Reports and Reviews. 8(1); DOI: 10.31579/2690-4861/140
Copyright: © 2021 Mohammed Habib, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 26 May 2021 | Accepted: 30 July 2021 | Published: 05 August 2021
Keywords: cardio-cerebral infarction syndrome (ccis); diagnosis; pathophysiology and treatment
Acute ischemic stroke and coronary artery disease are the major causes of death in Palestine and in the world. The prevalence of coronary artery disease has been reported in one fifth of stroke patients. Although high incidence rate of acute myocardial infarction after recent ischemic stroke and the high risk of acute ischemic stroke after recent myocardial infarction has been reported in several clinical or observational studies. So that acute or recent problem in the heart or brain that could result in an acute infarction of the other. In this review we describe the definition and new classification of the cardio-cerebral infarction syndrome with 3 subtypes that reflect the definition, pathophysiology and treatment options.
The incidence of acute ischemic stroke (AIS) after recent myocardial infarction (MI) during the hospital stay ranges from 0.7% to 2.2%. [1-3] AIS occurred more frequently in the first days after acute myocardial infarction (AMI), but incidence progressively decreased over time. [3-5] Brandi Witt et al, suggested that during hospitalization for MI 11.1 the AIS occurred per 1000 MI compared with 12.2 at one month and 21.4 at one year.The most positive predictors of ischemic stroke after MI included: older age, hypertension, diabetes, history of previous stroke, history of anterior location MI, previous MI, atrial fibrillation and heart failure [6].
The incidence of AMI after recent ischemic stroke was relatively low and unexpectedly highest during the first year after recent stroke. The 5-year cumulative incidence of AMI was 2.0%. The annual risk was highest in the first year after the index event 1.1%. Coronary heart disease was the most substantial risk factor for AMI after ischemic stroke and conferred an approximate 5‐fold greater risk. [7]
Both AIS and AMI are medical emergency conditions, which require rapid diagnosis and treatment. The incidence of AMI patients who diagnosed acute ischemic stroke about 0.009%. [8] In this article we divided cardio-cerebral infarction syndrome into 3 types according to AIS or AMI although diagnostic criteria, pathophysiology and treatment options according to recent clinical trials, metanalysis or case series.
Identify the definition and etiologies of cardio-cerebral infarction syndrome.
Describe the pathological findings in a patient with each subtype of cardio-cerebral infarction syndrome.
Outline the treatment and management options available for patients with each subtype of cardio-cerebral infarction syndrome.
Definition of cardio-cerebral infarction syndrome:
Cardio-cerebral infarction syndrome can generally be defined as Primary disorders (infarction or its complications) of 1 of these 2 organs (Heart or Brain) often result in secondary infarction/injury to the other or to both organs. (figure1).
PCI: percutaneous coronary intervention, CABG: coronary artery bypass graft surgery,
LV: left ventricle, EF: ejection fraction
Types of Cardio-Cerebral Infarction Syndrome: The Al-Shifa Hospital Classification of Cardio-Cerebral Infarction Syndrome divided into 3 types (figure 2)
Type I: concurrent cardio-cerebral infarction syndrome: acute myocardial infarction (< 12>Type IA: Cardiac causes, Type IB: Brain Causes, Type IC: Non-cardiac and non- brain causes)
Type 2: Acute ischemic stroke (<4> after recent myocardial infarction (myocardial infarction in the previous 3 months but more than 12 hours)
Type 3: Acute myocardial infarction (< 12> after recent ischemic stroke (ischemic stroke in the previous 3 months but more than 4.5 hours)
The recent ischemic stroke: ischemic stroke in the previous 3 months but more than 4.5 hours
The recent myocardial infarction: myocardial infarction in the previous 3 months but more than 12 hours.
Type I: concurrent cardio-cerebral infarction syndrome:
Definition: concurrent cardio-cerebral infarction syndrome can be diagnosed by the presence of synchronous acute onset of focal neurological deficit without intracranial hemorrhage and typical chest pain with evidence of elevation of cardiac enzymes and electrocardiogram changes to confirm myocardial infarction.
Diagnosis: concurrent AIS (a sudden onset of focal neurological deficit caused by an acute vascular narrowing causes) and AMI (acute elevation cardiac enzyme plus ischemic electrocardiogram and/or symptoms)
Pathophysiology: the pathophysiology of type I cardio-cerebral infarction syndrome can be divided into three categories:
(1) Cardiac causes or Type 1A (table 1): There are several cardiac causes that lead to concurrent acute stroke with acute myocardial infarction. The most of these is atrial fibrillation can be causes common source of both brain and coronary artery embolism [9]. Acute aortic dissection (type I) with dissection flap extending to coronary arteries and subclavian trunk or common carotid arteries origin had been confirmed to cause concurrent acute myocardial infarction and acute ischemic stroke [10]. In addition, vasospasm due to electrical injury have been reported as an uncommon cause of type I cardio-cerebral infarction syndrome [11].
Pre-existing left ventricular thrombus due to impaired left ventricular ejection fraction or prosthetic valve thrombosis due to low INR ratio can also lead to Type I cardio-cerebral infarction syndrome [12]. Also thrombus formation in the right ventricle in acute right ventricular infarction sitting with right ventricular dysfunction in combination with patent foramen ovale can lead to embolize thrombus for cerebral and coronary territories. Severe hypotension or cardiogenic shock following AMI can also lead to concurrent stroke and myocardial infarction [13].
(2) Brain causes or Type 1B:
Brain causes might be an alternative pathophysiology of concurrent cardio-cerebral infarction syndrome. It has been shown that the insular cortex plays a critical role in central autonomic system regulation [14]. Patients with AIS in the parietoinsular region were found to have higher risk of developing atrial fibrillation [15]. An abnormal electrocardiogram, including ST-segment elevation myocardial infarction (STEMI), was found to be related to ischemic stroke in the insular cortex [16]. In addition to electrocardiographic changes, elevated serum cardiac troponin was shown to be associated with acute ischemic stroke in right inferior parietal lobule [17]. hyperactivation of cardiac sympathetic from an insular cortex lesion can provoke elevation of cardiac enzyme [18]. Results from human studies the right-side stimulation of insular cortex resulted in a predominant sympathetic activation, whereas the left-side stimulation resulted in a predominant parasympathetic effect [18].
(3)Non cardiac and non-brain causes or Type 1C:
Recent studies suggested that coronavirus disease 2019 (COVID-19) infection can be increased the risk of both AIS and AMI. However, the evidence base is limited mainly to case reports and 2 cohort studies. The evidence that COVID-19 may increase the risk of acute ischemic cardiovascular events. The underlying mechanisms may cytokine-mediated hypercoagubility and plaque destabilization [19]. Severe hypotension can be causes concurrent infarction in brain and myocardial infarction.
According to the 2018 scientific statement guideline from the American Heart Association/ American Stroke Association (AHA/ASA), For patients presenting with synchronous AIS and AMI, treatment with IV alteplase (IV- rtPA) at the dose appropriate for acute ischemic stroke, followed by percutaneous coronary intervention (PCI) and stenting if indicated, is reasonable. [20], but no specific recommendation in this guideline for patient with contraindication for thrombolytic in ST Elevation myocardial infarction (STEMI) patients.
According to new trial [21]. In patients with AIS and concurrent MI, type of MI (STEMI or Non-STEMI) and the time elapsed between the 2 events should be taken in consideration while deciding to deliver IV–rtPA. The concurrent AIS and STEMI within 7 days was increased cardiac complication while recent or concurrent NSTEMI were not associated with cardiac complications.
We recommended treatment options for type I cardio-cerebral infarction syndrome (Figure 4):
If patients with STEMI within 12 hours concurrent with AIS within 4.5 hours and no contraindicated for thrombolytic treatment and hemodynamic stable we recommended IV alteplase at the dose appropriate for cerebral ischemia then pharmaco-invasive PCI.
In patients with non-STEMI and hemodynamic stable, we recommended IV alteplase and early invasive PCI within 12 hours and if the stroke related to large vessel occlusion (middle cerebral artery or intracranial internal carotid artery) mechanical thrombectomy within 6 hours is recommended.
If patients with contraindication for thrombolytic treatment and/or hemodynamic instability we recommended primary PCI for STEMI patients and early invasive strategy for non-STEMI patients. And if the ischemic stroke related to large vessel occlusion mechanical thrombectomy is recommended.
PCI: percutaneous coronary intervention, STEMI: ST elevation myocardial infarction, Non-STEMI: non-ST elevation myocardial infarction. ECG: electrocardiogram
Type 2: acute ischemic stroke after recent myocardial infarction
Definition: Acute ischemic stroke in patients with history of recent myocardial infarction in the previous 3 months but more than 12 hours
Diagnosis: AIS (a sudden onset of focal neurological deficit caused by an cerebral vascular narrowing cause) and recent history of MI (acute elevation cardiac enzyme plus ischemic electrocardiogram changes and/or symptoms)in the previous 3 months but not in first 12 hours from MI.
Pathophysiology (table 2):
Left ventricular mural thrombus (LVMT) due to impaired left ventricle ejection fraction (EF) <35>
The circulatory inflammatory cytokines may be initiated a cascade of events in the cerebral circulation. This phenomenon may contribute to plaque rupture and subsequent thrombus formation in the cerebral circulation [24].
Revascularization with early PCI has become the standard of care for patients with acute myocardial infarction and coronary artery bypass graft surgery (CABG) were associated with increased stroke risk. Similarly, analysis of the OASIS [25] registry found that patients with higher rates of invasive cardiac procedures (CABG and PCI) suffered from increased risk of ischemic stroke at 6 months (p = 0.004).
Atrial fibrillation (AF) and atrial flutter after myocardial infarction increased risk of ischemic stroke and occurs in up to 20% of patients and can cause increased in-hospital and long-term mortality [26].
Treatment:
According to the 2018 guideline of scientific statement from the American Heart
Association/American Stroke Association (AHA/ASA), [20]
For patients presenting with AIS and a history of recent MI in the past 3 months, treating the ischemic stroke with IV alteplase is reasonable if the recent MI was non-STEMI.(Class IIa)
For patients presenting with AIS and a history of recent MI in the past 3 months, treating the ischemic stroke with IV alteplase is reasonable if the recent MI was a STEMI involving the right or inferior myocardium. (Class IIa)
For patients presenting with AIS and a history of recent MI in the past 3 months, treating the ischemic stroke with IV alteplase may reasonable if the recent MI was a STEMI involving the left anterior myocardium. (Class IIb)
The main concerns about giving rt-PA to patients with AIS and history of recent MI are (Beyond the bleeding):
1. Thrombolysis-induced myocardial hemorrhage predisposing to myocardial wall rupture
2. Possible ventricular thrombus that could be embolize because of thrombolysis.
3-Post-myocardial infarction pericarditis that may become hemopericardium
The safety of IV rt-PA for acute ischemic stroke (AIS) treatment after recent myocardial infarction (MI) is still controversial. In recent Retrospective review article of 102 AIS patients admitted for AIS with history of recent MI in the previous 3 months. Patients according to treated with standard IV rt-PA dose for AIS were divided into 2 groups: treated or not treated. Four patients with STEMI patients in the week preceding ischemic stroke (8.5%) and IV rt-PA treated died from confirmed cardiac rupture/ tamponade. This complication occurred in 1 (1.8%) patients in the nontreated group (P=0.178), and no non-STEMI patients receiving IV rt-PA had cardiac complications [21].
The new recommendation according to 2021 guidelines of European Stroke Organization (ESO) on intravenous thrombolysis for acute ischemic stroke suggested that [27]:
Contraindication of rt-PA For patients with acute ischemic stroke of < 4> 6 h) ST elevation myocardial infarction during the last seven days.
Insufficient evidence to make a recommendation for patients with acute ischemic stroke of < 4>
IV rt-PA for patients with acute ischemic stroke of < 4>
The recent retrospective trial among 40 396 AIS patients with age ≥ 65 years, the patients treated with rt-PA were 241 patients (0.6%) had recent MI in the past 3 months, of which 19.5% (41 patients) were ST-segment–elevation myocardial infarction. Patients with recent MI had more severe stroke than those without. Among older patients receiving rt-PA for AIS, a recent history of MI in the past 3 months was associated with higher in-hospital mortality compared with no history of MI in ischemic stroke patients treated with rt-PA. This association was more prominent in patients with STEMI than those with NSTEMI. This association was not significant, if the time frame from the onset of MI to the indexed AIS was > 3 months [28].
Despite the increasing risk of mortality, further studies are necessary to determine whether the benefit of rt-PA outweighs its risk among AIS patients with a recent history of MI in last 3 months.
Thus, we recommended the treatment of type II cardio-cerebral infarction syndrome (figure 5):
Intravenous rt-PA for patients with acute ischemic stroke of < 4>
No intravenous rt-PA for patients with acute ischemic stroke of < 4>
For patients with acute ischemic stroke of < 4>
Anticoagulation with novel oral anticoagulation (such as Rivaroxaban) and clopidogrel is recommended in patients with AIS related to cardioembolic causes (left ventricle thrombus and/or atrial fibrillation) and must be at least 3 months then aspirin lifelong for left ventricle thrombus and 3 months rivaroxaban and clopidogrel then rivaroxaban lifelong for atrial fibrillation [29].
Type 3: acute myocardial infarction after recent ischemic stroke:
Definition: AMI in patients with history of AIS in the previous 3 months but not in first 4.5 hours.
Diagnosis: AMI (acute elevation of cardiac enzyme plus ischemic electrocardiogram changes and/or symptoms) and history of AIS (a sudden onset of focal neurological deficit caused by cerebral vascular narrowing) in the previous 3 months.
In general, the risk of acute myocardial infarction after ischemic stroke was low. But the most patients with stroke die of heart disease and one in three patients with ischemic stroke without cardiac history have more than 50% coronary stenosis and about 3% are at risk of developing myocardial infarction within a year of their stroke. So that patients with stroke need to be screened for silent heart disease and appropriate and aggressive management of total cardiovascular risk factors is required. Notably, patients with history of coronary heart disease showed a 5-fold risk of acute myocardial infarction after stroke onset, and those with cardio-embolism subtype had a higher risk than other subtypes [7]. Also, poststroke cardiac arrhythmias could be another possible cause of AMI after AIS (table 3).
Treatment (figure 6):
1-Revascularization: the use of thrombolytics is contraindicated and primary PCI for STEMI and early invasive PCI strategy for non-STEMI patient is recommended.
Recommendations of antithrombotic therapy in cardio-cerebral infarction syndrome:
The cardioembolic causes treatment must be included novel oral anticoagulation (NOAC) and prefer (Rivaroxaban) or oral anticoagulation OAC (warfarin) and dual or single antiplatelet according to 2020 non-ST elevation acute coronary syndrome guideline of European Society of Cardiology (29) and to prevention of bleeding in patients with Atrial Fibrillation undergoing PCI trial [30]. In single antiplatelet with (novel) oral anticoagulation (N) OAC preference for a clopidogrel over aspirin and prefer NOAC over OAC for the default strategy and in all other scenarios if no contraindications (Prosthetic valve or moderate to severe mitral stenosis). Algorithm for antithrombotic therapy and dosage listed of the following (figure 7):
Triple therapy for one week and must be included: Aspirin (75-100 mg) + Clopidogrel (75 mg) + (N) OAC (Rivaroxaban 2.5 mg twice or warfarin: INR 2-3 and TTR > 70%). If patient high risk of thrombosis the duration of triple therapy increase from one week to one month.
Dual therapy preferred included clopidogrel 75 mg daily and (N)OAC and duration 12 months to one year:
AF: (Clopidogrel (75 mg) + (N) OAC (Rivaroxaban 15 mg OD (GFR <60> 70%)
LVMT: first 3 months: (Clopidogrel (75 mg) + OAC (Rivaroxaban 15 mg OD (GFR <60> 70%). After 3 months: Aspirin (75-100 mg) + Clopidogrel (75 mg).
If patient high risk of bleeding the duration of dual therapy can be reduce from one year to 6 months.
After one year for lifelong single antiplatelet or (N)OAC:
AF: Rivaroxaban or warfarin (Rivaroxaban 20 mg OD (GFR <60> 70%), LVT: aspirin 100 mg tab once daily. If patient high risk of bleeding start only single antiplatelet or (N) OAC at 6 months for life long.
Initiation of anticoagulation (N) OAC after ischemic stroke:
Patients with a small stroke with National Institutes of health scale score (NIHSS) < 8> 8 initiate of anticoagulation in AF patients between 1 and 12 days after an ischemic stroke, depending on stroke severity.
In patient with NIHSS 8-15 anticoagulation initiate 6 days after an ischemic stroke, and if NIHSS > 16 initiate of anticoagulation must be >12 days after ischemic stroke. We suggest repeat brain imaging to determine the optimal initiation of anticoagulation in patients with a large stroke at risk for hemorrhagic transformation. NOACs seem to convey slightly better outcomes, mainly driven by fewer intracranial hemorrhages and hemorrhagic stroke (figure 8).
NIHSS: National Institutes of health scale score, CT: Computed Tomography (N) OAC: (New) oral anticoagulation
Recommendations of Lipid-lowering drugs after Cardio-cerebral infarction syndrome (32-35)
High intensity statins are recommended in all MI and/or AIS patients. The aim of treatment is to reduce LDL-C by > 50% from baseline and to achieve LDL-C <1>
If the target LDL-C is not achieved after 4-6 weeks with the maximally tolerated high intensity statin dose, we recommended combination of statin with ezetimibe.
If the target LDL-C is not achieved after 4-6 weeks despite maximally tolerated high intensity statin therapy and ezetimibe, we recommended the addition of a PCSK9 inhibitor to statin and ezetimibe.
Recommendations of (antihypertensive/anti-ischemic/anti failure drugs) after Cardio-cerebral infarction syndrome
Angiotensin-converting enzyme (ACE) inhibitors or Angiotensin receptor blocker (ARBs) are recommended in patients with heart failure with reduced LVEF (<40>
Beta-blockers are recommended in patients with prior MI, long-term oral treatment with a beta-blocker should be considered in order to reduce all-cause and cardiovascular mortality and morbidity and in patients with systolic LV dysfunction or heart failure with reduced LVEF (<40>
Mineralocorticoid receptor antagonist (MRAs) are recommended in patients with heart failure with reduced LVEF <40>
Recommendations of Proton pump inhibitors in patients with Cardio-cerebral infarction syndrome: [44]
In patients with dual antiplatelet and higher risk of gastrointestinal bleeding:
History of gastrointestinal bleeding or ulcer,
Corticosteroid use,
Oral anti-coagulant therapy,
Use of non-steroidal anti-inflammatory drugs, or two or more of
Old age more than 65 years.
Gastro-esophageal reflux disease.
History of Helicobacter pylori infection.
Dyspepsia.
In type 1 cardio-cerebral infarction syndrome: For patients presenting with concurrent AIS and acute MI, treatment with IV alteplase at the dose appropriate for cerebral ischemia, followed by percutaneous coronary intervention (PCI) and stenting if indicated. But if patient contraindicated to thrombolytic treatment and/or hemodynamic instability we recommended primary PCI for STEMI patients and early invasive strategy for non-STEMI patients. And if the stroke related to large vessel occlusion mechanical thrombectomy is recommended.
In type II cardio-cerebral infarction syndrome: For patients with acute ischemic stroke of < 4>
In type III cardio-cerebral infarction syndrome: the use of thrombolytics is contraindicated and primary PCI for STEMI and early invasive PCI strategy for non-STEMI patient is recommended.
No conflit of interest
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
