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Acute coronary syndrome in elderly can manifest with a variety of atypical presentation and may be associated with other comorbid conditions. We present an atypical presentation of ACS in an elderly left handed female presenting with sudden onset of slurred speech preceded by dizziness and vomiting. After through clinical examination and investigation she was managed as a case of non ST elevation myocardial infarction and ischaemic stroke. Â Key words: acute coronary syndrome, atypicalpresentation, ischaemic stroke

Aims: Nepal cannot afford renal replacement therapy (RRT) for ESRD due to lack of resources. Early diagnosis of CKD and its risk factors may reduce the need of RRT. Materials and Methods: In this first community-based screening program in Nepal, 3218 people iÝ 20 years were assessed by door-to-door survey in Dharan. Health status, lifestyle habit, physical examination and blood pressure were evaluated. Spot urine was examined for proteins and glucose by dipstick. Fasting blood glucose and serum creatinine were measured in a subset of 1000 people and the prevalence of CKD was evaluated. A cardiovascular risk factor score was also determined. Results: Overweight, obesity, hypertension, diabetes and proteinuria were found in 20%, 5.0%, 38.6%, 7.5%, and 5.1% respectively. 47% hypertensives were newly detected during the screening. In the subset of 1000 subjects, CKD was detected in 10.6%. Multivariate logistic regression analysis showed that age (P <0.0001) and presence of diabetes (P = 0.027) were statistically significant predictors for CKD. Two or more cardiovascular risk factors were present in 47.3%. 848 patients entered the management phase of the program with lifestyle modification and pharmacologic intervention. 15% drop out during follow-up. Five patients died (2 on RRT). Glycemic (fasting glucose < 120 mg/dL) and blood pressure control (< 140/90 mmHg) was achieved in 60% and 72%, respectively. Regression or stabilization of proteinuria was reported in 52% of patients. Conclusion: Burden of CKD and cardiovascular risk factors are high at community level in Dharan. Reasonable control of blood sugar, hypertension and proteinuria was achieved in this program. These findings indicate the need of activating a large prevention and intervention program to tackle CKD and CVD in Nepal. [ABSTRACT FROM AUTHOR]

Phytopythium root rot caused by Phytopythium vexans is an emerging threat to red maple and Freeman maple production that seriously impacts plant growth, aesthetic, and economic values. This study reports on the resistance of red maple and Freeman maple cultivars against root rot disease caused by P. vexans . Rooted cuttings were received from a commercial nursery and planted in 3-gallon containers. For each cultivar, six plants were inoculated by drenching 300 ml/plant of P. vexans suspension, prepared by blending two plates of 10-day-old P. vexans culture/liter sterile water. An equal number of plants remained noninoculated and were drenched with 300 ml of sterile water. Two trials were conducted for 4 months in the greenhouse during the summer of 2023. Plants were evaluated for growth, physiology, Phytopythium root rot severity (0 to 100% of roots affected), and pathogen reisolation frequency. Out of seven cultivars, Somerset had the lowest Phytopythium root rot severity and pathogen reisolation frequency. Cultivars Autumn Blaze, Brandywine, and October Glory were highly susceptible to P. vexans , whereas Sun Valley, Summer Red, and Celebration were found to have a partial resistance to P. vexans . Cultivars Autumn Blaze, Brandywine, and October Glory had significantly lower chlorophyll content, net photosynthesis, and stomatal conductance compared with the other three cultivars under pathogen inoculation. Phytopythium root rot reduced plant height, width, total plant, and root fresh weight. The disease severity was negatively correlated with width, chlorophyll content, net photosynthesis, and stomatal conductance. These results can aid growers and landscapers in developing effective P. vexans management strategies., Competing Interests: The author(s) declare no conflict of interest.

Background: Cranial nerve palsy (CNP) is a common complication of traumatic brain injury (TBI). Despite a high incidence of TBI in Nepal (382 per 100,000), literature on the specific management and outcome of CNP is lacking. This study aimed to examine the outcomes of TBI patients involving single versus multiple CNP., Methods: A retrospective chart review of 170 consecutive TBI patients admitted to the tertiary neurosurgical center in Nepal between April 2020 and April 2022 was conducted. Demographic, clinical, and etiological characteristics; imaging findings; and management strategies were recorded, compared, and analyzed using descriptive statistics. The Glasgow Outcome Scale Extended (GOSE) was used to measure the outcomes in two groups of patients (single and multiple CNP) at 3 months., Results: Out of 250 eligible patients, 80 were excluded and CNP was noted in 29 (17.1%) of the remaining 170. The median age was 34.9 years, and falls (60.6%) were the most common cause of trauma. TBI severity was categorized based on GCS: mild (82.4%), moderate (15.9%), and severe (1.8%). Cranial nerve involvement was seen in 29 (17.05%) patients: single cranial nerve involvement in 26 (89.65%) and multiple nerve involvement in 3 (10.34%). The most common isolated cranial nerve involved was the oculomotor nerve (37.9%). CT findings revealed a maximum of skull fractures with no significant association between CNP and CT findings., Conclusions: CNP is a common consequence of TBI with the most common etiology being falls followed by RTA. Single CNP was more common than multiple CNP with no significant difference in the outcome in the 3-month GOSE score. Further research is needed to determine the burden of traumatic CNP and establish specific management guidelines for different types of CNP., (© 2024. The Author(s).)

The eastern redbud ( Cercis canadensis L.) is an esthetically and economically important landscape tree with vibrant blossoms and attractive heart-shaped leaves. One-year-old eastern redbud seedlings grown in field condition in two commercial nurseries in Warren Co., Tennessee exhibited severe root rot in October 2021. Dark brown to black lesions and rot were observed in the affected roots (Fig. 1a). Disease severity was 50-75% of root area and disease incidence was approximately 30-40% of 10,000 plants. Surface sterilized (10% NaOCl; 1 min) symptomatic tissues were plated on V8-PARPH and incubated at 25°C. Whitish cottony mycelia with radiate and chrysanthemum flower-like growth patterns were observed within 4 days of incubation. Subglobose papillate sporangia (10.24 to 20.98 µm, n =50), filamentous to globose smooth oogonia, bell-shaped antheridia and spherical zoospores that are characteristic of Phytopythium vexans (de Cock et al. 2015) were observed in older cultures that were subjected to specific growth conditions as previously described by Ghimire & Baysal-Gurel (2023). Pathogen identification was confirmed by extracting total DNA using the DNeasy PowerLyzer Microbial Kit from 7-day-old cultures of isolates FBG0874, FBG1998, FBG2009 grown on V8-PARPH. P. vexans specific LAMP assay was conducted for the rapid molecular screening and confirmation of the isolates (Ghimire et al. 2023). Primer pairs ITS1/ITS4 (White et al. 1990), NL1/NL4 (Baten et al. 2014), Levup and Fm85mod (Robideau et al. 2011) were used to amplify and sequence the internal transcribed spacer (ITS), 28S large subunit (LSU) of ribosomal RNA and the cytochrome c oxidase subunit I (CoxI) of mitochondrial DNA genetic markers, respectively. The sequences (GenBank accession nos. OR204701, OR205212, OR205213: ITS; OR205214, OR205215, OR205216: LSU; OR220805, OR220806, OR220807: CoxI) were 100% similar to ITS, LSU, and CoxI genetic markers of P. vexans isolates in the NCBI database (MK011121: ITS, KX092469: LSU and KT692908: CoxI). Pathogenicity tests were performed on one-year-old eastern redbud seedlings grown in 1 gal containers to fulfill Koch's postulate. Eastern redbud seedlings were drench inoculated (150 ml/plant) with pathogen slurry (two plates of 7-day-old culture/liter) (Panth et al. 2021) of isolates FBG0874, FBG1998, and FBG2009 (five plants/isolate). Control plants were drenched with agar slurry without pathogen. The study was conducted in a greenhouse maintained at 21 to 23°C, 70%RH, with 16-h photoperiod and irrigated twice a day for 2 min using an overhead irrigation system. Fourteen days after inoculation dark brown to black lesions developed in the root of all inoculated plants that were identical to the symptoms observed in the original samples (Fig. 1b), while the roots of non-inoculated plants remained asymptomatic (Fig. 1c). Isolates resembling P. vexans morphological characteristics were recovered from inoculated plants, and their identity was confirmed as P. vexans using LAMP assay. P. vexans has been previously reported to cause root and crown rot in flowering cherry, ginkgo, and red maple in Tennessee (Baysal-Gurel et al. 2021, Panth et al. 2021). To our knowledge, this is the first report of P. vexans causing root rot of eastern redbud in Tennessee and the United States. Identification of this pathogen as the causal agent is important in designing and implementing effective management practices to mitigate this threat to redbud production.

Parkinson's disease which is the second most prevalent neurodegenerative disorder in the United States is a serious and complex disease that may progress to mild cognitive impairment and dementia. The early detection of the mild cognitive impairment and the identification of its biomarkers is crucial to support neurologists in monitoring the progression of the disease and allow an early initiation of effective therapeutic treatments that will improve the quality of life for the patients. In this paper, we propose the first deep-learning based approaches to detect mild cognitive impairment in the sleep Electroencephalography for patients with Parkinson's disease and further identify the discriminative features of the disease. The proposed frameworks start by segmenting the sleep Electroencephalography time series into three sleep stages (i.e., two non-rapid eye movement sleep-stages and one rapid eye movement sleep stage), further transforming the segmented signals in the time-frequency domain using the continuous wavelet transform and the variational mode decomposition and finally applying novel convolutional neural networks on the time-frequency representations. The gradient-weighted class activation mapping was also used to visualize the features based on which the proposed deep-learning approaches reached an accurate prediction of mild cognitive impairment in Parkinson's disease. The proposed variational mode decomposition-based model offered a superior accuracy, sensitivity, specificity, area under curve, and quadratic weighted Kappa score, all above 99% as compared with the continuous wavelet transform-based model (that achieved a performance that is almost above 92%) in differentiating mild cognitive impairment from normal cognition in sleep Electroencephalography for patients with Parkinson's disease. In addition, the features attributed to the mild cognitive impairment in Parkinson's disease were demonstrated by changes in the middle and high frequency variational mode decomposition components across the three sleep-stages. The use of the proposed model on the time-frequency representation of the sleep Electroencephalography signals will provide a promising and precise computer-aided diagnostic tool for detecting mild cognitive impairment and hence, monitoring the progression of Parkinson's disease., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Parajuli et al. 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.)

Fungus-farming ambrosia beetles in the tribe Xyleborini tunnel into plants and trees to establish chambers for cultivating their nutritional fungal mutualists and rearing offspring. Some xyleborine ambrosia beetles preferentially infest and perform better in living but weakened trees. Flood stress predisposes horticultural tree crops to infestation, but the impact of drought stress has not been well studied. Our objectives were to compare the effects of flood stress vs. drought stress on host selection and colonization by xyleborine ambrosia beetles and to assess the duration of flooding. Container-grown Cornus florida L. trees were flood stressed using a pot-in-pot system to submerge the roots in water while drought-stressed conditions were imposed by withholding irrigation and precipitation. When experimental trees were held under field conditions for 14 days, 7.5 × more ambrosia beetles landed on stems of the flood-stressed than on the drought-stressed trees. During two additional experiments over 14 and 22 days, ambrosia beetles tunneled into the flood-stressed trees but not the drought-stressed or standard irrigation trees. By simultaneously deploying trees that were flood stressed for varying lengths of time, it was found that more tunnel entrances, and xyleborine adults and offspring were recovered from trees that were flooded for 1-16 days and 7-22 days than from trees that were flooded for 14-29 days and 28-43 days. These results indicate that acute and severe drought stress does not predispose C. florida to infestation, but flood stress and the duration of flooding influence ambrosia beetle host selection and colonization. Understanding the role of host quality on ambrosia beetle preference behavior will assist with predicting the risk of infestation of these opportunistic insects in horticultural tree crops., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author CR declares that they were an editorial board member of Frontiers at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2023 Ranger, Parajuli, Gresham, Barnett, Villani, Walgenbach, Baysal-Gurel, Owen and Reding.)

Xylosandrus spp. ambrosia beetles (Coleoptera: Curculionidae: Scolytinae) are important wood-boring pests of nursery trees weakened by abiotic and biotic stressors. Acibenzolar-S-methyl (ASM), a plant defense elicitor, was tested for inhibiting Xylosandrus spp. tunneling (i.e., attacks) into flood-stressed flowering dogwoods (Cornus florida L. (Cornales: Cornaceae)). Container-grown dogwoods were treated with ASM substrate drench + flooding, ASM foliar spray + flooding, ASM drench + no flooding, ASM foliar + no flooding, no ASM + flooding, or no ASM + no flooding at 3 days before flood stress in a completely randomized design under field conditions. Trees were flooded for 14 days and then drained and watered as needed. Attacks were counted every 2 days for 28 days. Plant tissue samples were collected at 7 and 14 days after flooding to determine ethanol content using solid-phase microextraction-gas chromatography-mass spectrometry. Trees were dissected to determine gallery formation and depth, fungal colonization, and the presence of eggs, larvae, and adults. The highest number of Xylosandrus beetle species attacks were recorded from plants exposed to no ASM + flooding, but attacks were reduced in ASM treated trees (drench or foliar) + flooding. Trees treated with drenches had fewer attacks than foliar sprays. Plants assigned to no flood had the fewest beetle attacks. Moreover, ASM reduced Xylosandrus spp. gallery formation and depth, fungal colonization, and presence of eggs, larvae, and adults. All flooded trees produced ethanol. In conclusion, ASM induced a plant defense response to Xylosandrus spp. tunneling in dogwoods under flood stress conditions., (© The Author(s) 2023. Published by Oxford University Press on behalf of Entomological Society of America.)

American ginseng ( Panax quinquefolius L.) is an herbaceous perennial understory plant. It was listed as endangered species by the Convention on International Trade in Endangered Species of Wild Fauna and Flora (McGraw et al. 2013). Leaf spot symptoms were observed on 6-year-old cultivated American ginseng on a research plot (8 x 12 ft raised bed under a tree canopy) in Rutherford Co., TN in July 2021 (Fig. 1a). Symptomatic leaves were exhibiting light brown leaf spots with chlorotic haloes 0.5 to 0.8 cm in diameter, mostly confined within or bounded by veins. As the disease progressed, leaf spots expanded and coalesced into irregular shapes with necrotic centers, resulting in a tattered appearance of the leaf. Disease severity was about 50 to 80% of leaf area and incidence was 10% out of 20 plants. Plant tissues were surface sterilized with 10% NaOCl 2 for 60s and washed thrice with sterile water and plated on potato dextrose agar (PDA). Colony growth of the isolates FBG880 and FBG881 on PDA were round, white, thick, and flocculent at the front of the plate and showed a yellowish-ringed shape on the back 10 days after incubation at 25°C (light/dark: 12/12h). Acervular conidiomata containing abundant conidia were observed on PDA. They were globose, 1.0 to 1.8 mm in diameter, and found as solitary or aggregated clusters. Conidia contained five cells (average 13.03±3.50 x 14.31±3.93 µm, n = 30). The middle three cells were light brown to brown. The basal and apical cells were nearly triangular, and transparent, with two to three (7:3 ratios, respectively) apical appendages (average 13.27±3.27 µm) and a basal appendage (average 4.50±0.95 µm, n = 30). To determine pathogen identity, total DNA was extracted using DNeasy PowerLyzer Microbial Kit from fungal colonies on PDA (isolates FBG880 and FBG881). The ribosomal internal transcribed spacer (ITS) region, beta-tubulin (BT), and translation elongation factors 1-α (EF1) genetic markers were amplified using ITS1/ITS4 (White et al. 1990), T1/T2 (Stefańczyk et al. 2016), and EF1/EF2 (O'Donnell et al. 1998), respectively. The sequences (GenBank accession nos. ITS: OQ102470 and OQ103415; BT: OQ107059 and OQ107061; and EF1: OQ107060 and OQ107062) are 100% similar to Pestalotiopsis nanjingensis (CSUFTCC16 and CFCC53882) (Jiang et al. 2022; Li et al. 2021) (Fig. 2). Based on morphology and molecular characteristics, the isolates were identified as P. nanjingensis . To conduct the pathogenicity trial, six healthy 1-year-old American ginseng plants, germinated from seeds and grown in the greenhouse were spray inoculated with a conidial suspension (1×10 6 conidia/ml) (FBG880). Six control plants were sprayed with sterile water. All plants were covered with plastic bags and incubated in a greenhouse set at 21 to 23°C, 70% relative humidity and 16-h photoperiod. After 48 h, bags were removed and plants were maintained under the same conditions. After one month, while control plants remained asymptomatic (Fig. 1b), inoculated plants started to exhibit symptoms resembling those in the research plot (Fig. 1c). Fungal isolates resembling P. nanjingensis in cultural characters were consistently recovered from inoculated plants and their identity as P. nanjingensis was confirmed by DNA sequencing. To our knowledge, this is the first report of leaf spot disease caused by P. nanjingensis on American ginseng. Identification of this pathogen and confirmation of its pathogenicity are fundamental to future disease management approaches.

Red maple ( Acer rubrum L.) is an economically important ornamental nursery plant grown for its aesthetic value. In May 2022, field and container-grown red maple 'October Glory' plants exhibited severe leaf spots in a commercial nursery in Warren Co., Tennessee. Leaf spots were brown-to-black color with a yellow halo (Fig. 1a). Disease severity was about 40% of leaf area and incidence was 60-70% of 10,000 plants. Symptomatic leaf tissues were surface sterilized with 0.525% sodium hypochlorite for 1 min and washed twice with sterilized water. Bacterial colonies, cream colored and circular with smooth margins, were obtained on King's B (KB) and nutrient agar media after 3 days of incubation at 28°C. Bacteria were gram-negative and fluorescent on KB under UV light. The biochemical and physiological test results were negative for cytochrome C oxidase, pectolytic activity on potato slices, and arginine dehydrolase, but positive for gelatin liquefaction, aesculin hydrolysis, and levan production. The BIOLOG test was positive for the utilization of D-galactose, D-galacturonic acid, D-galactonic acid lactone, D-gluconic acid, and was negative for the utilization of β-methyl-D-glucoside, N-acetyl-D-glucosamine, α-hydroxybutyric acid, D-glucose-6-phosphate, α-keto-butyric acid, and α-keto-glutaric acid. To confirm the bacterial identity, total genomic DNA was extracted using DNeasy PowerLyzer Microbial Kit directly from pure cultures (strains FBG1662 and FBG4230). The small subunit ribosomal RNA (16S rRNA), RNA polymerase sigma factor ( rpo Dp and rpo Ds), citrate synthase ( glt A), DNA gyrase ( gyr B) genes were amplified and sequenced by primers 8F/1492R (Galkiewicz et al. 2008), rpoDpF/R, rpoDsF/R, gltAF/R, and gyrBF/R (Sarkar and Guttman 2004), respectively. The sequences of the two strains (GenBank accession nos. 16S: OP962145 and OP948281; rpo Dp: OP998258 and OP957300; rpo Ds: OP998259 and OP957299: glt A: OP998256 and OP957301; gyr B: OP998257 and OP957302) were >99% similar (100% coverage) to the complete genome of Pseudomonas syringae pv. syringae (CP026568) in the NCBI database. A phylogenetic analysis was performed and confirmed the identity using concatenated sequences of glt A, gyr B, rpo Dp, rpo Ds, and 16S of P. syringae pv. syringae and other closely related taxa retrieved from GenBank (Fig. 2). Based on morphological and molecular identification, both bacterial strains were identified as P. syringae pv. syringae . Pathogenicity test was conducted by spray inoculation of ten one-year-old red maple 'October Glory' with bacterial suspension (10 7 CFU/ml) using bacterial strain FBG4230. Ten plants were sprayed with sterilized water as control. All plants were covered with clear plastic for 24 h and incubated in a greenhouse at 21 to 23°C, 70%RH, 16-h photoperiod. At seven days after inoculation, brown-to-black leaf spots surrounded by yellow halo were developed on all inoculated plants (Fig. 1b), while the control plants remained symptomless. The bacterium was re-isolated from the inoculated plants and it was 100% identical to P. syringae pv. syringae using biochemical tests as well as sequence analysis. P. syringae has been reported pathogenic in red maple causing leaf spot in Oregon (Malvick and Moore, 1988). To our knowledge, this is the first report of bacterial leaf spot caused by P. syringae pv. syringae in red maple in Tennessee. Identification of this bacterial pathogen on red maple is crucial in developing timely management practices.

Mode-localized sensors have attracted attention because of their high parametric sensitivity and first-order common-mode rejection to temperature drift. The high-fidelity detection of resonator amplitude is critical to determining the resolution of mode-localized sensors where the measured amplitude ratio in a system of coupled resonators represents the output metric. Operation at specific bifurcation points in a nonlinear regime can potentially improve the amplitude bias stability; however, the amplitude ratio scale factor to the input measurand in a nonlinear regime has not been fully investigated. This paper theoretically and experimentally elucidates the operation of mode-localized sensors with respect to stiffness perturbations (or an external acceleration field) in a nonlinear Duffing regime. The operation of a mode-localized accelerometer is optimized with the benefit of the insights gained from theoretical analysis with operation in the nonlinear regime close to the top critical bifurcation point. The phase portraits of the amplitudes of the two resonators under different drive forces are recorded to support the experimentally observed improvements for velocity random walk. Employing temperature control to suppress the phase and amplitude variations induced by the temperature drift, 1 /f noise at the operation frequency is significantly reduced. A prototype accelerometer device demonstrates a noise floor of 95 ng/√Hz and a bias instability of 75 ng, establishing a new benchmark for accelerometers employing vibration mode localization as a sensing paradigm. A mode-localized accelerometer is first employed to record microseismic noise in a university laboratory environment., Competing Interests: Conflict of interestA.A.S. is a co-founder and director of Silicon Microgravity Ltd., (© The Author(s) 2022.)

Private forest (PF) program has the potential to be one of the most efficient forest management programs in Nepal but it has not gained the momentum compared to the other forest management regimes. Considering this, this paper aims to portray policy provisions, existing institutional arrangements as well as landholder experiences and perceptions over the existing mechanisms of PF registration, management, and forest product harvesting. Using the Sudoorpashchim province of Nepal as a case study, we conducted policy and literature reviews, key informant interviews, household surveys, and field observations. We found only 300 PFs registered in the Sudoorpashchim province, with lowland districts having the highest proportion (87%). Institutional arrangements and procedures for timber harvesting and selling were found to be lengthy and complex, with this being a major issue for PF owners with small forest areas. Government initiatives are inadequate to facilitate PF development due to poor implementation of policy provisions, as well as the lack of appropriate incentives and program packages. Despite a very small government investment in PF development, we found the return from PFs in terms of timber supply to be substantially higher than other forest management regimes. Among others, PF owners perceive the cumbersome regulatory procedures and lack of technical support to be the most pertinent factors responsible for the limited growth of PFs. Based on our results, we have discussed and recommended a number of policy and institutional measures to mainstream PF development programs, in order to support economic prosperity of the nation.

Background: Stroke is usually end result of predisposing conditions that originated years before the ictus. Identification of its modifiable risk factors can help in planning preventive strategies., Objective: To study the risk factors of stroke in adult patients., Methods: A hospital based prospective cross sectional study was carried out in 160 stroke patients admitted in Manipal Teaching Hospital, Pokhara from November 2007- October 2010. Diagnosis of stroke was confirmed by CT scan of brain. Patients were then investigated for presence of conventional risk factors. The data was statistically analysed using Epi-Info., Results: The mean age of stroke patients was 65.98 years +/- 10.69 with 126 (78.8%) of patients belonging to age group = 60 years. It afflicted higher percentage of males 104 (65%) than females 56 (35%). Analysis of stroke subtypes showed preponderance of haemorrhagic stroke in 85 (53.1%) as against infarction in 75 (46.9%) of cases. Other conventional modifiable risk factors were seen as follows: hypertension 98 (61.2 %), cigarette smoking 95 (59.4%), alcohol use 43 (26.9%), left ventricular hypertrophy 44 (27.5%), atrial fibrillation 37(23%), elevated triglyceride 37(23%), diabetes mellitus 15 (9.3%) and elevated total cholesterol 12 (7.5%). Multiple risk factors (=2) were seen in 122 (76.5 %) cases., Conclusions: The maximum occurrence of stroke was seen in patients > 60 years. Overall male preponderance and higher occurrence of haemorrhagic stroke was seen in our study. Significant risk factors in order of descending order were hypertension, cigarette smoking, left ventricular hypertrophy, alcohol use, atrial fibrillation and elevated triglycerides.

Acute coronary syndrome in elderly can manifest with a variety of atypical presentation and may be associated with other comorbid conditions. We present an atypical presentation of ACS in an elderly left handed female presenting with sudden onset of slurred speech preceded by dizziness and vomiting. After through clinical examination and investigation she was managed as a case of non ST elevation myocardial infarction and ischaemic stroke.