Up-to-date information on hearth health, respiratory & COVID-19.

Post–COVID 2021Conditions Among Adult COVID-19 Survivors Aged 18–64 and ≥65 Years — United States, March 2020–November

MMWR CDD | May 27, 2022

As more persons are exposed to and infected by SARS-CoV-2, reports of patients who experience persistent symptoms or organ dysfunction after acute COVID-19 and develop post-COVID conditions have increased. COVID-19 survivors have twice the risk for developing pulmonary embolism or respiratory conditions; one in five COVID-19 survivors aged 18–64 years and one in four survivors aged ≥65 years experienced at least one incident condition that might be attributable to previous COVID-19. Implementation of COVID-19 prevention strategies, as well as routine assessment for post-COVID conditions among persons who survive COVID-19, is critical to reducing the incidence and impact of post-COVID conditions, particularly among adults aged ≥65 years.

Disentangling a Thorny Issue: Myocarditis and Pericarditis Post COVID-19 and Following mRNA COVID-19 Vaccines

Pharmaceuticals, April 25, 2022

Considering the clinical significance for myocarditis and pericarditis after immunization with mRNA COVID-19 vaccines, the present pharmacovigilance study aimed to describe these events reported with mRNA COVID-19 vaccines in the Vaccine Adverse Events Reporting System (VAERS). From 1990 to July 2021, the mRNA vaccines were the most common suspected vaccines related to suspected cases of myocarditis and/or pericarditis (myocarditis: N = 1,165; 64.0%; pericarditis: N = 743; 55.1%), followed by smallpox vaccines (myocarditis: N = 222; 12.2%; pericarditis: N = 200; 14.8%). We assessed all suspected cases through the case definition and classification of the Brighton Collaboration Group, and only definitive, probable, and possible cases were included in the analysis. Our findings suggested that myocarditis and pericarditis mostly involve young male, especially after the second dose with a brief time to onset. Nevertheless, this risk is lower (0.38/100,000 vaccinated people; 95% CI 0.36–0.40) than the risk of developing myocarditis after SARS-CoV-2 infection (1000–4000 per 100,000 people) and the risk of developing “common” viral myocarditis (1–10 per 100,000 people/year). Comparing with the smallpox vaccine, for which is already well known the association with myocarditis and pericarditis, our analysis showed a lower probability of reporting myocarditis (ROR 0.12, 95% CI 0.10–0.14) and pericarditis (ROR 0.06, 95% CI 0.05–0.08) following immunization with mRNA COVID-19 vaccines.

ACC Guidance on the cardiovascular impact of COVID-19 and post-acute sequelae of SARS-CoV-2

Cardiovascular Business, April 21, 2022

[Video] Ty Gluckman, MD, MHA, medical director, Center for Cardiovascular Analytics, Research, and Data Science (CARDS) at Providence St. Joseph Health in Portland, Oregon, explains the main points of the American College of Cardiology (ACC) expert consensus on the cardiovascular consequences stemming from a COVID-19 infection. Gluckman was the co-chair of the expert consensus decision pathway that can be used for the evaluation and management of adults with cardiovascular consequences from a COVID-19 infection. This includes cardiac issues by long-COVID. These ACC guidelines were designed to help clinicians learn how to manage COVID patients with cardiovascular involvement during both the acute infection and long-COVID. The post-acute phase symptoms are referred to in the document by the official clinical designation of long-COVID as post-acute sequelae of SARS-CoV-2 infection (PASC).

Cardiovascular Manifestations in Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19 According to Age

Children, April 20, 2022

Cardiac involvement in multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus-19 disease is often observed with a high risk of heart failure. The aim is to describe cardiovascular involvement, management and early outcome in MIS-C by comparing cardiovascular manifestations in children younger and older than 6 years old. This retrospective observational study included 25 children with MIS-C, admitted to a single pediatric center between March 2020 and September 2021. The median age was 5 years (13 patients under 6 years and 12 over 6 years); coronary artery abnormalities were observed in 77% of preschoolers, with small and medium aneurysms in half of the cases and two cases of mild ventricular dysfunction. School-age children presented myopericardial involvement with mild to moderate ventricular dysfunction in 67% of cases, and two cases of transient coronary dilatation. There was a significant NT-pro-BNP and inflammatory markers increase in 25 of the patients, and mild elevation of troponin 1 in 9. All patients were treated with intravenous immunoglobulin and corticosteroids, and 8 with anakinra. None of the patients needed inotropes or intensive care unit admission. Our study shows the frequent cardiovascular involvement in MIS-C with a peculiar distribution, according to different age group: coronary artery anomalies were more frequent in the younger group, and myopericardial disease in the older one. A prompt multi-target, anti-inflammatory therapy could probably contribute to a favorable outcome.

How delivering cardiopulmonary resuscitation and basic life support skills training through places of worship can help save lives and address health inequalities

European Heart Journal, April 20, 2022

Early delivery of high-quality cardiopulmonary resuscitation (CPR) and rapid defibrillation strengthen the initial links of the chain of survival and can help improve out-of-hospital cardiac arrest (OHCA) outcomes. However, health inequalities exist in OHCA survival at regional and global levels, which reduces the chances of survival, with disproportionately lower CPR delivery rates seen in areas of socio-economic deprivation and ethnic minority groups. In the United Kingdom for example, the British Muslim and South Asian communities also have higher levels of health disparities in cardiovascular disease, diabetes, and physical activity, which can predispose them to poorer outcomes from OHCA. Thus, when developing and delivering training for the public, it is important to ensure that there is equitable access.

SARS-CoV-2 Vaccination and Myocarditis in a Nordic Cohort Study of 23 Million Residents

JAMA Cardiology, April 20, 2022

Reports of myocarditis after SARS-CoV-2 messenger RNA (mRNA) vaccination have emerged. To evaluate the risks of myocarditis and pericarditis following SARS-CoV-2 vaccination by vaccine product, vaccination dose number, sex, and age. Four cohort studies were conducted according to a common protocol, and the results were combined using meta-analysis. Participants were 23 122 522 residents aged 12 years or older. They were followed up from December 27, 2020, until incident myocarditis or pericarditis, censoring, or study end (October 5, 2021). Data on SARS-CoV-2 vaccinations, hospital diagnoses of myocarditis or pericarditis, and covariates for the participants were obtained from linked nationwide health registers in Denmark, Finland, Norway, and Sweden. The 28-day risk periods after administration date of the first and second doses of a SARS-CoV-2 vaccine, including BNT162b2, mRNA-1273, and AZD1222 or combinations thereof. A homologous schedule was defined as receiving the same vaccine type for doses 1 and 2. Incident outcome events were defined as the date of first inpatient hospital admission based on primary or secondary discharge diagnosis for myocarditis or pericarditis from December 27, 2020, onward. Secondary outcome was myocarditis or pericarditis combined from either inpatient or outpatient hospital care. Poisson regression yielded adjusted incidence rate ratios (IRRs) and excess rates with 95% CIs, comparing rates of myocarditis or pericarditis in the 28-day period following vaccination with rates among unvaccinated individuals. Among 23 122 522 Nordic residents (81% vaccinated by study end; 50.2% female), 1077 incident myocarditis events and 1149 incident pericarditis events were identified. Within the 28-day period, for males and females 12 years or older combined who received a homologous schedule, the second dose was associated with higher risk of myocarditis, with adjusted IRRs of 1.75 (95% CI, 1.43-2.14) for BNT162b2 and 6.57 (95% CI, 4.64-9.28) for mRNA-1273. Among males 16 to 24 years of age, adjusted IRRs were 5.31 (95% CI, 3.68-7.68) for a second dose of BNT162b2 and 13.83 (95% CI, 8.08-23.68) for a second dose of mRNA-1273, and numbers of excess events were 5.55 (95% CI, 3.70-7.39) events per 100 000 vaccines after the second dose of BNT162b2 and 18.39 (9.05-27.72) events per 100 000 vaccines after the second dose of mRNA-1273. Estimates for pericarditis were similar.

Right Ventricular Abnormality in Patients Hospitalized With COVID-19 Infection During Omicron Variant Surge

American Journal of Cardiology, April 19, 2022

Echocardiographic changes in the acute phase of COVID-19 infection have been extensively reported during the COVID-19 pandemic. Measures of right ventricular (RV) performance during acute infection have been associated with mortality. We aimed at studying the association of in-hospital mortality with echocardiographic measures of RV performance during the COVID-19 infection surge in New York City attributed to the spread of the Omicron variant. In this retrospective study, we enrolled consecutive patients hospitalized with COVID-19 infection who underwent clinically indicated echocardiograms from December 15, 2021, to January 26, 2022. Omicron became the predominant strain in the United States in December 2021 and accounted for >99% of COVID-19 cases. Echocardiograms were performed adhering to a focused, time-efficient protocol with appropriate use of personal protective equipment and limited viral exposure time. Portable ultrasound machines were used: CX50 (Philips Medical Systems, Bothell, Washington) and Vivid S70 (GE Healthcare Systems, Milwaukee, Wisconsin). Echocardiographic studies were interpreted by experienced echocardiography attending physicians. RV abnormality was defined as basal RV diastolic diameter >4.1 cm in the RV-focused apical view and/or tricuspid annular plane systolic excursion <1.7 cm from the apical 4-chamber view. The primary end point was in-hospital mortality. Kaplan-Meier curves and Cox regression analysis were used to explore the associations of clinical and echocardiographic predictors with in-hospital mortality.

Coronavirus 2019 (COVID-19) venovenous extracorporeal oxygenation: Single community hospital results and insights

Journal of Cardiac Surgery, April 19, 2022

The role of extracorporeal membrane oxygenation (ECMO) for patients with refractory respiratory failure due to coronavirus 2019 (COVID-19) is still unclear even now over a year into the pandemic. ECMO is becoming more commonplace even at smaller community hospitals. While the advantages of venovenous (VV) ECMO in acute respiratory distress syndrome (ARDS) from COVID-19 have not been fully determined, we believe the benefits outweighed the risks in our patient population. Here we describe all patients who underwent VV ECMO at our center. All patients placed on ECMO at our center since the beginning of the pandemic, May 5, 2020, until February 20, 2021 were included in our study. All patients placed on ECMO during the time period described above were followed until discharge or death. The primary endpoint was in-hospital death. Secondary outcomes included discharge disposition, that is, whether patients were sent to a long-term acute care center (LTAC), inpatient rehabilitation, or went directly home. A total of 41 patients were placed on VV ECMO for refractory acute respiratory failure. Survival to discharge, the primary end point, was 63.4% (26/41). Inpatient mortality was 36.6% (15/41). We show here that a successful high-volume VV ECMO program for ARDS is achievable at even a medium-size community hospital. We think our success can be replicated by most small- and medium-size community hospitals with cardiothoracic surgery programs and intensivist teams.

Characterization of COVID-19-associated cardiac injury: evidence for a multifactorial disease in an autopsy cohort

Laboratory Investigation, April 18, 2022

As the coronavirus disease 2019 (COVID-19) pandemic evolves, much evidence implicates the heart as a critical target of injury in patients. The mechanism(s) of cardiac involvement has not been fully elucidated, although evidence of direct virus-mediated injury, thromboembolism with ischemic complications, and cytokine storm has been reported. We examined suggested mechanisms of COVID-19-associated heart failure in 21 COVID-19-positive decedents, obtained through standard autopsy procedure, compared to clinically matched controls and patients with various etiologies of viral myocarditis. We developed a custom tissue microarray using regions of pathological interest and interrogated tissues via immunohistochemistry and in situ hybridization. Severe acute respiratory syndrome coronavirus 2 was detected in 16/21 patients, in cardiomyocytes, the endothelium, interstitial spaces, and percolating adipocytes within the myocardium. Virus detection typically corresponded with troponin depletion and increased cleaved caspase-3. Indirect mechanisms of injury—venous and arterial thromboses with associated vasculitis including a mixed inflammatory infiltrate—were also observed. Neutrophil extracellular traps (NETs) were present in the myocardium of all COVID-19 patients, regardless of injury degree. Borderline myocarditis (inflammation without associated myocyte injury) was observed in 19/21 patients, characterized by a predominantly mononuclear inflammatory infiltrate. Edema, inflammation of percolating adipocytes, lymphocytic aggregates, and large septal masses of inflammatory cells and platelets were observed as defining features, and myofibrillar damage was evident in all patients. Collectively, COVID-19-associated cardiac injury was multifactorial, with elevated levels of NETs and von Willebrand factor as defining features of direct and indirect viral injury.

The Impact of Cardiovascular Risk Factors on the Course of COVID-19

Journal of Clinical Medicine, April 18, 2022

The aim of our review is to indicate and discuss the impact of cardiovascular risk factors, such as obesity, diabetes, lipid profile, hypertension and smoking on the course and mortality of COVID-19 infection. The coronavirus disease 2019 (COVID-19) pandemic is spreading around the world and becoming a major public health crisis. All coronaviruses are known to affect the cardiovascular system. There is a strong correlation between cardiovascular risk factors and severe clinical complications, including death in COVID-19 patients. All the above-mentioned risk factors are widespread and constitute a significant worldwide health problem. Some of them are modifiable and the awareness of their connection with the COVID-19 progress may have a crucial impact on the current and possible upcoming infection. We searched for research papers describing the impact of selected cardiovascular risk factors on the course, severity, complications and mortality of COVID-19 infection form PubMed and Google Scholar databases. Using terms, for example: “COVID-19 cardiovascular disease mortality”, “COVID-19 hypertension/diabetes mellitus/obesity/dyslipidemia”, “cardiovascular risk factors COVID-19 mortality” and other related terms listed in each subtitle. The publications were selected according to the time of their publications between January 2020 and December 2021. From the PubMed database we obtain 1552 results. Further studies were sought by manually searching reference lists of the relevant articles. Relevant articles were selected based on their title, abstract or full text. Articles were excluded if they were clearly related to another subject matter or were not published in English. The types of articles are mainly randomized controlled trial and systematic review. An additional criterion used by researchers was co-morbidities and age of patients in study groups. From a review of the publications, 105 of them were selected for this work with all subheadings included. The intention of this review was to summarize current knowledge about comorbidities and development of COVID-19 infection. We tried to focus on the course and mortality of the abovementioned virus disease in patients with concomitant CV risk factors. Unfortunately, we were unable to assess the quality of data in screened papers and studies we choose because of the heterogenicity of the groups. The conducted studies had different endpoints and included different groups of patients in terms of nationality, age, race and clinical status. We decide to divide the main subjects of the research into separately described subtitles such as obesity, lipid profile, hypertension, diabetes, smoking. We believe that the studies we included and gathered are very interesting and show modern and present-day clinical data and approaches to COVID-19 infection in specific divisions of patients.

Coronary Microvascular Dysfunction is Common in Patients Hospitalized with COVID-19 Infection

Microcirculation, April 18, 2022

Microvascular disease is considered as one of the main drivers of morbidity and mortality in severe COVID-19, and microvascular dysfunction has been demonstrated in the subcutaneous and sublingual tissues in COVID-19 patients. The presence of coronary microvascular dysfunction (CMD) has also been hypothesized, but direct evidence demonstrating CMD in COVID-19 patients is missing. In the present study, we aimed to investigate CMD in patients hospitalized with COVID-19, and to understand whether there is a relationship between biomarkers of myocardial injury, myocardial strain and inflammation and CMD. Thirty-nine patients that were hospitalized with COVID-19 and 40 control subjects were included to the present study. Biomarkers for myocardial injury, myocardial strain, inflammation and fibrin turnover were obtained at admission. A comprehensive echocardiographic examination, including measurement of coronary flow velocity reserve (CFVR), were done after the patient was stabilized. Patients with COVID-19 infection had a significantly lower hyperemic coronary flow velocity, resulting in a significantly lower CFVR (2.0±0.3 vs. 2.4±0.5,p<0.001). Patients with severe COVID-19 had a lower CFVR compared to those with moderate COVID-19 (1.8±0.2 vs. 2.2±0.2, p<0.001) driven by a trend towards higher basal flow velocity. CFVR correlated with troponin (p=0.003,r:-0.470), B-type natriuretic peptide (p<0.001,r:-0.580), C-reactive protein (p<0.001,r:-0.369), interleukin-6 (p<0.001,r:-0.597) and d-dimer (p<0.001,r:-0.561), with the three latter biomarkers having the highest areas-under-curve for predicting CMD. CMD is common in patients with COVID-19, and is related with the severity of the infection. CMD may also explain the “cryptic” myocardial injury seen in patients with severe COVID-19 infection.

How rare is heart inflammation in COVID-19 patients?

Nature Italy, April 15, 2022

Acute myocarditis, inflammation of the heart muscle that can compromise its ability to pump blood, is a rare but serious complication of SARS-CoV-2 infection. Italian researchers at Niguarda Hospital in Milan and Brescia University have led an international, multicentre study to estimate its frequency and consequences1. They found that acute myocarditis affected 2.4 per 1,000 hospitalised COVID-19 patients, who had an average age of 38 years. One in five died or needed temporary mechanical circulatory support, but patients who recover do not usually have permanent cardiac damage. The authors looked at data from patients admitted to 23 hospitals in Europe and the United States from February 2020 to April 2021 to evaluate the frequency, clinical features and outcomes of acute myocarditis. “Amid widespread concerns about cardiac involvement and long-term consequences of SARS-CoV-2 infection, it is important to precisely define the disease,” says Enrico Ammirati, cardiologist at De Gasperis Cardio Center and Transplant Center Niguarda Hospital and co-author of the study. The scientists considered acute myocarditis diagnosed in hospitalised patients using cardiac muscle biopsy or magnetic resonance imaging plus increased levels of troponin, a blood biomarker of heart injury. “That’s why our reported prevalence is lower compared with studies involving large numbers of COVID-19 convalescents submitted to magnetic resonance alone,” Ammirati explains. Those studies found rates of 50% or higher of symptomatic or asymptomatic cardiac injury, including but not limited to myocarditis.

The Incidence of Myocarditis and Pericarditis in Post COVID-19 Unvaccinated Patients—A Large Population-Based Study

Journal of Clinical Medicine, April 15, 2022

Myocarditis and pericarditis are potential post-acute cardiac sequelae of COVID-19 infection, arising from adaptive immune responses. We aimed to study the incidence of post-acute COVID-19 myocarditis and pericarditis. Retrospective cohort study of 196,992 adults after COVID-19 infection in Clalit Health Services members in Israel between March 2020 and January 2021. Inpatient myocarditis and pericarditis diagnoses were retrieved from day 10 after positive PCR. Follow-up was censored on 28 February 2021, with minimum observation of 18 days. The control cohort of 590,976 adults with at least one negative PCR and no positive PCR were age- and sex-matched. Since the Israeli vaccination program was initiated on 20 December 2020, the time-period matching of the control cohort was calculated backward from 15 December 2020. Nine post-COVID-19 patients developed myocarditis (0.0046%), and eleven patients were diagnosed with pericarditis (0.0056%). In the control cohort, 27 patients had myocarditis (0.0046%) and 52 had pericarditis (0.0088%). Age (adjusted hazard ratio [aHR] 0.96, 95% confidence interval [CI]; 0.93 to 1.00) and male sex (aHR 4.42; 95% CI, 1.64 to 11.96) were associated with myocarditis. Male sex (aHR 1.93; 95% CI 1.09 to 3.41) and peripheral vascular disease (aHR 4.20; 95% CI 1.50 to 11.72) were associated with pericarditis. Post COVID-19 infection was not associated with either myocarditis (aHR 1.08; 95% CI 0.45 to 2.56) or pericarditis (aHR 0.53; 95% CI 0.25 to 1.13). We did not observe an increased incidence of neither pericarditis nor myocarditis in adult patients recovering from COVID-19 infection.

Cerebrovascular Complications of COVID-19 and COVID-19 Vaccination

Circulation Research, April 14, 2022

The risk of stroke and cerebrovascular disease complicating infection with SARS-CoV-2 has been extensively reported since the onset of the pandemic. The striking efforts of many scientists in cooperation with regulators and governments worldwide have rapidly brought the development of a large landscape of vaccines against SARS-CoV-2. The novel DNA and mRNA vaccines have offered great flexibility in terms of antigen production and led to an unprecedented rapidity in effective and safe vaccine production. However, as mass vaccination has progressed, rare but catastrophic cases of thrombosis have occurred in association with thrombocytopenia and antibodies against PF4 (platelet factor 4). This catastrophic syndrome has been named vaccine-induced immune thrombotic thrombocytopenia. Rarely, ischemic stroke can be the symptom onset of vaccine-induced immune thrombotic thrombocytopenia or can complicate the course of the disease. In this review, we provide an overview of stroke and cerebrovascular disease as a complication of the SARS-CoV-2 infection and outline the main clinical and radiological characteristics of cerebrovascular complications of vaccinations, with a focus on vaccine-induced immune thrombotic thrombocytopenia. Based on the available data from the literature and from our experience, we propose a therapeutic protocol to manage this challenging condition. Finally, we highlight the overlapping pathophysiologic mechanisms of SARS-CoV-2 infection and vaccination leading to thrombosis.

Disparity in Obesity and Hypertension Risks Observed Between Pacific Islander and Asian American Health Fair Attendees in Los Angeles, 2011–2019

Journal of Racial and Ethnic Health Disparities, April 14, 2022

The Pacific Islander American population is understudied due to being aggregated with Asian Americans. In this study, we conduct a comparative analysis of directly measured body mass index (BMI), body fat percentage (%BF), and blood pressure (BP) between Pacific Islander Americans and Asian Americans from health screenings in Los Angeles, California. We hope to reveal intra-APIA health disparities masked by this data aggregation. We analyzed BMI, %BF, and BP that were objectively measured by trained personnel at health screenings in Los Angeles between January 2011 and December 2019. We performed multivariable multinomial logistic regression models with obesity and hypertensive categories as outcome variables and ethnicity as the primary independent variable of interest. Models controlled for year of visit, participant age, sex, income, education level, years living in the USA, employment status, English proficiency, regular doctor access, and health insurance status. A total of 4,832 individuals were included in the analysis. Multivariable analyses revealed that Pacific Islander participants were at significantly higher risks for being classified as obese compared with all Asian American subgroups studied, including Chinese, Korean, Thai, Vietnamese, Filipino, and Japanese. Pacific Islanders also exhibited significantly lower predicted probability of having a normal blood pressure compared with Chinese and Thai participants. Some variation between Asian subgroups were also observed. Pacific Islander participants had higher risk of several sentinel health problems compared to Asian American participants. Disaggregation of PI Americans from the APIA umbrella category in future studies is necessary to unmask the critical needs of this important community.

Lockdown surgery: the impact of coronavirus disease 2019 measures on cardiac cases

Interactive Cardiovascular and Thoracic Surgery, April 13, 2022

The need to ration medical equipment and interventions during the coronavirus disease 2019 pandemic translated to an ever-lengthening wait list for surgical care. Retrospective analysis of lockdowns is of high importance to learn from the current situation for future pandemics. This monocentric study assessed the impact of lockdown periods on cardiac surgery cases and outcomes. The single-centre cross-sectional descriptive observational study was conducted to investigate the first lockdown period and the following post-lockdown period in comparison to the same periods during the previous 3 years at the Department of Cardiac Surgery at the Medical University of Innsbruck. Data were prospectively collected and retrospectively analysed from the department-specific quality management system. The primary objective was to compare the number of open-heart procedures between the pre-lockdown and the lockdown period. The secondary objectives were to analyse the characteristics and the outcomes of open-heart procedures. There were no differences in patient demographics. A significant decrease of 29% in weekly surgical procedures was observed during the lockdown period. The surgical case-mix was unaffected: The numbers of aortic valve replacements, coronary artery bypass grafts, mitral valve repair or replacement procedures and others remained stable. The urgency of cases increased significantly, and the general health conditions of patients appeared to be worse. However, outcomes were unchanged.

Clevidipine and COVID 19: From Hypertension to Inflammatory Response

Dovepress, April 13, 2022

Globally, more than 4 million have died from COVID-19, World Health Organization (WHO) to declare COVID-19 a pandemic. The COVID 19 pathology, produced by SARS-COV2, a virus from the coronavirus family, emerged at the end of 2019. The majority of cases usually have a mild or moderate form, characterized by fever, cough, intense asthenia and multiple symptoms derived from the initial replicative effect and subsequent hyperimmune effect. Severe cases present with Acute Respiratory Distress Syndrome (ARDS), due to pneumonia with bilateral involvement, which lead to hospital admission of patients and the need for admission to intensive care units (ICU) of approximately 10‒20%. According to the different series; the mortality of the condition once the patient is admitted to the ICU is close to 35‒45%. Currently, more than 4 million people have died in the world due to this pathology. The volume of infections generated the declaration by the World Health Organization (WHO) of the pandemic situation. Factors associated with a higher risk of progression into severe disease include age and comorbidities, especially systemic arterial hypertension due to its high incidence in the general population. Clevidipine can be rapidly and effectively adjusted to the clinical status of the patient, since it can be withdrawn and its effects reversed in just a few minutes, and contains high concentrations of lipids, and it could reduce the inflammatory response induced by SARS-COV2, which is key to progression into severe disease. However, its application in pro-inflammatory settings has not yet been explored, although it must play a key role in inflammation as a scavenger molecule.

Fourth Dose of BNT162b2 mRNA Covid-19 Vaccine in a Nationwide Setting

New England Journal of Medicine, April 13, 2022

With large waves of infection driven by the B.1.1.529 (omicron) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), alongside evidence of waning immunity after the booster dose of coronavirus disease 2019 (Covid-19) vaccine, several countries have begun giving at-risk persons a fourth vaccine dose. To evaluate the early effectiveness of a fourth dose of the BNT162b2 vaccine for the prevention of Covid-19–related outcomes, we analyzed data recorded by the largest health care organization in Israel from January 3 to February 18, 2022. We evaluated the relative effectiveness of a fourth vaccine dose as compared with that of a third dose given at least 4 months earlier among persons 60 years of age or older. We compared outcomes in persons who had received a fourth dose with those in persons who had not, individually matching persons from these two groups with respect to multiple sociodemographic and clinical variables. A sensitivity analysis was performed with the use of parametric Poisson regression. The primary analysis included 182,122 matched pairs. Relative vaccine effectiveness in days 7 to 30 after the fourth dose was estimated to be 45% (95% confidence interval [CI], 44 to 47) against polymerase-chain-reaction–confirmed SARS-CoV-2 infection, 55% (95% CI, 53 to 58) against symptomatic Covid-19, 68% (95% CI, 59 to 74) against Covid-19–related hospitalization, 62% (95% CI, 50 to 74) against severe Covid-19, and 74% (95% CI, 50 to 90) against Covid-19–related death. The corresponding estimates in days 14 to 30 after the fourth dose were 52% (95% CI, 49 to 54), 61% (95% CI, 58 to 64), 72% (95% CI, 63 to 79), 64% (95% CI, 48 to 77), and 76% (95% CI, 48 to 91). In days 7 to 30 after a fourth vaccine dose, the difference in the absolute risk (three doses vs. four doses) was 180.1 cases per 100,000 persons (95% CI, 142.8 to 211.9) for Covid-19–related hospitalization and 68.8 cases per 100,000 persons (95% CI, 48.5 to 91.9) for severe Covid-19. In sensitivity analyses, estimates of relative effectiveness against documented infection were similar to those in the primary analysis. A fourth dose of the BNT162b2 vaccine was effective in reducing the short-term risk of Covid-19–related outcomes among persons who had received a third dose at least 4 months earlier.

What is the association of renin–angiotensin–aldosterone system inhibitors with COVID-19 outcomes: retrospective study of racially diverse patients?

British Medical Journal, April 12, 2022

The objective of this study was to describe the clinical outcomes of COVID-19 in a racially diverse sample from the US Southeast and examine the association of renin–angiotensin–aldosterone system (RAAS) inhibitor use with COVID-19 outcome. This study is a retrospective cohort of 1024 patients with reverse-transcriptase PCR-confirmed COVID-19 infection, admitted to a 1242-bed teaching hospital in Alabama. Data on RAAS inhibitors use, demographics and comorbidities were extracted from hospital medical records. In-hospital mortality, a need of intensive care unit, respiratory failure, defined as invasive mechanical ventilation (iMV) and 90-day same-hospital readmissions. Among 1024 patients (mean (SD) age, 57 (18.8) years), 532 (52.0%) were African Americans, 514 (50.2%) male, 493 (48.1%) had hypertension, 365 (36%) were taking RAAS inhibitors. During index hospitalisation (median length of stay of 7 (IQR (4–15) days) 137 (13.4%) patients died; 170 (19.2%) of survivors were readmitted. RAAS inhibitor use was associated with lower in-hospital mortality (adjusted HR, 95% CI (0.56, (0.36 to 0.88), p=0.01) and no effect modification by race was observed (p for interaction=0.81). Among patients with hypertension, baseline RAAS use was associated with reduced risk of iMV, adjusted OR, 95% CI (aOR 0.58, 95% CI 0.36 to 0.95, p=0.03). Patients with heart failure were twice as likely to die from COVID-19, compared with patients without heart failure. In this retrospective study of racially diverse patients, hospitalised with COVID-19, prehospitalisation use of RAAS inhibitors was associated with 40% reduction in mortality irrespective of race.

Rate of acute myocarditis low in hospitalized patients with COVID-19

Healio | Cardiology Today, April 12, 2022

The prevalence of acute myocarditis was low in hospitalized patients with COVID-19 during the first 14 months of the pandemic, researchers reported in Circulation. The researchers conducted a retrospective cohort study of 56,963 hospitalized patients with COVID-19 from 23 centers in the United States and Europe from February 2020 to April 2021. “While COVID-19 is a virus that predominantly leads to acute respiratory illness, there has been a small group of individuals who also experience cardiac complications,” Enrico Ammirati, MD, PhD, a cardiologist at De Gasperis Cardio Center and Transplant Center at Niguarda Hospital in Milan, said in a press release. “A small study previously indicated acute myocarditis is a rare occurrence in people infected with COVID-19. Our analysis of international data offers better insight to the occurrence of acute myocarditis during COVID-19 hospitalization, particularly before the COVID-19 vaccines were widely available.” The researchers suspected 112 patients of having acute myocarditis and identified 97 as having possible acute myocarditis. Of those, 54 patients (median age, 38 years; 39% women) were identified has having definite or probable acute myocarditis after cardiac MRI and/or endomyocardial biopsy. The prevalence of definite or probable acute myocarditis was 2.4 per 1,000 COVID-19 hospitalizations and the prevalence of possible acute myocarditis was 4.1 per 1,000 COVID-19 hospitalizations, Ammirati and colleagues found. Among those with definite or probable acute myocarditis, the most common symptoms were chest pain (55.5%) and dyspnea (53.7%), according to the researchers.

Clinical Practice Changes in Monitoring Hypertension early in the COVID-19 Pandemic

American Journal of Hypertension, April 11, 2022

Clinical practices can use telemedicine and other strategies (e.g., self-measured blood pressure [SMBP]) for remote monitoring of hypertension to promote control while decreasing risk of exposure to SARS-CoV-2, the virus that causes COVID-19. The DocStyles survey collected data from primary care providers (PCPs), obstetricians-gynecologists (OB/GYNs), and nurse practitioners/physician assistants (NP/PAs) in fall 2020 (n=1,502). We investigated clinical practice changes for monitoring hypertension that were implemented early in the COVID-19 pandemic and examined differences by clinician and practice characteristics (p<0.05). Overall, 369 (24.6%) of clinicians reported their clinical practices made no changes in monitoring hypertension early in the pandemic, 884 (58.9%) advised patients to monitor blood pressure at home or a pharmacy, 699 (46.5%) implemented or increased use of telemedicine for blood pressure monitoring visits, and 545 (36.3%) reduced the frequency of office visits for blood pressure monitoring. Compared with NP/PAs, PCPs were more likely to advise SMBP monitoring (adjusted prevalence ratios (aPR) 1.28, 95% confidence intervals (CI) 1.11-1.47), implement or increase use of telemedicine (aPR 1.23, 95% CI 1.04-1.46) and reduce the frequency of office visits (aPR 1.37, 95% CI 1.11-1.70) for blood pressure monitoring, and less likely to report making no practice changes (aPR 0.63, 95% CI 0.51-0.77).

Myopericarditis following COVID-19 vaccination and non-COVID-19 vaccination: a systematic review and meta-analysis

The Lancet | Respiratory Medicine, April 11, 2022

Myopericarditis is a rare complication of vaccination. However, there have been increasing reports of myopericarditis following COVID-19 vaccination, especially among adolescents and young adults. We aimed to characterise the incidence of myopericarditis following COVID-19 vaccination, and compare this with non-COVID-19 vaccination. We did a systematic review and meta-analysis, searching four international databases from Jan 1, 1947, to Dec 31, 2021, for studies in English reporting on the incidence of myopericarditis following vaccination (the primary outcome). We included studies reporting on people in the general population who had myopericarditis in temporal relation to receiving vaccines, and excluded studies on a specific subpopulation of patients, non-human studies, and studies in which the number of doses was not reported. Random-effects meta-analyses were conducted, and the intra-study risk of bias and certainty of evidence were assessed. We analysed the difference in incidence of myopericarditis among subpopulations, stratifying by the type of vaccine (COVID-19 vs non-COVID-19) and age group (adult vs paediatric). Among COVID-19 vaccinations, we examined the effect of the type of vaccine (mRNA or non-mRNA), sex, age, and dose on the incidence of myopericarditis. The overall incidence of myopericarditis from 22 studies (405 272 721 vaccine doses) was 33·3 cases (95% CI 15·3–72·6) per million vaccine doses, and did not differ significantly between people who received COVID-19 vaccines (18·2 [10·9–30·3], 11 studies [395 361 933 doses], high certainty) and those who received non-COVID-19 vaccines (56·0 [10·7–293·7], 11 studies [9 910 788 doses], moderate certainty, p=0·20). Compared with COVID-19 vaccination, the incidence of myopericarditis was significantly higher following smallpox vaccinations (132·1 [81·3–214·6], p<0·0001) but was not significantly different after influenza vaccinations (1·3 [0·0–884·1], p=0·43) or in studies reporting on various other non-smallpox vaccinations (57·0 [1·1–3036·6], p=0·58). Among people who received COVID-19 vaccines, the incidence of myopericarditis was significantly higher in males (vs females), in people younger than 30 years (vs 30 years or older), after receiving an mRNA vaccine (vs non-mRNA vaccine), and after a second dose of vaccine (vs a first or third dose).

SARS-CoV-2 Infection and Associated Cardiovascular Manifestations and Complications in Children and Young Adults: A Scientific Statement From the American Heart Association

Circulation, April 11, 2022

Coronavirus disease 2019 (COVID-19) resulted in a global pandemic and has overwhelmed health care systems worldwide. In this scientific statement, we describe the epidemiology, pathophysiology, clinical presentations, treatment, and outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and multisystem inflammatory syndrome in children and young adults with a focus on cardiovascular manifestations and complications. We review current knowledge about the health consequences of this illness in children and young adults with congenital and acquired heart disease, the public health burden and health disparities of this infection in these populations, and vaccine-associated myocarditis.

Patients with allergic disorders have greater risk of high blood pressure and coronary heart disease

News Medical, April 11, 2022

Data from the National Health Interview Survey demonstrated adults with a history of allergic disorders have an increased risk of high blood pressure and coronary heart disease, with the highest risk seen in Black male adults. The study is being presented at ACC Asia 2022 Together with the Korean Society of Cardiology Spring Conference on April 15-16, 2022. Previous studies reported an association between allergic disorders and cardiovascular disease, which remain controversial findings, Guo said. The current study aimed to determine whether adults with allergic disorders have increased cardiovascular risk. The study used 2012 data from the National Health Interview Survey (NHIS), which is a cross-sectional survey of the United States population. The allergic group included adults with at least one allergic disorder, including asthma, respiratory allergy, digestive allergy, skin allergy and other allergy. Overall, the study included 34,417 adults, over half of whom were women and averaged 48.5 years old. The allergic group included 10,045 adults. The researchers adjusted for age, sex, race, smoking, alcohol drinking and body mass index; they also examined subgroups stratified by demographic factors. The researchers found a history of allergic disorders was associated with increased risk of developing high blood pressure and coronary heart disease. In further analyses, individuals with a history of allergic disorders between ages 18 and 57 had a higher risk of high blood pressure. A higher risk of coronary heart disease was seen in study participants who were between ages 39-57, male and Black/African American. Asthma contributed most to the risk of high blood pressure and coronary heart disease.

New-Onset Atrial Fibrillation in COVID-19 Infection: A Case Report and Review of Literature

Cureus, April 7, 2022

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, many cases of arrhythmias have been reported in patients with COVID-19 infection. We present the case of a 66-year-old female with no known cardiovascular history who presented with worsening shortness of breath and productive cough and tested positive for COVID-19 infection in the ED. The patient had a recent hospitalization for COVID-19 infection during which she was treated with dexamethasone and remdesivir therapy and her course remained uncomplicated at that time. Following this, she developed worsening shortness of breath at home for which she presented to the ED. During this hospitalization, she was treated with dexamethasone, remdesivir, and supplemental oxygen. On day six of hospitalization, the patient became tachycardic and had palpitations. Cardiac monitor and EKG showed evidence of new-onset atrial fibrillation (NOAF). Initially patient received metoprolol and diltiazem, both of which failed to achieve adequate rate control. Following this, the patient was started on carvedilol 30 mg every six hours, which attained good rate control. Her CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74, and sex category) score was 4 for which she was started on apixaban 5mg twice daily. The patient was discharged on the same medications. Despite increasing reported incidences of NOAF in COVID-19 infection, only little is known about the optimal management strategies and possible etiopathology. The aim of our review is to highlight the possible mechanisms triggering atrial fibrillation in COVID-19 infection and go over the management strategies while reviewing the available literature.

Severe COVID linked to RAAS and hyperlipidemia associated metabolic syndrome conditions

News Medical, April 6, 2022

A recent study posted to the medRxiv preprint server investigated the association of renin-angiotensin-aldosterone system (RAAS)-mediated hypertension (HT) with coronavirus disease 2019 (COVID-19). Various studies have reported the role of angiotensin-converting enzyme-2 (ACE-2) receptors as the point of entry for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This information makes the ACE-2 receptors a critical focus in the assessment of RAAS-mediated hypertension and COVID-19 severity. In the present study, researchers explored the physiology of risk factors related to the impact of COVID-19 on RAAS-targeted HT drugs and the interactions of hyperlipidemia (HL) with other risk factors associated with severe COVID-19. The team collected data from electronic health records obtained from emergency and clinical health services and insurance records. The extracted records were classified into different sets based on several measures. The study results showed that among the two sample sets extracted, the random cohort comprised 997,140 individuals, the COVID-19-infected cohort comprised 269,536 patients, and the control group comprised 269,987 individuals. The team found a strong association between HT and severe COVID-19. Additionally, distinctive metabolic syndrome features were observed among the study populations, including susceptibility to HT drugs, type 2 diabetes, and subsequent kidney failure. In these populations, calcium channel blockers were the primary choice of medicines for HT treatment, whereas RAAS drugs were not used often by severe COVID-19 patients. The study findings showed that the RAAS complex played an important role in the exacerbation of chronic kidney disease in severe COVID-19 patients. The team also noted a trend that indicated that RAAS drugs suppressed the correlation of hypertension with severe COVID-19 more significantly than non-RAAS drugs.

ECG can pinpoint hospitalized COVID-19 patients at high risk of mortality

News Medical, April 4, 2022

A simple electrocardiogram (ECG) can pinpoint hospitalized COVID-19 patients at high risk of death who might need intensive management. That’s the finding of a study presented at EHRA 2022, a scientific congress of the European Society of Cardiology (ESC). Specifically, the research showed that a prolonged QT interval on the ECG was an independent risk factor for both myocardial injury and one-year mortality. An ECG records electrical activity as it travels through the heart. The information is displayed as a graph, which is divided into sections according to the location in the heart. The QT interval refers to the electrical signal from the moment the ventricles of the heart contract until they finish relaxing and is measured in milliseconds. Patients with a prolonged QT interval are at increased risk for life-threatening arrhythmias (heart rhythm disorders) and cardiac arrest. This study examined the association between QT prolongation and long-term mortality in patients hospitalized with COVID-19. It also evaluated the relationship between prolonged QT interval and myocardial injury, a condition in which cells in the heart die. A total of 335 consecutive patients hospitalized with COVID-19 were prospectively studied. All patients had an ECG upon admission. Patients were deemed to have myocardial injury if they showed reduced function on an echocardiogram, which is an ultrasound of the heart, and/or had troponin in the bloodstream. Troponin is a protein found only in heart cells. When the heart is damaged, for example in myocardial injury, troponin is released into the bloodstream. At one year, 41% of patients in the prolonged QT interval group had died compared to 17% in the normal QT interval group. QT prolongation was associated with a 1.85-fold increased risk of dying within a year after adjusting for age, co-existing conditions and severity of COVID-19. When patients were divided into four groups according to the presence of myocardial injury (yes/no) and QT prolongation (yes/no), those with both conditions had a 6.6-fold higher likelihood of one-year mortality compared to patients without QT prolongation and no myocardial injury.

How to use digital devices to detect and manage arrhythmias: an EHRA practical guide

EP Europace, April 3, 2022

The recent advances in technology combined with the need to manage patients remotely during the coronavirus disease-19 (COVID-19) pandemic, have led to a rapid adaptation of the use of digital devices in clinical practice. The term digital devices for heart rhythm monitoring in this paper encompasses many of the novel devices, such as patches, various wearable devices, and handheld devices that have been approved by regulatory authorities for medical purposes. Cardiac implantable electronic devices (CIEDs), devices that can deliver therapy (such as life vests) and Holter monitors fall outside the scope of this paper. Although many perceive the potential benefits from digital workflow, recent surveys show disparities in management with concerns from healthcare professionals of data overload and unsolicited registrations from unfamiliar digital devices. The aim of the document is to provide up-to-date practical guidance on the use of digital devices for arrhythmias, from early detection through management and implementation, using the categories of consensus.

The impact of pre-existing hypertension and its treatment on outcomes in patients admitted to hospital with COVID-19

Hypertension Research, March 29, 2022

The impact of pre-existing hypertension on outcomes in patients with the novel corona virus (SARS-CoV-2) remains controversial. To address this, we examined the impact of pre-existing hypertension and its treatment on in-hospital mortality in patients admitted to hospital with Covid-19. Using the CAPACITY-COVID patient registry we examined the impact of pre-existing hypertension and guideline-recommended treatments for hypertension on in-hospital mortality in unadjusted and multi-variate-adjusted analyses using logistic regression. Data from 9197 hospitalised patients with Covid-19 (median age 69 [IQR 57–78] years, 60.6% male, n = 5573) was analysed. Of these, 48.3% (n = 4443) had documented pre-existing hypertension. Patients with pre-existing hypertension were older (73 vs. 62 years, p < 0.001) and had twice the occurrence of any cardiac disease (49.3 vs. 21.8%; p < 0.001) when compared to patients without hypertension. The most documented class of anti-hypertensive drugs were angiotensin receptor blockers (ARB) or angiotensin converting enzyme inhibitors (ACEi) (n = 2499, 27.2%). In-hospital mortality occurred in (n = 2020, 22.0%), with more deaths occurring in those with pre-existing hypertension (26.0 vs. 18.2%, p < 0.001). Pre-existing hypertension was associated with in-hospital mortality in unadjusted analyses (OR 1.57, 95% CI 1.42,1.74), no significant association was found following multivariable adjustment for age and other hypertension-related covariates (OR 0.97, 95% CI 0.87,1.10). Use of ACEi or ARB tended to have a protective effect for in-hospital mortality in fully adjusted models (OR 0.88, 95% CI 0.78,0.99). After appropriate adjustment for confounding, pre-existing hypertension, or treatment for hypertension, does not independently confer an increased risk of in-hospital mortality patients hospitalized with Covid-19.

Vascular Dysfunction of COVID-19 Is Partially Reverted in the Long-Term

Circulation Research, March 29, 2022

COVID-19 is characterized by severe inflammation during the acute phase and increased aortic stiffness in the early postacute phase. In other models, aortic stiffness is improved after the reduction of inflammation. We aimed to evaluate the mid- and long-term effects of COVID-19 on vascular and cardiac autonomic function. The primary outcome was aortic pulse wave velocity (aPWV). The cross-sectional Study-1 included 90 individuals with a history of COVID-19 and 180 matched controls. The longitudinal Study-2 included 41 patients with COVID-19 randomly selected from Study-1 who were followed-up for 27 weeks. Study-1: Compared with controls, patients with COVID-19 had higher aPWV and brachial PWV 12 to 24 (but not 25–48) weeks after COVID-19 onset, and they had higher carotid Young’s elastic modulus and lower distensibility 12 to 48 weeks after COVID-19 onset. In partial least squares structural equation modeling, the higher the hs-CRP (high-sensitivity C-reactive protein) at hospitalization was, the higher the aPWV 12 to 48 weeks from COVID-19 onset (path coefficient: 0.184; P=0.04). Moreover, aPWV (path coefficient: −0.186; P=0.003) decreased with time. Study-2: mean blood pressure and carotid intima-media thickness were comparable at the end of follow-up, whereas aPWV (−9%; P=0.01), incremental Young’s elastic modulus (−17%; P=0.03), baroreflex sensitivity (+28%; P=0.049), heart rate variability triangular index (+15%; P=0.01), and subendocardial viability ratio (+12%; P=0.01×10−4) were significantly improved. There was a trend toward improvement in brachial PWV (−6%; P=0.14) and carotid distensibility (+18%; P=0.05). Finally, at the end of follow-up (48 weeks after the onset of COVID-19) aPWV (+6%; P=0.04) remained significantly higher in patients with COVID-19 than in control subjects.

FDA authorizes second COVID-19 booster shot for adults aged 50 years or older

Healio | Infectious Disease, March 29, 2022

The FDA on Tuesday authorized a second booster dose of COVID-19 vaccine for people aged 50 years or older and certain immunocompromised patients, citing evidence that it improves protection against severe disease. The authorization applies to the messenger RNA vaccines made by Pfizer-BioNTech and Moderna. The FDA previously authorized a booster shot for older adults in September. They are now eligible for a fourth shot. Immunocompromised adults who received a recommended three-dose primary series of either vaccine have been eligible for a fourth dose since October and may now receive a fifth dose. Following the authorization, the CDC updated its recommendations to include an additional dose for these populations, adding that adults who received a primary vaccine and booster dose of Johnson & Johnson’s vaccine at least 4 months ago may now receive a second booster dose of an mRNA vaccine. The FDA specified that a second booster dose of either mRNA vaccine may be administered to people aged 50 years or older at least 4 months after they received their first booster dose of any authorized or approved COVID-19 vaccine.

Inflammatory cytokines and cardiac arrhythmias: the lesson from COVID-19

Nature Reviews Immunology, March 28, 2022

Although inflammatory cytokines are implicated in the pathogenesis of cardiac arrhythmias, inflammation is still largely overlooked in the current management of heart rhythm disorders. Now, COVID-19, a systemic inflammatory disease, causes an unexpectedly high prevalence of arrhythmic events, emphasizing the relevance of inflammation in the pathogenesis of cardiac arrhythmias. Cardiac arrhythmias are a leading cause of morbidity and mortality in Western countries, but the underlying mechanisms are still ill-defined. Over the past decade, systemic inflammation has been shown to promote a wide spectrum of cardiac arrhythmias, particularly atrial fibrillation, long-QT syndrome and Torsades de Pointes and atrioventricular blocks. Moreover, inflammatory cytokines also seem to be involved in arrhythmogenic cardiomyopathy and other arrhythmogenic syndromes. Nevertheless, inflammation is still largely overlooked in the management of arrhythmias, and as yet, agents that target the immune-inflammatory system have not become standard treatments as antiarrhythmics. There is increasing evidence that these medications may be effective in the clinic; however, large randomized placebo controlled trials are yet to be carried out. The unexpectedly high prevalence of arrhythmic events after COVID-19 has caused a marked increase in interest in this topic. Suddenly, millions of patients share the same, repetitive and well-defined cause of systemic inflammation along with frequent cardiac arrhythmias.

Post-COVID-19 assessment may be needed in some high-hazard workers before return to work

Healio | Cardiology Today, March 26, 2022

The Aviation and Occupational Cardiology Task Force of the European Association of Preventive Cardiology issued a statement on the post-COVID-19 infection evaluation of high-hazard workers prior to return to dangerous work. The task force defined high-hazard workers as pilot and non-pilot aircrews, drivers of heavy goods vehicles, train drivers, professional taxi services, fire crew, police, divers, military, mountaineers, polar workers, offshore workers, and astronauts and space workers. Published in the European Journal of Preventive Cardiology, the position statement includes a decision pathway for cardiopulmonary assessment for occupationally informed physicians based on high-hazard worker COVID-19 symptom severity as well as recommendations for testing modalities. “The challenge in assessing patients with ongoing symptoms following COVID-19 infection is the requirement to discriminate symptoms caused by organ pathology, from those caused by a more typical post-viral syndrome, documented in many well-characterized viral diseases,” Rienk Rienks, MD, PhD, cardiologist at the Central Military Hospital, University Hospital Utrecht, the Netherlands, and colleagues wrote. “This challenge is often compounded by health anxiety, which is particularly pertinent to employees undertaking high-hazard work due to additional concerns regarding future employment. Whilst the overall likelihood of significant pathology in this cohort may be low, employers need to be able to sign off an employee to undertake their high-hazard (and high risk) employment, and to ensure risk is mitigated. Even those who are asymptomatic may need investigation, given that subclinical disease may be occupationally significant.” The position statement included a COVID-19 assessment tool, a flow chart to assist clinical risk triage based on COVID-19 symptoms, hypoxia and ECG findings.

Stroke ‘exceedingly rare’ after COVID-19 vaccination

Healio | Neurology, March 24, 2022

Strokes were reported to be a rare adverse event following the administration of a COVID-19 vaccine, according to a study in Neurology. Using data provided by the Mexican Ministry of Health, Diego Lopez-Mena, MD, of the National Institute of Neurology and Neurosurgery in Mexico City, and colleagues conducted a nationwide retrospective, descriptive study that analyzed stroke incidence per million COVID-19 vaccine doses administered in hospitalized adults from December 2020 to August 2021. Strokes were reported only if they were confirmed within the first 30 days after vaccination. During the study, 79,399,446 doses of six different COVID-19 vaccines from Pfizer/BioNTech, AstraZeneca, Sinovac Biotech, CanSino Biologics, Johnson & Johnson and Sputnik V were administered. A total of 28,646 adverse events occurred within the first 30 days. Of those, 27,968 (98%) were classified as non-serious, and 56 were confirmed as stroke (8.2% of serious adverse events; 55.5% women; median age, 65 years). Overall, stroke incidence was 0.71 cases per 1,000,000 administered doses (95% CI, 0.54-0.92), and the median time from vaccination to stroke was 2 days (interquartile range = 1-5 days). Further, the most frequent type of stroke was acute ischemic stroke, which occurred in 43 of the 56 patients (75%; incidence rate = 0.54 per 1,000,000; 95% CI, 0.40-0.73); nine strokes were intracerebral hemorrhages (16.1%; IR – 0.11 per 1,000,000; 95% CI, 0.06-0.22). The most common risk factors were hypertension (58.9%) and diabetes mellitus (39.3%).

Long COVID and cardiovascular disease: a learning health system approach

Nature Reviews Cardiology, March 24, 2022

Cardiovascular disease is both a risk factor and potential outcome of the direct, indirect and long-term effects of COVID-19. A recent analysis in >150,000 survivors of COVID-19 demonstrates an increased 1-year risk of numerous cardiovascular diseases. Preventing and managing this new disease burden presents challenges to health systems and requires a learning health system approach. Xie and colleagues systematically assessed the incidence of numerous CVD subtypes in 153,760 individuals with COVID-19 from the US Department of Veterans Affairs national database who survived beyond 30 days, comparing them with control groups from the same database from before and during the pandemic and with no evidence of SARS-CoV-2 infection. The investigators found an increased risk and excess burden of incident CVDs among all subgroup of patients with COVID-19 (non-hospitalized, hospitalized and those admitted to the intensive care unit) compared with the control groups. These diseases included atrial fibrillation (HR 1.71, 95% CI 1.64–1.79), ischaemic heart disease (HR 1.72, 95% CI 1.56–1.90), pericarditis (HR 1.85, 95% CI 1.61–2.13), myocarditis (HR 5.38, 95% CI 3.80–7.59), heart failure (HR 1.72, 95% CI 1.65–1.80) and thromboembolic disease (HR 2.93, 95% CI 2.73–3.15). To summarize, bidirectional relationships exist between CVD and COVID-19. Multimorbidity and CVD are key considerations in patients with long COVID, who require multidisciplinary and integrated care. Long COVID, including cardiovascular complications, has potentially far-reaching implications for health system resources, including staffing, infrastructure and funding.

Rise in heart disease, stroke deaths seen during first year of pandemic

Healio | Cardiology Today, March 23, 2022

CDC data show heart disease and stroke deaths increased during the first year of the COVID-19 pandemic due to factors other than an aging population, reversing prior trends and widening race disparities. From 2019 to 2020, researchers also found Black adults had both the greatest increase and the highest overall rate of heart disease and stroke deaths compared with adults from other races and ethnicities. “We had been making progress in reducing deaths from heart disease and stroke, primarily due to preventive measures and timely interventions,” Stephen Sidney, MD, MPH, director of research clinics and senior research scientist with Kaiser Permanente Northern California Division of Research, told Healio. “Our study showed the pandemic didn’t just stop these gains, it reversed them, with Black, Latino and Asian adults hit hardest. This tells us we are not doing enough nationwide to make health care equally accessible to all and to optimize the preventive measures we know can improve CV health.” Sidney and colleagues analyzed CDC data collected from 2011 to 2020 to assess age-adjusted mortality rates for heart disease and stroke, age-specific numbers of deaths and population estimates, using the WONDER database. Researchers estimated year-to-year change in age-associated deaths by multiplying the age-specific death rate for 1 year by the age-specific population of the next year. Risk-associated mortality was calculated as change in total deaths minus age-associated change in deaths, representing deaths associated with underlying changes in disease risk. During the first year of the COVID-19 pandemic, heart disease and stroke deaths increased by 5.8% and 6.8%, respectively. However, the age-associated increases were 1.6% and 1.7% for heart disease and stroke, respectively, whereas risk-associated increases were 4.1% for heart disease and 5.2% for stroke.

In Conversation: Long COVID’s cardiovascular implications

Medical News Today, March 22, 2022

Millions of people worldwide live with long COVID, a condition characterized by symptoms of COVID-19 and other syndromes months after the initial illness has subsided. One aspect of particular concern is its cardiovascular implications, including a rise in postural orthostatic tachycardia syndrome (POTS) and increased cardiovascular disease risk. Our latest In Conversation episode delves into this topic. It is unclear how many people around the world live with long COVID. However, one study that is yet to undergo peer review estimates that as of August 2021, about 43% of people who tested positive for COVID-19, and more than half of those who received hospitalized care for this disease, ended up developing long COVID.

Closed Loop Medicine announces completion of precision medicine clinical trial for patients with high blood pressure

News Medical, March 22, 2022

Closed Loop Medicine Ltd, a leader in the development of single prescription drug plus digital therapy (DTx) combination products to enable precision dosing and care, announced today that the last patient has completed participation in a clinical trial investigating the Company’s integrated precision care product solution for patients with hypertension. Closed Loop Medicine is developing drug and digital therapeutic combination products centred around dose optimization, to improve outcomes for patients, support clinicians, and enable a move towards a value-based medicine proposition for health systems by delivering precision care at a population health scale. The clinical trial, called PERSONAL COVID BP, aimed to investigate whether a combination product that links a drug to a smart phone app can enable patients to personalize and optimise their therapy regimen to treat hypertension. Importantly, the technology in the study allowed patients shielding from COVID-19 to report COVID-19 infection related symptoms as well as control their blood pressure remotely, on a daily basis, from home. The Company rapidly evolved its approach to continue studies through the COVID-19 lockdown, by re-designing studies to run remotely and through technology development, including using the uMED decentralised clinical trial platform. The interventional arm of the study exceeded its recruitment target of 200 patients, with patients receiving drug therapy while using an app to monitor blood pressure and any potential side effects. The data from this study is being used to drive the development of the Company’s highly innovative product that will deliver precision control of blood pressure at population health scale. The product will save lives by addressing the number one killer in the western world, high blood pressure – which, even in the pre-vaccination year of COVID-19 in 2020, killed more people than cancer or COVID-19.

Effect of Antiplatelet Therapy on Survival and Organ Support–Free Days in Critically Ill Patients With COVID-19: A Randomized Clinical Trial

Journal of the American Medical Association, March 22, 2022

The efficacy of antiplatelet therap

Anticoagulation in Patient

y in critically ill patients with COVID-19 is uncertain. Our objective was to determine whether antiplatelet therapy improves outcomes for critically ill adults with COVID-19. In an ongoing adaptive platform trial (REMAP-CAP) testing multiple interventions within multiple therapeutic domains, 1557 critically ill adult patients with COVID-19 were enrolled between October 30, 2020, and June 23, 2021, from 105 sites in 8 countries and followed up for 90 days. Patients were randomized to receive either open-label aspirin (n = 565), a P2Y12 inhibitor (n = 455), or no antiplatelet therapy (control; n = 529). Interventions were continued in the hospital for a maximum of 14 days and were in addition to anticoagulation thromboprophylaxis. The primary endpoint was organ support–free days (days alive and free of intensive care unit–based respiratory or cardiovascular organ support) within 21 days, ranging from −1 for any death in hospital (censored at 90 days) to 22 for survivors with no organ support. There were 13 secondary outcomes, including survival to discharge and major bleeding to 14 days. The primary analysis was a bayesian cumulative logistic model. An odds ratio (OR) greater than 1 represented improved survival, more organ support–free days, or both. Efficacy was defined as greater than 99% posterior probability of an OR greater than 1. Futility was defined as greater than 95% posterior probability of an OR less than 1.2 vs control. Intervention equivalence was defined as greater than 90% probability that the OR (compared with each other) was between 1/1.2 and 1.2 for 2 noncontrol interventions. The aspirin and P2Y12 inhibitor groups met the predefined criteria for equivalence at an adaptive analysis and were statistically pooled for further analysis. Enrollment was discontinued after the prespecified criterion for futility was met for the pooled antiplatelet group compared with control. Among the 1557 critically ill patients randomized, 8 patients withdrew consent and 1549 completed the trial (median age, 57 years; 521 [33.6%] female). The median for organ support–free days was 7 (IQR, −1 to 16) in both the antiplatelet and control groups (median-adjusted OR, 1.02 [95% credible interval {CrI}, 0.86-1.23]; 95.7% posterior probability of futility). The proportions of patients surviving to hospital discharge were 71.5% (723/1011) and 67.9% (354/521) in the antiplatelet and control groups, respectively (median-adjusted OR, 1.27 [95% CrI, 0.99-1.62]; adjusted absolute difference, 5% [95% CrI, −0.2% to 9.5%]; 97% posterior probability of efficacy). Among survivors, the median for organ support–free days was 14 in both groups. Major bleeding occurred in 2.1% and 0.4% of patients in the antiplatelet and control groups (adjusted OR, 2.97 [95% CrI, 1.23-8.28]; adjusted absolute risk increase, 0.8% [95% CrI, 0.1%-2.7%]; 99.4% probability of harm).

Pericardial Involvement in Patients Hospitalized With COVID‐19: Prevalence, Associates, and Clinical Implications

Journal of the American Heart Association, March 21, 2022

The scope of pericardial involvement in COVID‐19 infection is unknown. We aimed to evaluate the prevalence, associates, and clinical impact of pericardial involvement in hospitalized patients with COVID‐19. Consecutive patients with COVID‐19 underwent clinical and echocardiographic examination, irrespective of clinical indication, within 48 hours as part of a prospective predefined protocol. Protocol included clinical symptoms and signs suggestive of pericarditis, calculation of modified early warning score, ECG and echocardiographic assessment for pericardial effusion, left and right ventricular systolic and diastolic function, and hemodynamics. We identified predictors of mortality and assessed the adjunctive value of pericardial effusion on top of clinical and echocardiographic parameters. The study included 530 patients. Pericardial effusion was found in 75 (14%), but only 17 patients (3.2%) fulfilled the criteria for acute pericarditis. Pericardial effusion was independently associated with modified early warning score, brain natriuretic peptide, and right ventricular function. It was associated with excess mortality (hazard ratio [HR], 2.44; P=0.0005) in nonadjusted analysis. In multivariate analysis adjusted for modified early warning score and echocardiographic and hemodynamic parameters, it was marginally associated with mortality (HR, 1.86; P=0.06) and improvement in the model fit (P=0.07). Combined assessment for pericardial effusion with modified early warning score, left ventricular ejection fraction, and tricuspid annular plane systolic excursion was an independent predictor of outcome (HR, 1.86; P=0.02) and improved model fit (P=0.02). In hospitalized patients with COVID‐19, pericardial effusion is prevalent, but rarely attributable to acute pericarditis. It is associated with myocardial dysfunction and mortality. A limited echocardiographic examination, including left ventricular ejection fraction, tricuspid annular plane systolic excursion, and assessment for pericardial effusion, can contribute to outcome prediction.

Association of Amlodipine with the Risk of In-Hospital Death in Patients with COVID-19 and Hypertension: A Reanalysis on 184 COVID-19 Patients with Hypertension

Pharmaceuticals, March 21, 2022

Association between calcium channel blockers (CCBs) or functional inhibitors of acid sphingomyelinase (FIASMAs) use and decreased mortality in people with COVID-19 has been reported in recent studies. Since amlodipine is both a CCB and a FIASMA, the aim of this study was to investigate the association between chronic amlodipine use and the survival of people with hypertension infected with COVID-19. This retrospective cohort study used data extracted from the medical records of adult inpatients with hypertension and laboratory-confirmed COVID-19. We re-analyzed the data of the retrospective cohort study using only the 184 patients (103 males, 81 females) with a mean age of 69.54 years (SD = 14.6) with hypertension. The fifty-five participants (29.9%) receiving a chronic prescription of amlodipine were compared with the 129 patients who did not receive a chronic prescription of amlodipine. Univariate and multivariate logistic regressions were used to explore the relationships between mortality and sex, age, comorbidities, smoking, and amlodipine status. Out of the 184 participants, 132 (71.7%) survived and 52 (28.3%) died. The mortality rates were, respectively, 12.73% (n = 7) and 34.88% (n = 45) for the amlodipine and non-amlodipine groups. Multivariate logistic regression was significant (Chi square (5) = 29.11; p < 0.0001). Chronic kidney disease and malignant neoplasm were significant predictors as well as amlodipine status. For chronic kidney disease and malignant neoplasm, the odds ratio with 95% confidence interval (95% CI) were, respectively, 2.16 (95% CI: 1.04–4.5; p = 0.039) and 2.46 (95% CI: 1.01–6.01; p = 0.047). For amlodipine status the odds ratio was 0.29 (95% CI: 0.11–0.74; p = 0.009). The result of the present study suggests that amlodipine may be associated with reduced mortality in people with hypertension infected with COVID-19. Further research and randomized clinical trials are needed to confirm the potential protective effect of amlodipine in people with hypertension infected with COVID-19.

Fulminant Giant Cell Myocarditis following Heterologous Vaccination of ChAdOx1 nCoV-19 and Pfizer-BioNTech COVID-19

Medicina, March 20, 2022

The global spread of the coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has resulted in countless deaths. To prevent this, several COVID-19 vaccines have been used worldwide. The ChAdOx1 nCoV-19 (or AZD1222) vaccine is an adenoviral vector-based vaccine and its design was based on the vaccine for the previous Middle East Respiratory Syndrome Coronavirus. Pfizer-BioNTech COVID-19, using mRNA, encodes a pre-fusion membrane-bound stabilized full-length S-2P encapsulated with lipid nanoparticles. Vaccination is crucial in controlling the spread of COVID-19 and decreasing the COVID-19 morbidity and mortality rates. The development of myocarditis and inflammatory myocardial cellular infiltrates have been reported after vaccination, especially after the smallpox vaccine. Witberg et al. reported association between the development of myocarditis and the receipt of messenger RNA (mRNA) vaccines against COVID-19. The estimated incidence of myocarditis was 2.13 cases per 100,000 persons. Most cases of myocarditis were mild or moderate in severity. Two previous studies on myocarditis, following COVID-19 mRNA vaccination, reported cardiac biopsy results, which showed no evidence of myocarditis. Almost all patients had resolution of symptoms and signs, and improvement in clinical markers and imaging with or without treatment. In our case, the patient presents a rapid deterioration of cardiac function, following heterologous ChAdOx1 nCoV-19 and Pfizer-BioNTech COVID-19 vaccination and cardiac transplantation. We present a case of fulminant giant cell myocarditis (GCM) following heterologous vaccination with the ChAdOx1 nCoV-19 and Pfizer-BioNTech COVID-19 vaccines and discuss its clinicopathologic findings.

Does Losartan reduce the severity of COVID-19 in hypertensive patients?

BMC Cardiovascular Disorders, March 19, 2022

One of the global problems is to control the coronavirus epidemic, and the role of different medicines is still unknown to policymakers. This study was conducted to evaluate the effects of losartan on the mortality rate of COVID-19 in hypertensive patients. The research sample of analytical study included 1458 patients presenting to COVID-19 diagnostic centers in Yazd that were examined in the first six months of 2020. Data were analyzed using descriptive statistics as well as chi-square, Fisher’s exact test, t test, and logistic regression. Of 1458 subjects that were studied, 280 were hypertensive of whom 179 tested positive for SARS-CoV-2 PCR. The results showed a lower chance of death by more than 5 times in hypertensive patients who used losartan (P = 0.003). Moreover, regarding the effect of losartan on the prevention of COVID-19 in hypertensive patients, it was found that this medicine played a protective role although this relationship was not statistically significant (P = 0.86). The results showed that losartan reduced the chance of mortality in hypertensive patients. It is recommended that the effect of losartan and other blood pressure medicines on COVID-19 patients be investigated in larger studies as well as laboratory investigations.

Significant association between ischemic heart disease and elevated risk for COVID-19 mortality: A meta-analysis

The American Journal of Emergency Medicine, March 18, 2022

A number of previous papers have examined the association between ischemic heart disease (IHD) and the risk for mortality among patients with coronavirus disease 2019 (COVID-19), but there have been inconsistent findings across studies. For example, a few studies have found that there was a significant association between IHD and an elevated risk for COVID-19 mortality, but some other studies have concluded that IHD was not significantly associated with the risk for COVID-19 mortality. Therefore, we performed this quantitative meta-analysis to determine whether there was a significant association between IHD and COVID-19 mortality or not. Gender, age and several comorbidities have been documented to affect the clinical outcomes of COVID-19 patients, indicating that those variables might affect the relationship between IHD and the risk for COVID-19 mortality. Taken together, the pooled effect on the relationship between IHD and COVID-19 mortality was estimated on the basis of adjusted effects in this meta-analysis. We searched PubMed, Web of Science and EMBASE using the following keywords: (“SARS-CoV-2” or “COVID-19” or “2019-nCoV”) and (“ischemic heart disease”) and (“death” or “mortality” or “fatality” or “deceased” or “non-survivor”). A total of 36 studies (335, 720 cases) were included in this meta-analysis. Our meta-analysis demonstrated that there was a significant association between IHD and an elevated risk of COVID-19 mortality (pooled effect size = 1.27, 95% confidence interval (CI) [1.17–1.38]). In summary, our meta-analysis showed that IHD was significantly associated with an increased risk for death among COVID-19 patients. Further well-designed studies with large sample sizes are required to verify the findings of our present study.

Multisystem inflammatory syndrome-related refractory cardiogenic shock in adults after COVID-19 infection: a case series

European Heart Journal Case Reports, March 18, 2022

A novel multisystem inflammatory syndrome in children (MIS-C) temporally associated with the coronavirus disease 2019 (COVID-19) infection has been reported, arising weeks after the peak incidence of COVID-19 infection in adults. Patients with MIS-C have been reported to have cardiac involvement and clinical features overlapping with other acute inflammatory syndromes such as Kawasaki-Disease, toxic shock syndrome, and macrophage activation syndrome. MIS-C may follow Covid-19 infection, most of the time after its asymptomatic form, even though it can lead to serious and life-threatening illness. In this case series, we discuss two cases of young adults with no former medical history who fit with the criteria defined in MIS-C. They both developed a refractory cardiogenic shock and required intensive care treatment including mechanical circulatory support, specifically the use of venous-arterial extracorporeal membrane oxygenation (VA-ECMO). They were both treated early with intravenous immune globulin and adjunctive high-dose steroids. They recovered ad integrum in less than two weeks. MIS-C occurs 2 to 4 weeks after infection with SARS-CoV-2. Patients with MIS-C should ideally be managed in an intensive care environment since rapid clinical deterioration may occur. It would be preferable to have a multi-disciplinary care to improve outcomes. Patients should be monitored for shock. Elucidating the mechanism of this new entity may have importance for understanding COVID-19 far beyond the patients who have had MIS-C to date. The pathogenesis seems to involve post-infectious immune dysregulation so early administration intravenous immune globulin associated to corticosteroids appears appropriate. It implies early recognition of the syndrome even in young adults.

ACC Issues Playbook for Long COVID With Cardiac Involvement

MedPage Today, March 16, 2022

People with long COVID and cardiovascular symptoms may now follow a prescribed path for evaluation and treatment recommended by the American College of Cardiology (ACC). According to the new guidance, people with post-acute sequelae of SARS-CoV-2 infection (PASC) should undergo evaluation with laboratory tests, electrocardiograms (ECGs), echocardiography, ambulatory rhythm monitoring, and/or additional pulmonary testing depending on the clinical presentation, according to Ty Gluckman, MD, MHA, of Providence St. Joseph Health in Tigard, Oregon, and colleagues of the writing group. Abnormal test results would merit cardiology consultation and further evaluation, Gluckman’s team said in a new ACC expert consensus decision pathway, published online in the Journal of the American College of Cardiology. The statement suggests that PASC patients should be split into two groups—those with outright, documented cardiovascular disease; and those with “cardiovascular syndrome,” a heterogeneous disorder that includes a wide range of cardiovascular symptoms that cannot be explained by testing. In the case of PASC-cardiovascular syndrome, the predominant symptom should drive evaluation and management. People with unexplained tachycardia and exercise intolerance, for example, should avoid cardiovascular deconditioning and maintain physical activity by means of seated exercises (e.g., rowing, swimming or cycling). They can transition back to upright exercise as symptoms improve.

Myocardial performance index increases at long-term follow-up in patients with mild to moderate COVID-19

Echocardiography, March 16, 2022

The long-term cardiovascular effects of Coronavirus disease-2019 (COVID-19) are not yet well known. Myocardial performance index (MPI) is a non-invasive, inexpensive and reproducible echocardiographic parameter that reflects systolic and diastolic cardiac functions. The aim of the study was to compare MPI with a healthy control group in patients with mild or moderate COVID-19 infection who subsequently had unexplained cardiac symptoms. The study included 200 patients aged 18–70 years who were diagnosed with COVID-19 infection at least 2 months ago and defined cardiac symptoms in their follow-up. Patients with mild or moderate symptoms, no history of hospitalization, and no other pathology that could explain cardiac symptoms were included in the study. As the control group, 182 healthy volunteers without COVID-19 were evaluated. Echocardiographic examination was performed on the entire study group. Isovolumetric contraction time (IVCT), isovolumetric relaxation time (IVRT), and ejection time (ET) were measured by tissue Doppler imaging. MPI was calculated with the IVCT+IVRT/ET formula. The mean age of the study group was 44.24 ± 13.49 years. In the patient group the MPI was significantly higher (.50 ± .11 vs .46 ± .07, p < .001), IVRT was longer (69.67 ± 15.43 vs 65.94 ± 12.03 ms, p = .008), and ET was shorter (271.09 ± 36.61 vs 271.09 ± 36.61 ms, p = .028). IVCT was similar between groups (63.87 ± 13.66 vs. 63.21 ± 10.77 ms, p = .66). Mitral E and mitral A wave, E’, A’, and E/A were similar in both groups.

Cardiac involvement in coronavirus disease 2019 assessed by cardiac magnetic resonance imaging: a meta-analysis

Heart and Vessels, March 16, 2022

In this systematic review and meta-analysis, we sought to evaluate the prevalence of cardiac involvement in patients with COVID-19 using cardiac magnetic resonance imaging. A literature review was performed to investigate the left ventricular (LV) and right ventricular (RV) ejection fraction (EF), the prevalence of LV late gadolinium enhancement (LGE), pericardial enhancement, abnormality on T1 mapping, and T2 mapping/T2-weighted imaging (T2WI), and myocarditis (defined by modified Lake Louis criteria). Pooled mean differences (MD) between COVID-19 patients and controls for LVEF and RVEF were estimated using random-effects models. We included data from 10.462 patients with COVID-19, comprising 1.010 non-athletes and 9.452 athletes from 29 eligible studies. The meta-analysis showed a significant difference between COVID-19 patients and controls in terms of LVEF [MD = − 2.84, 95% confidence interval (CI) − 5.11 to − 0.56, p < 0.001] and RVEF (MD = − 2.69%, 95% CI − 4.41 to − 1.27, p < 0.001). However, in athletes, no significant difference was identified in LVEF (MD = − 0.74%, 95% CI − 2.41 to − 0.93, p = 0.39) or RVEF (MD = − 1.88%, 95% CI − 5.21 to 1.46, p = 0.27). In non-athletes, the prevalence of LV LGE abnormalities, pericardial enhancement, T1 mapping, T2 mapping/T2WI, myocarditis were 27.5% (95%CI 17.4–37.6%), 11.9% (95%CI 4.1–19.6%), 39.5% (95%CI 16.2–62.8%), 38.1% (95%CI 19.0–57.1%) and 17.6% (95%CI 6.3–28.9%), respectively. In athletes, these values were 10.8% (95%CI 2.3–19.4%), 35.4% (95%CI − 3.2 to 73.9%), 5.7% (95%CI − 2.9 to 14.2%), 1.9% (95%CI 1.1–2.7%), 0.9% (0.3–1.6%), respectively. Both LVEF and RVEF were significantly impaired in COVID-19 patients compared to controls, but not in athletes. In addition, the prevalence of myocardial involvement is not negligible in patients with COVID-19.

Epicardial adipose tissue in contemporary cardiology

Nature Reviews | Cardiology, March 16, 2022

Interest in epicardial adipose tissue (EAT) is growing rapidly, and research in this area appeals to a broad, multidisciplinary audience. EAT is unique in its anatomy and unobstructed proximity to the heart and has a transcriptome and secretome very different from that of other fat depots. EAT has physiological and pathological properties that vary depending on its location. It can be highly protective for the adjacent myocardium through dynamic brown fat-like thermogenic function and harmful via paracrine or vasocrine secretion of pro-inflammatory and profibrotic cytokines. EAT is a modifiable risk factor that can be assessed with traditional and novel imaging techniques. Coronary and left atrial EAT are involved in the pathogenesis of coronary artery disease and atrial fibrillation, respectively, and it also contributes to the development and progression of heart failure. In addition, EAT might have a role in coronavirus disease 2019 (COVID-19)-related cardiac syndrome. EAT is a reliable potential therapeutic target for drugs with cardiovascular benefits such as glucagon-like peptide 1 receptor agonists and sodium–glucose co-transporter 2 inhibitors. This Review provides a comprehensive and up-to-date overview of the role of EAT in cardiovascular disease and highlights the translational nature of EAT research and its applications in contemporary cardiology.

Impact of the COVID‐19 Pandemic on Patients Without COVID‐19 With Acute Myocardial Infarction and Heart Failure

Journal of the American Heart Association, March 15, 2022

Excess mortality from cardiovascular disease during the COVID‐19 pandemic has been reported. The mechanism is unclear but may include delay or deferral of care, or differential treatment during hospitalization because of strains on hospital capacity. We used emergency department and inpatient data from a 12‐hospital health system to examine changes in volume, patient age and comorbidities, treatment (right‐ and left‐heart catheterization), and outcomes for patients with acute myocardial infarction (AMI) and heart failure (HF) during the COVID‐19 pandemic compared with pre‐COVID‐19 (2018 and 2019), controlling for seasonal variation. We analyzed 27 427 emergency department visits or hospitalizations. Patient volume decreased during COVID‐19 for both HF and AMI, but age, race, sex, and medical comorbidities were similar before and during COVID‐19 for both groups. Acuity increased for AMI as measured by the proportion of patients with ST‐segment elevation. There were no differences in right‐heart catheterization for patients with HF or in left heart catheterization for patients with AMI. In‐hospital mortality increased for AMI during COVID‐19 (odds ratio [OR], 1.46; 95% CI, 1.21–1.76), particularly among the ST‐segment–elevation myocardial infarction subgroup (OR, 2.57; 95% CI, 2.24–2.96), but was unchanged for HF (OR, 1.02; 95% CI, 0.89–1.16). Cardiovascular volume decreased during COVID‐19. Despite similar patient age and comorbidities and in‐hospital treatments during COVID‐19, mortality increased for patients with AMI but not patients with HF. Given that AMI is a time‐sensitive condition, delay or deferral of care rather than changes in hospital care delivery may have led to worse cardiovascular outcomes during COVID‐19.

Left ventricular thrombus of unknown etiology in a patient with COVID-19 disease with no significant medical history

Cardiovascular Revascularization Medicine, March 12, 2022

The incidence of left ventricular thrombus is relatively low. Ventricular thrombi typically manifest in patients with reduced ejection fraction and post myocardial infarction. The impact of COVID-19’s hypercoagulability state is presented here. A 44-year-old male who contracted COVID-19, progressed to moderate disease requiring inpatient treatment with supplemental oxygen. During the course of the hospital stay, while receiving National Institutes of Health guideline directed thromboembolism prophylaxis for COVID-19 infected patients, the patient developed a left ventricular thrombus, which consequently embolized and occluded the left anterior descending and left circumflex coronary arteries requiring rheolytic thrombectomy.

Anticoagulation in Patients With COVID-19: JACC Review Topic of the Week

Journal of the American College of Cardiology, March 8, 2022

Clinical, laboratory, and autopsy findings support an association between coronavirus disease-2019 (COVID-19) and thromboembolic disease. Acute COVID-19 infection is characterized by mononuclear cell reactivity and pan-endothelialitis, contributing to a high incidence of thrombosis in large and small blood vessels, both arterial and venous. Observational studies and randomized trials have investigated whether full-dose anticoagulation may improve outcomes compared with prophylactic dose heparin. Although no benefit for therapeutic heparin has been found in patients who are critically ill hospitalized with COVID-19, some studies support a possible role for therapeutic anticoagulation in patients not yet requiring intensive care unit support. We summarize the pathology, rationale, and current evidence for use of anticoagulation in patients with COVID-19 and describe the main design elements of the ongoing FREEDOM COVID-19 Anticoagulation trial, in which 3,600 hospitalized patients with COVID-19 not requiring intensive care unit level of care are being randomized to prophylactic-dose enoxaparin vs therapeutic-dose enoxaparin vs therapeutic-dose apixaban.

Critical Illness Among Patients Hospitalized With Acute COVID-19 With and Without Congenital Heart Defects

Circulation, March 7, 2022

[Research Letter] Given the increased risk for severe COVID-19 ill-ness in individuals with cardiac disease, individuals with congenital heart defects (CHDs) might have increased risk of severe illness from COVID-19 as well. Most publications on CHD and COVID-19 illness have been restricted to patients at congenital cardiology centers, limiting generalizability, because many individuals with CHD do not receive specialized cardiology care. Furthermore, the studies did not include comparison groups without CHD or adjust for difference in established risk factors for critical COVID-19, and comparisons to general population estimates may be confounded. We compared the period prevalence of critical COVID-19 illness (intensive care unit [ICU] admission invasive mechanical ventilation [IMV], or death) among hospitalized patients with COVID-19 with and without CHD. Among patients with CHD, we examined characteristics associated with critical COVID-19 illness. We used data on inpatient encounters from March 2020 through January 2021 from the Premier Health-care Database Special COVID-19 Release, an all-payor database representing ≈20% of US hospital admissions. The current analyses compared period prevalence of critical COVID-19 between patients with and without CHD at the same hospitals, adjusted for and stratified by established high-risk factors for severe COVID-19 infection, and found up to 2 times higher adjusted prevalence of critical COVID-19 among patients with CHD, although results are specific to hospitalized patients.

Evaluation of the Knowledge, Attitude, and Practice of COVID-19 Prevention Methods Among Hypertensive Patients in North Shoa, Ethiopia

Risk Management and Healthcare Policy, March 4, 2022

The occurrence of coronavirus diseases 2019 (COVID-19) has affected more than 247 million populations around the world. People with comorbidities such as hypertension, diabetes mellitus, congestive heart failure, kidney disease, elderly people, and people with weak immunity develop severe types of COVID-19 if exposed to the disease. Therefore, this study aimed to assess knowledge, attitude, and practice of COVID-19 prevention methods among hypertensive patients in North Shoa, Oromia region, Ethiopia. Data were collected using a structured questionnaire and study participants were recruited using a simple random sampling technique. A total of 360 (97.0%) hypertension patients responded. This study revealed that 210 (58.3%) study participants had good knowledge of COVID-19 prevention methods, 199 (55.3%) had a favorable attitude towards COVID-19 prevention methods, and 210 (58.3%) hypertension patients at follow-up practiced COVID-19 prevention methods. Respondents who received less than two thousand Ethiopian birrs monthly and respondents who followed electronic news media were significantly associated with the use of sanitizer, respondents who had a favorable attitude towards the COVID-19 prevention method were significantly associated with mask-wearing, and respondents who received less than two thousand Ethiopian birrs monthly were significantly associated with maintaining a physical distance. Generally, this study finding revealed that the level of knowledge, attitude, and practice towards COVID-19 prevention among hypertension patients was low. Therefore, increasing knowledge, attitude, and practice on COVID-19 among hypertension patients requires a coordinated effort from the government, non-government, and health professionals.

Myocarditis post SARS-CoV-2 vaccination: a systematic review

QJM: An International Journal of Medicine, March 3, 2022

Variable clinical criteria taken by medical professionals across the world for myocarditis following COVID-19 vaccination along with wide variation in treatment necessitates understanding and reviewing the same. A systematic review was conducted to elucidate the clinical findings, laboratory parameters, treatment and outcomes of individuals with Myocarditis after COVID-19 vaccination after registering with PROSPERO. Electronic databases including MEDLINE, EMBASE, PubMed, LitCovid, Scopus, ScienceDirect, Cochrane Library, Google Scholar, Web of Science were searched. A total of 85 articles encompassing 2184 patients were analysed. It was a predominantly male (73.4%) and young population (Mean age 25.5 ± 14.2 years) with most having taken an mRNA-based vaccines (99.4%). The mean duration from vaccination to symptom onset was 4.01 ± 6.99 days. Chest pain (90.1%), dyspnoea (25.7%) and fever (11.9%) were the most common symptoms. Only 2.3% had comorbidities. CRP was elevated in 83.3% and cardiac troponin in 97.6% patients. An abnormal ECG was reported in 979/1313 (74.6%) patients with ST-segment elevation being most common (34.9%). Echocardiographic data was available for 1243 patients (56.9%) of whom 288 (23.2%) had reduced left ventricular ejection fraction. NSAIDS (76.5%), steroids (14.1%) followed by colchicine (7.3%) were used for treatment. Only 6 patients died among 1317 of whom data was available. Myocarditis following COVID-19 vaccination is often mild, seen more commonly in young healthy males and is followed by rapid recovery with conservative treatment.

Association of COVID-19 Infection With Survival After In-Hospital Cardiac Arrest Among US Adults

JAMA Network Open, March 2, 2022

[Research Letter] Early on in the COVID-19 pandemic, investigators reported poor survival rates (<3%) after in-hospital cardiac arrest (IHCA) among patients with COVID-19 infection in the US and China. These findings have prompted discussions regarding universal do-not-resuscitate orders for patients with COVID-19. However, these results were from single-center studies that comprised only 295 patients with COVID-19 in hospitals that were overwhelmed early during the pandemic. Whether the poor IHCA survival rate reported in earlier studies is broadly representative of patients with COVID-19 in US hospitals remains unknown. This study examined the association of COVID-19 infection with survival outcomes of US adults after IHCA. The study used data from the American Heart Association Get With the Guidelines–Resuscitation (GWTG-R) registry, which contains detailed information on patients who experience cardiac arrest at participating hospitals in the United States. Within the GWTG-R registry, we identified all adults (aged ≥18 years) who developed IHCA during March to December 2020. Race and ethnicity were self-reported by the study patients, and these data were collected in the GWTG-R registry to examine disparities in care and outcomes of IHCA patients. This study included 24 915 patients with IHCA from 286 hospitals who had a mean (SD) age of 64.7 (15.2) years. There were 9848 women (39.5%) and 15 066 men (60.5%), with sex missing for 1 patient. In terms of race and ethnicity, 6170 patients (24.8%) were Black, 15 223 (61.1%) were White, 949 (3.8%) were of other race or ethnicity (American Indian or Alaska Native, Asian or Pacific Islander, and other races and ethnicities), and 2573 (10.3%) were of unkown race or ethnicity. A suspected or confirmed COVID-19 infection was present in 5916 patients (23.7%). Patients with COVID-19 were younger, more frequently men and of Black race, and more likely to have an initial nonshockable rhythm, pneumonia, respiratory insufficiency, or sepsis and be receiving mechanical ventilation and vasopressors at the time of IHCA. Patients with COVID-19 and IHCA had lower rates of survival to discharge (11.9% vs 23.5%; adjusted RR, 0.65 [95% CI, 0.60-0.71]; P < .001) and ROSC (53.7% vs 63.6%; adjusted RR, 0.86 [95% CI, 0.83-0.90]; P < .001). They were also more likely to have received delayed defibrillation (27.7% vs 36.6%; RR, 1.30 [95% CI, 1.09-1.55]; P = .003) but not delayed epinephrine treatment. The association between COVID-19 infection and worse survival outcomes was consistent for patients with nonsurgical diagnoses, patients in the intensive care unit (ICU), and patients who had received timely defibrillation or epinephrine treatment.

The COVID Heart—One Year After SARS-CoV-2 Infection, Patients Have an Array of Increased Cardiovascular Risks

Journal of the American Medical Association, March 2, 2022

An analysis of data from nearly 154 000 US veterans with SARS-CoV-2 infection provides a grim preliminary answer to the question: What are COVID-19’s long-term cardiovascular outcomes? The study, published in Nature Medicine by researchers at the Veterans Affairs (VA) St Louis Health Care System, found that in the year after recovering from the illness’s acute phase, patients had increased risks of an array of cardiovascular problems, including abnormal heart rhythms, heart muscle inflammation, blood clots, strokes, myocardial infarction, and heart failure. What’s more, the heightened risks were evident even among those who weren’t hospitalized with acute COVID-19. The new analysis in Nature Medicine examined a comprehensive, prespecified set of cardiovascular outcomes among patients in the US Veterans Health Administration (VHA) system who survived the first 30 days of COVID-19. The researchers estimated the risks and excess burden of cardiovascular outcomes per 1000 persons 12 months after COVID-19 using electronic medical record data from 3 large cohorts. The cohorts largely comprised older White male patients. The COVID-19 cohort, which averaged 61 years old, included 89% males and about 71% White individuals. But, because the study was large, it also included almost 17 000 female patients; about 37 000 Black patients; and almost 8000 Latino, Asian, American Indian, Native Hawaiian, and patients of other races with COVID-19. The increased risks were most pronounced for heart failure and atrial fibrillation, but the breadth of cardiovascular disease involvement was “eye opening,” according to study senior author Ziyad Al-Aly, MD, chief of research and development at the VA St Louis Health Care System and a clinical epidemiologist at Washington University in St Louis. The researchers also were surprised to see elevated risks for people who were not hospitalized for COVID-19 during the acute phase—the segment that represents the majority of people with SARS-CoV-2 infection. However, the study did not analyze symptomatic vs asymptomatic infections, a potential area for further research.

An insight into the mechanisms of COVID-19, SARS-CoV2 infection severity concerning β-cell survival and cardiovascular conditions in diabetic patients

Molecular and Cellular Biochemistry, March 2, 2022

A significantly high percentage of hospitalized COVID-19 patients with diabetes mellitus (DM) had severe conditions and were admitted to ICU. In this review, we have delineated the plausible molecular mechanisms that could explain why there are increased clinical complications in patients with DM that become critically ill when infected with SARS-CoV2. RNA viruses have been classically implicated in manifestation of new onset diabetes. SARS-CoV2 infection through cytokine storm leads to elevated levels of pro-inflammatory cytokines creating an imbalance in the functioning of T helper cells affecting multiple organs. Inflammation and Th1/Th2 cell imbalance along with Th17 have been associated with DM, which can exacerbate SARS-CoV2 infection severity. ACE-2-Ang-(1–7)-Mas axis positively modulates β-cell and cardiac tissue function and survival. However, ACE-2 receptors dock SARS-CoV2, which internalize and deplete ACE-2 and activate Renin-angiotensin system (RAS) pathway. This induces inflammation promoting insulin resistance that has positive effect on RAS pathway, causes β-cell dysfunction, promotes inflammation and increases the risk of cardiovascular complications. Further, hyperglycemic state could upregulate ACE-2 receptors for viral infection thereby increasing the severity of the diabetic condition. SARS-CoV2 infection in diabetic patients with heart conditions are linked to worse outcomes. SARS-CoV2 can directly affect cardiac tissue or inflammatory response during diabetic condition and worsen the underlying heart conditions.

Enhanced External Counterpulsation Eases ‘Long COVID’

Medical Professionals Reference, March 1, 2022

In a living systematic review and updated article published online March 1 in the Annals of Internal Medicine, final practice points are presented for use of remdesivir for hospitalized patients with COVID-19. Anjum S. Kaka, MD, from the University of Minnesota School of Medicine in Minneapolis, and colleagues updated the living review of remdesivir for adults hospitalized with COVID-19. The authors note that 1 new randomized controlled trial (RCT) and one new subtrial comparing a 10-day course of remdesivir with control (placebo or standard care) were identified since the last update. Based on the evidence from 5 RCTs, the researchers found that the updated results confirm a 10-day course of remdesivir probably results in little to no reduction in mortality compared with control. Amir Qaseem, MD, PhD, from the American College of Physicians in Philadelphia, and colleagues updated the living, rapid practice points for the use of remdesivir as a COVID-19 treatment. The authors note that five days of remdesivir should be considered for hospitalized patients with COVID-19 who do not require invasive ventilation or extracorporeal membrane oxygenation (ECMO). Extending remdesivir to 10 days should be considered for patients who develop the need for invasive ventilation or ECMO within a 5-day course. Initiation of remdesivir should be avoided for hospitalized patients with COVID-19 who are already on invasive ventilation or ECMO.

TEA Clinical Profile of Infective Endocarditis in Patients with Recent COVID-19: A Systematic Review

American Journal of the Medical Sciences, February 27, 2022

Coronavirus disease 2019 (COVID-19) can progress to cardiovascular complications which are linked to higher in-hospital mortality rates. Infective endocarditis (IE) can develop in patients with recent COVID-19 infections, however, characterization of IE following COVID-19 infection has been lacking. To better characterize this disease, we performed a systematic review with descriptive analysis of the clinical features and outcomes of these patients. Our search was conducted in 8 libraries for all published reports of probable or definite IE in patients with a prior COVID-19 confirmed diagnosis. After ensuring an appropriate inclusion of the articles, we extracted data related to clinical characteristics, modified duke criteria, microbiology, outcomes, and procedures. Searches generated a total of 323 published reports, and 20 articles met our inclusion criteria. The mean age of patients was 52.2 ± 16.9 years and 76.2% were males. Staphylococcus aureus was isolated in 8 (38.1%) patients, Enterococcus faecalis in 3 patients (14.3%) and Streptococcus mitis/oralis in 2 (9.5%) patients. The mean time interval between COVID-19 and IE diagnoses was 16.7 ± 15 days. Six (28.6%) patients required critical care due to IE, 7 patients (33.3%) underwent IE-related cardiac surgery and 5 patients (23.8%) died during their IE hospitalization. Our systematic review provides a profile of clinical features and outcomes of patients with a prior COVID-19 infection diagnosis who subsequently developed IE. Due to the ongoing COVID-19 pandemic, it is essential that clinicians appreciate the possibility of IE as a unique complication of COVID-19 infection.

Serial Assessment of Myocardial Injury Markers in Mechanically Ventilated Patients With SARS-CoV-2 (from the Prospective MaastrICCht Cohort)

American Journal of Cardiology, February 24, 2022

Myocardial injury in COVID-19 is associated with in-hospital mortality. However, the development of myocardial injury over time and whether myocardial injury in patients with COVID-19 at the intensive care unit is associated with outcome is unclear. This study prospectively investigates myocardial injury with serial measurements over the full course of intensive care unit admission in mechanically ventilated patients with COVID-19. As part of the prospective Maastricht Intensive Care COVID cohort, predefined myocardial injury markers, including high-sensitivity cardiac troponin T (hs-cTnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and electrocardiographic characteristics were serially collected in mechanically ventilated patients with COVID-19. Linear mixed-effects regression was used to compare survivors with nonsurvivors, adjusting for gender, age, APACHE-II score, daily creatinine concentration, hypertension, diabetes mellitus, and obesity. In 90 patients, 57 (63%) were survivors and 33 (37%) nonsurvivors, and a total of 628 serial electrocardiograms, 1,565 hs-cTnT, and 1,559 NT-proBNP concentrations were assessed. Log-hs-cTnT was lower in survivors compared with nonsurvivors at day 1 (β −0.93 [−1.37; −0.49], p <0.001) and did not change over time. Log-NT-proBNP did not differ at day 1 between both groups but decreased over time in the survivor group (β −0.08 [−0.11; −0.04] p <0.001) compared with nonsurvivors. Many electrocardiographic abnormalities were present in the whole population, without significant differences between both groups. In conclusion, baseline hs-cTnT and change in NT-proBNP were strongly associated with mortality. Two-thirds of patients with COVID-19 showed electrocardiographic abnormalities. Our serial assessment suggests that myocardial injury is common in mechanically ventilated patients with COVID-19 and is associated with outcome.

Persistent cardiac injury—An important component of long COVID-19 syndrome

eBioMedicine, February 24, 2022

[Commentary] As the COVID-19 pandemic goes on, we continue to identify the long-term complications or symptoms among patients who recovered from this infection, be it mild or severe.1 These complications are collectively recognized as “COVID-19 long-hauler syndrome”. It is crucial to understand the factors leading to the development of these long-term sequelae to identify, prevent and manage them using appropriate interventions. Acute cardiac injury (ACI), marked by elevation of troponin levels in the blood over the 99th percentile, is an important phenomenon shown to occur in nearly 30% of patients admitted to the hospital with COVID19 infection.2 ACI has been shown to be associated with an elevated risk of critical illness, increased duration of hospital stay and mortality. Multiple processes, both ischaemic and non-ischaemic, have been shown to contribute to the development of ACI in COVID-19 patients. The most important among them is the direct myocardial injury caused by SARS-CoV-2.4 Tavazzi et al. demonstrated direct viral infection in the interstitial cells of the myocardium on endomyocardial biopsy, accompanied by low-grade inflammation. But to date, there has been no demonstration of COVID-19 genome in the cardiac tissue in patients with clinical myocarditis. Other mechanisms postulated to increase myocardial injury include systemic inflammation, vascular endothelial damage, cardiomyocyte apoptosis, abnormal myocardial strain, microthrombi formation and supplydemand mismatch. The precise mechanisms of myocardial injury in patients with COVID-19 are still unclear. It is also unknown if the myocardial injury is a direct effect of the virus or a response to systemic inflammation or both. As we continue to obtain long-term data on COVID19 survivors, it is imperative to look at how the patients with troponin elevation during their hospital admission fair after discharge.

Long COVID: post-acute sequelae of COVID-19 with a cardiovascular focus

European Heart Journal, February 18, 2022

Emerging as a new epidemic, long COVID or post-acute sequelae of coronavirus disease 2019 (COVID-19), a condition characterized by the persistence of COVID-19 symptoms beyond 3 months, is anticipated to substantially alter the lives of millions of people globally. Cardiopulmonary symptoms including chest pain, shortness of breath, fatigue, and autonomic manifestations such as postural orthostatic tachycardia are common and associated with significant disability, heightened anxiety, and public awareness. A range of cardiovascular (CV) abnormalities has been reported among patients beyond the acute phase and include myocardial inflammation, myocardial infarction, right ventricular dysfunction, and arrhythmias. Pathophysiological mechanisms for delayed complications are still poorly understood, with a dissociation seen between ongoing symptoms and objective measures of cardiopulmonary health. COVID-19 is anticipated to alter the long-term trajectory of many chronic cardiac diseases which are abundant in those at risk of severe disease. In this review, we discuss the definition of long COVID and its epidemiology, with an emphasis on cardiopulmonary symptoms. We further review the pathophysiological mechanisms underlying acute and chronic CV injury, the range of post-acute CV sequelae, and impact of COVID-19 on multiorgan health. We propose a possible model for referral of post-COVID-19 patients to cardiac services and discuss future directions including research priorities and clinical trials that are currently underway to evaluate the efficacy of treatment strategies for long COVID and associated CV sequelae.

Major cardiovascular risk factors common yet undertreated in patients with COPD

Healio | Pulmonology, February 17, 2022

Among patients with COPD, major cardiovascular risk factors were common but inadequately monitored, treated and controlled, researchers reported in the Annals of the American Thoracic Society. “COPD inherently conveys high cardiovascular risk due to cumulative smoking burden, advanced population age and clustering of additional risk factors, intertwined with socioeconomic deprivation, impaired health literacy and reduced physical activity,” Nathaniel M. Hawkins, MD, MPH, assistant professor in the division of cardiology at the University of British Columbia, Vancouver, and colleagues wrote. “Risk factors were very common in our cohort, with one-quarter having diabetes, > 50% hypertension, > 60% dyslipidemia, > 70% overweight and > 80% smoking history.” The cross-sectional analysis evaluated medical records of 32,695 patients with COPD (mean age, 68.4 years; 50.7% women) in the Canadian Primary Care Sentinel Surveillance Network from 2013 to 2018. These patients were matched for age, sex and rural residence with 32,638 control participants (mean age, 68.4 years; 50.7% women). Researchers identified five CV risk factors in the cohort: hypertension, dyslipidemia, diabetes, obesity and smoking. The mean Framingham Risk Score was 20.6% among patients with COPD compared with 18.6% among controls. Nearly 54% of patients with COPD were categorized as having high CV risk. All five CVD risk factors were more common among patients with COPD compared with controls: hypertension (52.3% vs. 44.9%); dyslipidemia (62% vs. 57.8%); diabetes (25% vs. 20.2%); obesity (40.8% vs. 36.8%); and smoking (40.9% vs. 11.4%). In addition, CV therapies were underutilized in patients with COPD. Angiotensin-converting enzyme inhibitors were used in 69%, statins in 69% and smoking-cessation therapies in 27%.

Myocardial Injury Pattern at MRI in COVID-19 Vaccine–associated Myocarditis

Radiology, February 15, 2022

There is limited data on the pattern and severity of myocardial injury in patients with COVID-19 vaccination associated myocarditis. The objective is to describe myocardial injury following COVID-19 vaccination and to compare these findings to other causes of myocarditis. In this retrospective cohort study, consecutive adult patients with myocarditis with at least one T1-based and at least one T2-based abnormality on cardiac MRI performed at a tertiary referral hospital between 2019-2021 were included. Patients were classified into one of three groups: myocarditis following COVID-19 vaccination, myocarditis following COVID-19 illness, and other myocarditis not associated COVID-19 vaccination or illness. Of the 92 included patients, 21 (22%) had myocarditis following COVID-19 vaccination (mean age 31 years ±14 [standard deviation]; 17 men; mRNA-1273 in 12 [57%] and BNT162b2 in 9 [43%]). Ten patients (11%) had myocarditis following COVID-19 illness (mean age 51 years ±14; 3 men), and 61 (66%) had other myocarditis (mean age 44 years ±18; 36 men). MRI findings in vaccine associated myocarditis included late gadolinium enhancement (LGE) in 17 (81%) and left ventricular dysfunction in 6 (29%). Compared with other causes of myocarditis, patients with vaccine-associated myocarditis had higher left ventricular ejection fraction and less extensive LGE, even after controlling for age, sex, and duration between symptom onset and MRI. The most frequent location of LGE in all groups was subepicardial at the basal inferolateral wall, although septal involvement was less common in vaccine associated myocarditis. At short-term follow-up (median 22 [IQR 7-48] days), all patients with vaccine associated myocarditis were asymptomatic with no adverse events.

In older adults with COVID-19, stroke risk highest in first 3 days after diagnosis

Healio | Cardiology Today, February 13, 2022

In older adults with COVID-19, ischemic stroke risk was much higher in the first 3 days after diagnosis than at points thereafter, researchers reported at the International Stroke Conference. “Stroke following the diagnosis of COVID-19 is a possible complication of COVID-19 that patients and clinicians should be aware of,” Quanhe Yang, PhD, senior scientist in the CDC’s Division for Heart Disease and Stroke Prevention, said in a press release. “Vaccination and other preventive measures for COVID-19 are important to reduce the risk of infection and complications including stroke.” Yang and colleagues analyzed 37,379 Medicare beneficiaries aged 65 years or older (median age, 80 years; 57% women) diagnosed with COVID-19 from April 2020 to February 2021 and hospitalized for acute ischemic stroke from January 2019 to February 2021. The study employed a self-controlled case series design and compared stroke risk in risk periods up to 28 days after COVID-19 diagnosis and other (control) periods. According to the researchers, ischemic stroke risk was more than 10-fold higher in the first 3 days after COVID-19 diagnosis compared with control periods (incidence rate ratio [IRR] = 10.3; 95% CI, 9.86-10.8). When day 0 was excluded, the increase in risk was attenuated but remained significant (IRR = 1.77; 95% CI, 1.57-2.01). Ischemic stroke risk was also elevated at 4 to 7 days (IRR = 1.61; 95% CI, 1.44-1.8), at 8 to 14 days (IRR = 1.44; 95% CI, 1.32-1.57) and 15 to 28 days (IRR = 1.09; 95% CI, 1.02-1.18), after COVID-19 diagnosis compared with control periods, Yang and colleagues found.

COVID-19 and Moral Injury: a Mental Health Pandemic for Frontline Health Care Workers

Pulmonology Advisor, February 11, 2022

More than 2 years ago, the alarm and first warnings of a global pandemic sounded. Now with over 830,000 deaths caused by COVID-19 in the US, there looms on the horizon a second underlying curve with equally serious long-term consequences: a mental health pandemic. The mental health fallout from the COVID-19 pandemic demands recognition, intervention, and mitigation strategies. Among the many at-risk populations are frontline health care workers who have been at the epicenter of the global pandemic, working long shifts with at times a tenuous safety net and limited support, and caring for COVID-19 patients with limited resources, mixed messaging, and uncertainty with regards to an end to the crisis. The psychological effects in some health care providers are akin to the moral trauma or moral injury that is recognized in combat veterans with post-traumatic stress disorder (PTSD). Mental health professionals and other health care providers caring for frontline health care workers who present with insomnia, depression, anxiety, panic attacks, PTSD, and suicidal thoughts should recognize and validate their experiences and moral injury. Intervention strategies including health promotion, resilience training, and ongoing multilevel support will play an important role in flattening the moral injury curve. Leaders in health care have the opportunity to create and foster a culture of open, nonjudgmental communication. In the face of unpredictable events such as the COVID-19 pandemic, natural disasters, and social and political unrest that impact health care delivery, strategies are available to promote mental health recovery and return to stability and wellness among frontline health care workers.

Heart-disease risk soars after COVID — even with a mild case

Nature, February 10, 2022

Massive study shows a long-term, substantial rise in risk of cardiovascular disease, including heart attack and stroke, after a SARS-CoV-2 infection. Even a mild case of COVID-19 can increase a person’s risk of cardiovascular problems for at least a year after diagnosis, a new study shows. Researchers found that rates of many conditions, such as heart failure and stroke, were substantially higher in people who had recovered from COVID-19 than in similar people who hadn’t had the disease. What’s more, the risk was elevated even for those who were under 65 years of age and lacked risk factors, such as obesity or diabetes. “It doesn’t matter if you are young or old, it doesn’t matter if you smoked, or you didn’t,” says study co-author Ziyad Al-Aly at Washington University in St. Louis, Missouri, and the chief of research and development for the Veterans Affairs (VA) St. Louis Health Care System. “The risk was there.” Al-Aly and his colleagues based their research on an extensive health-record database curated by the United States Department of Veterans Affairs. The researchers compared more than 150,000 veterans who survived for at least 30 days after contracting COVID-19 with two groups of uninfected people: a group of more than five million people who used the VA medical system during the pandemic, and a similarly sized group that used the system in 2017, before SARS-CoV-2 was circulating. People who had recovered from COVID-19 showed stark increases in 20 cardiovascular problems over the year after infection. For example, they were 52% more likely to have had a stroke than the contemporary control group, meaning that, out of every 1,000 people studied, there were around 4 more people in the COVID-19 group than in the control group who experienced stroke. The risk of heart failure increased by 72%, or around 12 more people in the COVID-19 group per 1,000 studied. Hospitalization increased the likelihood of future cardiovascular complications, but even people who avoided hospitalization were at higher risk for many conditions.

In survivors of acute COVID-19, CV risk, burden ‘substantial’

Healio | Cardiology Today, February 9, 2022

Compared with controls, survivors of acute COVID-19 have elevated CV risks and burdens at 1 year, even if they were not hospitalized for COVID-19, researchers reported in Nature Medicine. “Our results provide evidence that the risk and 1-year burden of cardiovascular disease in survivors of acute COVID-19 are substantial,” Yan Xie, MPH, biostatistician in the Clinical Epidemiology Center at the VA St. Louis Health Care System, and colleagues wrote. Xie and colleagues used Veterans Affairs databases to create three cohorts: 153,760 veterans who survived the first 30 days of COVID-19, a contemporary control group of 5,637,647 veterans who had no evidence of COVID-19 and a historical control group of 5,859,411 veterans from 2017 who did not have COVID-19. Participants were followed for approximately 1 year, corresponding to 12,095,836 person-years of follow-up, for incidence of various CV outcomes. The COVID-19 cohort was stratified into three groups representing disease severity: not hospitalized, hospitalized and admitted to the ICU. “Care strategies of people who survived the acute episode of COVID-19 should include attention to cardiovascular health and disease,” Xie and colleagues wrote. “Our study shows that the risk of incident cardiovascular disease extends well beyond the acute phase of COVID-19.” Read about the CV outcomes at 1 year of this COVID-19 cohort.

COVID-19 impact ‘substantial’ on outcomes for in-hospital cardiac arrest

Healio | Cardiology, February 8, 2022

The rate of survival after in-hospital cardiac arrest was lower during the initial surge of COVID-19 compared with prior years, even among patients hospitalized without confirmed COVID-19, researchers reported. According to data published in Circulation: Cardiovascular Quality and Outcomes, resuscitation times for in-hospital cardiac arrests were shorter during the initial surge of the pandemic and delayed epinephrine treatment was more prevalent compared with years before the pandemic. Chan and colleagues conducted a retrospective study to compare survival of in-hospital cardiac arrest during the COVID-19 pre-surge (Jan. 1-Feb. 29, 2020), surge (March 1-May 15, 2020) and immediate post-surge (May 16-June 30, 2020) compared with survival in 2015 through 2019. Researchers identified 61,586 in-hospital cardiac arrests that occurred from 2015 to 2020. During the pre-surge period, 24.2% of patients who experienced in-hospital cardiac arrest survived to discharge compared with 24.7% from 2015 to 2019 (adjusted OR = 1.12; 95% CI, 1.02-1.22). However, researchers observed lower survival during the surge period, with 19.6% surviving to discharge compared with 26% from 2015 to 2019 (aOR = 0.81; 95% CI, 0.75-0.88). Lower survival rate was most pronounced in counties with higher monthly COVID-19 mortality rates, with 28% lower survival in high COVID-19 mortality areas and 42% lower survival in very high COVID-19 mortality areas (P for interaction < .001), according to the researchers. During the post-surge period, survival to discharge rates were not different compared with the rates from 2015 to 2019 (22.3% vs. 25.8%; aOR = 0.93; 95% CI, 0.83-1.04), and also no longer differed in communities with higher COVID-19 mortality rates compared with communities with low COVID-19 mortality rates (P for interaction = .16)

Remote-delivered cardiac rehabilitation during COVID-19: a prospective cohort comparison of health-related quality of life outcomes and patient experiences

European Journal of Cardiovascular Nursing, February 8, 2022

Enforced suspension and reduction of in-person cardiac rehabilitation (CR) services during the coronavirus disease-19 (COVID-19) pandemic restrictions required rapid implementation of remote delivery methods, thus enabling a cohort comparison of in-person vs. remote-delivered CR participants. This study aimed to examine the health-related quality of life (HRQL) outcomes and patient experiences comparing these delivery modes. Participants across four metropolitan CR sites receiving in-person (December 2019 to March 2020) or remote-delivered (April to October 2020) programmes were assessed for HRQL (Short Form-12) at CR entry and completion. A General Linear Model was used to adjust for baseline group differences and qualitative interviews to explore patient experiences. Participants (n = 194) had a mean age of 65.94 (SD 10.45) years, 80.9% males. Diagnoses included elective percutaneous coronary intervention (40.2%), myocardial infarction (33.5%), and coronary artery bypass grafting (26.3%). Remote-delivered CR wait times were shorter than in-person [median 14 (interquartile range, IQR 10–21) vs. 25 (IQR 16–38) days, P < 0.001], but participation by ethnic minorities was lower (13.6% vs. 35.2%, P < 0.001). Remote-delivered CR participants had equivalent benefits to in-person in all HRQL domains but more improvements than in-person in Mental Health, both domain [mean difference (MD) 3.56, 95% confidence interval (CI) 1.28, 5.82] and composite (MD 2.37, 95% CI 0.15, 4.58). From qualitative interviews (n = 16), patients valued in-person CR for direct exercise supervision and group interactions, and remote-delivered for convenience and flexibility (negotiable contact times). Remote-delivered CR implemented during COVID-19 had equivalent, sometimes better, HRQL outcomes than in-person, and shorter wait times. Participation by minority groups in remote-delivered modes are lower. Further research is needed to evaluate other patient outcomes.

Long-term cardiovascular outcomes of COVID-19

Nature Medicine, February 7, 2022

The cardiovascular complications of acute coronavirus disease 2019 (COVID-19) are well described, but the post-acute cardiovascular manifestations of COVID-19 have not yet been comprehensively characterized. Here we used national healthcare databases from the US Department of Veterans Affairs to build a cohort of 153,760 individuals with COVID-19, as well as two sets of control cohorts with 5,637,647 (contemporary controls) and 5,859,411 (historical controls) individuals, to estimate risks and 1-year burdens of a set of pre-specified incident cardiovascular outcomes. We show that, beyond the first 30 d after infection, individuals with COVID-19 are at increased risk of incident cardiovascular disease spanning several categories, including cerebrovascular disorders, dysrhythmias, ischemic and non-ischemic heart disease, pericarditis, myocarditis, heart failure and thromboembolic disease. These risks and burdens were evident even among individuals who were not hospitalized during the acute phase of the infection and increased in a graded fashion according to the care setting during the acute phase (non-hospitalized, hospitalized and admitted to intensive care). Our results provide evidence that the risk and 1-year burden of cardiovascular disease in survivors of acute COVID-19 are substantial. Care pathways of those surviving the acute episode of COVID-19 should include attention to cardiovascular health and disease.

Clinical predictors of acute cardiac injury and normalization of troponin after hospital discharge from COVID-19

eBioMedicine, February 7, 2022

Although acute cardiac injury (ACI) is a known COVID-19 complication, whether ACI acquired during COVID-19 recovers is unknown. This study investigated the incidence of persistent ACI and identified clinical predictors of ACI recovery in hospitalized patients with COVID-19 2.5 months post-discharge. This retrospective study consisted of 10,696 hospitalized COVID-19 patients from March 11, 2020 to June 3, 2021. Demographics, comorbidities, and laboratory tests were collected at ACI onset, hospital discharge, and 2.5 months post-discharge. ACI was defined as serum troponin-T (TNT) level >99th-percentile upper reference limit (0.014ng/mL) during hospitalization, and recovery was defined as TNT below this threshold 2.5 months post-discharge. Four models were used to predict ACI recovery status. There were 4,248 (39.7%) COVID-19 patients with ACI, with most (93%) developed ACI on or within a day after admission. In-hospital mortality odds ratio of ACI patients was 4.45 [95%CI: 3.92, 5.05, p<0.001] compared to non-ACI patients. Of the 2,880 ACI survivors, 1,114 (38.7%) returned to our hospitals 2.5 months on average post-discharge, of which only 302 (44.9%) out of 673 patients recovered from ACI. There were no significant differences in demographics, race, ethnicity, major commodities, and length of hospital stay between groups. Prediction of ACI recovery post-discharge using the top predictors (troponin, creatinine, lymphocyte, sodium, lactate dehydrogenase, lymphocytes and hematocrit) at discharge yielded 63.73%-75.73% accuracy. Persistent cardiac injury is common among COVID-19 survivors. Readily available patient data accurately predict ACI recovery post-discharge. Early identification of at-risk patients could help prevent long-term cardiovascular complications.

Description of cardiovascular imaging abnormalities among hospitalized COVID-19 patients with elevated cardiac biomarkers

European Heart Journal – Cardiovascular Imaging, February 4, 2022

Myocardial injury is commonly encountered among severely-ill COVID-19 patients. Underlying mechanisms, however, remain incompletely understood. Describing cardiovascular imaging (CVI) abnormalities in this population will provide additional insight into mechanisms of myocardial injury with COVID-19 and may potentially guide management for these patients. Therefore, we aimed to describe CVI abnormalities in COVID-19 patients with elevated high-sensitivity cardiac troponin (hs-cTn). Consecutive hospitalized COVID-19 patients (n = 694) between February and July 2020 were retrospectively identified, including 409 patients with available hs-cTn (≥14 ng/dL was considered abnormal) Abnormality with any CVI—including transthoracic echocardiography (TTE), cardiac CT angiography, cardiac MR or invasive coronary angiography (ICA)—were identified through review of electronic records. Hospitalized COVID-19 patients with abnormal hs-cTn (107/409; 26.2%) had more frequent utilization of CVI compared with those with normal hs-cTn (61.7% vs. 30.5%, OR:3.7, 95%CI [2.3,5.8]) or those without available hs-cTn data (61.7% vs. 29.9%, OR:3.8, 95%CI [2.4,6]). Most utilized CVI modalities were TTE (63/107; 58.9%) followed by ICA (6/107; 5.6%). Echocardiographic abnormalities detected include right or left ventricular systolic dysfunction (22%), pericardial effusion (11%), while coronary artery disease was identified in 83.3% of patients who underwent ICA. In this single center experience, cardiac biomarker elevation in hospitalized COVID-19 patients was associated with a 3-fold increase in the likelihood of CVI utilization, most commonly TTE. Ventricular systolic dysfunction and severe coronary artery disease were commonly encountered in patients with abnormal hs-cTn. However, these results need to be interpreted in the context of inconsistent use of CVI in patients with elevated cardiac biomarkers, which may preclude arrival at definitive conclusions. Prospective studies with standardized use of CVI in high-risk COVID-19 patients are warranted to advance our understanding of cardiac toxicity with COVID-19.

Comparison of left heart echocardiographic parameters including strain in patients with COVID-19 pneumonia three months and one year after discharge

European Heart Journal – Cardiovascular Imaging, February 4, 2022

The long-term effect of a complicated course of COVID-19 on echocardiography (EchoCG) parameters, in particular on left heart, has not been sufficiently studied. To compare EchoCG parameters of left heart in patients with proven COVID-19 pneumonia 3 months and one year after discharge. The patients were identified according to the data of the medical information system of the monohospital from April 2020 to July 2021 within the framework of “One-year Cardiac Follow-up of COVID-19 Pneumonia”. A total of 116 men and women were included, mean age 49 ± 14.4 years, females 49.6%. During hospitalization, chest computed tomography detected mild lesions in 31.3%, moderate lesions in 33.3%, severe lesions in 29.3% and critical lesions in 6.1%. All patients underwent clinical examination including transthoracic EchoCG with 3 months ± 2 weeks and one year ± 3 weeks after discharge. All images were digitally stored and analyzed using off-line post processing with TomTec (Philips). The LV global and segmental longitudinal strain (LS) were studied in 100 individuals with satisfactory visualization quality 3 month after discharge and in 81 individuals one year after discharge. During the observation, the average body mass index of the subjects increased (28.7 ± 5.8 kg/m2 3 months after discharge vs 29.4 ± 6.1% one year after discharge, p < 0.001), as well as the rate of cardiovascular diseases (67% 3 months after discharge versus 79% one year after discharge, p = 0.008). Significant dynamics of mean left heart EchoCG parameters were observed. The mean index of left atrium (LA) maximal volume decreased (26.0 ± 7.2 vs 25.3 ± 7.4, p = 0.015), index of LA minimal volume increased (9.9 ± 5.4 vs 10.8 ± 5.6 ml/m2, p = 0.011). Left ventricular (LV) end-diastolic, end-systolic and stroke volume indexes decreased (49.3 ± 11.3 vs 46.9 ± 9.9 ml/m2, p = 0.008; 16.0 ± 5.6 vs 14.4 ± 4.1 ml/m2, p = 0.001; 36.7 ± 12.8 vs 30.8 ± 8.1 ml/m2, p < 0,001, respectively). The LV myocardial mass index increased (70.0 [60.8–84.0] vs 75.4 [68.2–84.9] g/m², p = 0.024). LV ejection fraction increased (68.1 ± 5.3 vs 69.7 ± 4.6%, p = 0.013). The LV global LS (-20.3 ± 2.2 vs -19.4 ± 2.7%, p = 0.001) and the LV segmental LS worsened: in mid segments (antero-septal -21.1 ± 3.3 vs -20.4 ± 4.1%, p = 0.039; inferior -21.0 ± 2.7 vs -20.0 ± 2.9%, p = 0.039; lateral -18.4 ± 3.7 vs -17.6 ± 4.4%, p = 0.021), and in apical segments (anterior -22.3 ± 5.0 vs -20.8 ± 5.2%, p = 0.006; inferior -24.6 ± 4.9 vs -22.7 ± 4.6, p = 0.003; lateral -22.7 ± 4.5 vs -20.4 ± 4.8%, p < 0.001; septal -25.3 ± 4.2 vs -23.1 ± 4,4%, p < 0.001; apical -23.7 ± 4.1 vs -21.8 ± 4.1%, p < 0.001). Compared to 3 month after discharge, in patients one year after COVID-19 pneumonia the LA maximal volume, LV end-diastolic, end-systolic and stroke volumes decrease, and the LV ejection fraction increased.

Right Ventricular Dysfunction in Critically Ill Patients With COVID-19

American Journal of Cardiology, January 25, 2022

Right ventricular (RV) dysfunction is a common complication in patients with acute respiratory distress syndrome (ARDS) occurring in 22% to 50% of patients. RV dysfunction in the context of ARDS is attributed to increased pulmonary vascular resistance and is associated with increased mortality in patients with ARDS even when lung protective ventilation strategies are employed. Severe COVID-19 is characterized by ARDS and respiratory failure of varying severity. In patients with COVID-19, RV dysfunction was found in 39% of 100 consecutively hospitalized patients on echocardiograms performed within 24 hours of hospital admission. Although RV dysfunction is reportedly common in patients with COVID-19, whether it is associated with worse outcomes is unknown. We reviewed medical records of patients admitted to the intensive care unit for COVID-19 at 2 hospitals. We identified 282 patients who required mechanical ventilation and had an echocardiogram performed during their hospitalization. Data abstracted from echocardiogram reports included the summary description of RV size and systolic function, tricuspid annular plane systolic excursion, and estimated RV systolic pressure in addition to left ventricular ejection fraction. We compared clinical characteristics and outcomes between patients with and without evidence of RV dysfunction using the t test or Mann–Whitney U test for continuous variables and the chi-square or Fischer’s exact test for categoric variables. Two-tailed p ≤0.05 were considered statistically significant. Overall, the mean age of the cohort was 62 (SD 13) and included 183 men (64.9%). Of the 282 hospitalized patients for COVID-19 who were mechanically ventilated and had an echocardiogram, 61 had evidence of at least mild RV dysfunction (21.6%). Only 6 patients (2.1%) showed signs of severe RV dysfunction. Patients with signs of RV dysfunction were more likely to have a history of congestive heart failure (16.4% vs 3.6%, p <0.001) and have a lower body mass index but otherwise had no significant differences in clinical characteristics compared with patients without RV dysfunction. There was no statistically significant difference in the incidence of acute kidney injury requiring renal replacement therapy in patients with RV dysfunction (6.6%) compared with those without RV dysfunction (9.5%, p = 0.47). Most importantly, in-hospital mortality was similar between patients with and without RV dysfunction (62.3% compared with 59.7%, respectively; p = 0.72). Among patients with abnormal RV function who died (n = 38), only 4 (10.5%) had severe RV dysfunction.

Myocarditis low after COVID-19 vaccination, but odds elevated in male teens, young adults

Healio | Cardiology Today, January 25, 2022

Despite low absolute rates, researchers observed elevated odds of cardiac injury among male adolescents and young adults after messenger RNA-based COVID-19 vaccination in a large U.S. study, as well as a smaller study in Hong Kong. Among 192.4 million vaccinated adolescents and young adults in the U.S., researchers observed 1,991 cases of myocarditis after at least one dose. According to the analysis published in JAMA, there were no confirmed cases of myocarditis among individuals younger than 30 years who died after receipt of a messenger RNA (mRNA)-based COVID-19 vaccination without another identifiable cause. “Onset of myocarditis typically follows an inciting process, often a viral illness; however, no antecedent cause is identified in many cases,” Matthew E. Oster, MD, pediatric cardiologist at Children’s Healthcare of Atlanta, and colleagues wrote. “It has been hypothesized that vaccination can serve as a trigger for myocarditis; however, only the smallpox vaccine has previously been causally associated with myocarditis based on reports among U.S. military personnel, with cases typically occurring 7 to 12 days after vaccination.” A total of 1,626 reports met the CDC’s definition of probable or confirmed myocarditis. Seventy-three percent of these individuals were younger than 30 years while 33% were younger than 18 years (median age, 21 years). The researchers reported that among cases for which dosage information was reported, 82% occurred after the second vaccination dose, and that among cases for which dosage information and time to symptom onset were reported, 74% occurred within 7 days. Abnormal ECG findings were present in 72% of myocarditis cases and among patients who received a cardiac MRI, abnormal findings consistent with myocarditis were present in 72%. Among the 721 patients who received an echocardiogram, 12% had reduced left ventricular ejection fraction. Researchers found no cases of myocarditis that required heart transplant, extracorporeal membrane oxygenation or a ventricular assist device.

Anxiety, home blood pressure monitoring, and cardiovascular events among older hypertension patients during the COVID-19 pandemic

Hypertension Research, January 21, 2022

The global coronavirus disease 2019 (COVID-19) pandemic has led to a health crisis. It remains unclear how anxiety affects blood pressure (BP) and cardiovascular risk among older patients with hypertension. In this study, we extracted longitudinal data on home BP monitored via a smartphone-based application in 3724 elderly patients with hypertension from a clinical trial (60–80 years; 240 in Wuhan and 3484 in non-Wuhan areas) to examine changes in morning BP during the COVID-19 outbreak in China. Anxiety was evaluated using Generalized Anxiety Disorder-7 item scores. Changes in morning systolic BP (SBP) were analyzed for five 30-day periods during the pandemic (October 21, 2019 to March 21, 2020), including the pre-epidemic, incubation, developing, outbreak, and plateau periods. Data on cardiovascular events were prospectively collected for one year. A total of 262 individuals (7.0%) reported an increased level of anxiety, and 3462 individuals (93.0%) did not. Patients with anxiety showed higher morning SBP than patients without anxiety, and the between-group differences in SBP change were +1.2 mmHg and +1.7 mmHg during the outbreak and plateau periods (P < 0.05), respectively. The seasonal BP variation in winter among patients with anxiety was suppressed during the pandemic. Anxious patients had higher rates of uncontrolled BP. During the 1-year follow-up period, patients with anxiety had an increased risk of cardiovascular events with a hazard ratio of 2.47 (95% confidence interval, 1.10–5.58; P = 0.03). In summary, COVID-19-related anxiety was associated with a short-term increase in morning SBP among older patients and led to a greater risk of cardiovascular events.

Cardiac Dysfunction and Arrhythmias 3 Months After Hospitalization for COVID‐19

Journal of the American Heart Association, January 20, 2022

The extent of cardiac dysfunction post‐COVID‐19 varies, and there is a lack of data on arrhythmic burden. This was a combined multicenter prospective cohort study and cross‐sectional case‐control study. Cardiac function assessed by echocardiography in patients with COVID‐19 3 to 4 months after hospital discharge was compared with matched controls. The 24‐hour ECGs were recorded in patients with COVID‐19. A total of 204 patients with COVID‐19 consented to participate (mean age, 58.5 years; 44% women), and 204 controls were included (mean age, 58.4 years; 44% women). Patients with COVID‐19 had worse right ventricle free wall longitudinal strain (adjusted estimated mean difference, 1.5 percentage points; 95% CI, −2.6 to −0.5; P=0.005) and lower tricuspid annular plane systolic excursion (−0.10 cm; 95% CI, −0.14 to −0.05; P<0.001) and cardiac index (−0.26 L/min per m2; 95% CI, −0.40 to −0.12; P<0.001), but slightly better left ventricle global strain (−0.8 percentage points; 95% CI, 0.2–1.3; P=0.008) compared with controls. Reduced diastolic function was twice as common compared with controls (60 [30%] versus 29 [15%], respectively; odds ratio, 2.4; P=0.001). Having dyspnea or fatigue were not associated with cardiac function. Right ventricle free wall longitudinal strain was worse after intensive care treatment. Arrhythmias were found in 27% of the patients, mainly premature ventricular contractions and nonsustained ventricular tachycardia (18% and 5%, respectively). At 3 months after hospital discharge with COVID‐19, right ventricular function was mildly impaired, and diastolic dysfunction was twice as common compared with controls. There was little evidence for an association between cardiac function and intensive care treatment, dyspnea, or fatigue. Ventricular arrhythmias were common, but the clinical importance is unknown.

One-year outcomes of invasively managed acute coronary syndrome patients with COVID-19

Heart & Lung, January 20, 2022

There is a limited data about the one-year outcomes of patients diagnosed with acute coronary syndrome (ACS) and coronavirus disease 2019 (COVID-19). The objective was to assess one-year mortality of invasively managed patients with ACS and COVID-19 compared to ACS patients without COVID-19. In our investigation, we defined the study time period as April 30 through September 1, 2020. The control groups consisted of ACS patients without COVID-19 at the same time period and ACS patients prior to the pandemic, within the same months as those of the study. COVID-19 infection was confirmed in all participants utilizing real-time polymerase chain reaction testing. This investigation examined 721 ACS participants in total. Among the participants, 119 patients were diagnosed with ACS and COVID-19, while 149 were diagnosed with ACS and without COVID-19. The other 453 ACS participants were diagnosed before the outbreak of the pandemic, within the same months as those of the study. One-year mortality rates were higher in the ACS participants with COVID-19 than in the ACS participants without COVID-19 and the pre-COVID-19 ACS participants (21.3% vs. 6.5% vs. 6.9%, respectively). An ACS along with COVID-19 was the only independent predictor of one-year mortality (HR=2.902, 95%CI=1.211–6.824, P = 0.018). According to the Kaplan-Meier survival curves, patients with ACS and COVID-19 had a lower chance of survival in the short-term and one-year periods. This is believed to be the first study to report that ACS patients with COVID-19 had higher one-year risk of mortality compared to ACS patients without COVID-19.

Constrictive pericarditis after SARS-CoV-2 vaccination: A case report

International Journal of Infectious Diseases, January 19, 2022

Coronavirus disease 2019 (COVID-19) and vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are associated with cardiovascular complications. We report a case of right-sided heart failure due to constrictive pericarditis that developed after administration of messenger ribonucleic acid (mRNA) vaccines against SARS-CoV-2. A 70-year-old woman presented with body weight gain, peripheral edema, and dyspnea on effort, which developed over a period of one week after the second vaccine injection. The jugular venous pressure was high with a prominent y descent (Friedreich’s sign) and paradoxical increase on inspiration (Kussmaul’s sign). The results of IgM and IgG testing specific to SARS-CoV-2 spike and nucleocapsid proteins were consistent with mRNA vaccine-induced antibody, not COVID-19 infection. Echocardiography demonstrated pericardial thickening and septal bounce of the interventricular septum. Computed tomography also revealed pericardial thickening compared with the previous examination four months earlier. A diagnosis of right-sided heart failure due to constrictive pericarditis was confirmed based on pressure analysis during cardiac catheterization.

Combined Role of Troponin and Natriuretic Peptides Measurements in Patients With Covid-19 (from the Cardio-COVID-Italy Multicenter Study)

American Journal of Cardiology, January 19, 2022

Data concerning the combined prognostic role of natriuretic peptide (NP) and troponin in patients with COVID-19 are lacking. The aim of the study is to evaluate the combined prognostic value of NPs and troponin in hospitalized COVID-19 patients. From March 1, 2020 to April 9, 2020, consecutive patients with COVID-19 and available data on cardiac biomarkers at admission were recruited. Patients admitted for acute coronary syndrome were excluded. Troponin levels were defined as elevated when greater than the 99th percentile of normal values. NPs were considered elevated if above the limit for ruling in acute heart failure (HF). A total of 341 patients were included in this study, mean age 68 § 13 years, 72% were men. During a median follow-up period of 14 days, 81 patients (24%) died. In the Cox regression analysis, patients with elevated both NPs and troponin levels had higher risk of death compared with those with normal levels of both (hazard ratio 2.94; 95% confidence interval 1.31 to 6.64; p = 0.009), and this remained significant after adjustment for age, gender, oxygen saturation, HF history, and chronic kidney disease. Interestingly, NPs provided risk stratification also in patients with normal troponin values (hazard ratio 2.86; 95% confidence interval 1.21 to 6.72; p = 0.016 with high NPs levels). These data show the combined prognostic role of troponin and NPs in COVID-19 patients. NPs value may be helpful in identifying patients with a worse prognosis among those with normal troponin values. Further, NPs’ cut-point used for diagnosis of acute HF has a predictive role in patients with COVID-19.

Longitudinal Assessment of Cardiac Outcomes of Multisystem Inflammatory Syndrome in Children Associated With COVID‐19 Infections

Journal of the American Heart Association, January 19, 2022

In multisystem inflammatory syndrome in children, there is paucity of longitudinal data on cardiac outcomes. We analyzed cardiac outcomes 3 to 4 months after initial presentation using echocardiography and cardiac magnetic resonance imaging. We included 60 controls and 60 cases of multisystem inflammatory syndrome in children. Conventional echocardiograms and deformation parameters were analyzed at 4 time points: (1) acute phase (n=60), (2) subacute phase (n=50; median, 3 days after initial echocardiography), (3) 1‐month follow‐up (n=39; median, 22 days), and (4) 3‐ to 4‐month follow‐up (n=25; median, 91 days). Fourteen consecutive cardiac magnetic resonance imaging studies were reviewed for myocardial edema or fibrosis during subacute (n=5) and follow‐up (n=9) stages. In acute phase, myocardial injury was defined as troponin‐I level ≥0.09 ng/mL (>3 times normal) or brain‐type natriuretic peptide >800 pg/mL. All deformation parameters, including left ventricular global longitudinal strain, peak left atrial strain, longitudinal early diastolic strain rate, and right ventricular free wall strain, recovered quickly within the first week, followed by continued improvement and complete normalization by 3 months. Median time to normalization of both global longitudinal strain and left atrial strain was 6 days (95% CI, 3–9 days). Myocardial injury at presentation (70% of multisystem inflammatory syndrome in children cases) did not affect short‐term outcomes. Four patients (7%) had small coronary aneurysms at presentation, all of which resolved. Only 1 of 9 patients had residual edema but no fibrosis by cardiac magnetic resonance imaging. Our short‐term study suggests that functional recovery and coronary outcomes are good in multisystem inflammatory syndrome in children. Use of sensitive deformation parameters provides further reassurance that there is no persistent subclinical dysfunction after 3 months.

Even mild COVID-19 cases can result in lingering heart issues

Cardiovascular Business, January 17, 2022

Mild and moderate COVID-19 infections can cause lingering changes to a patient’s heart and cardiovascular system, according to a new analysis published in European Heart Journal. “Autopsy studies indicate that SARS-CoV-2 affects multiple organs beyond the respiratory tract, including the heart, brain, and kidneys,” wrote lead author Elina Larissa Petersen, a cardiology specialist at the University Heart and Vascular Center in Hamburg, Germany, and colleagues. “Some patients continue to suffer from heterogeneous symptoms after the acute phase of critical illness. These conditions are described as ‘post-COVID-19 syndrome’ or—if symptoms continue longer than six months—as ‘long COVID-19 syndrome’. Clinical, imaging, or laboratory findings should accompany the diagnosis of post- or long COVID-19.” Petersen et al. reviewed data from more than 400 patients with a prior COVID-19 infection and more than 1,300 matched controls. Female patients made up 52.6% of the COVID-19 group and 54.1% of the control group. The median age was 55 years old for the COVID-19 group and 57 years old for the control group. Of the COVID-19 patients included in this study, 3.2% never experienced symptoms, 58.4% presented with mild symptoms and 31.2% presented with moderate symptoms. The median time between initial diagnosis and follow-up for this study was 9.6 months. All patients from the COVID-19 and control groups underwent the same assessment, which included body plethysmography, transthoracic echocardiography, cardiac MRI, compression ultrasound and routine laboratory work. Overall, a prior COVID-19 infection was associated with consistent subclinical changes, including lower measures of left and right ventricular function and a higher concentration of certain cardiac biomarkers. Even these slight changes in ventricular function, over time, can increase a patient’s risk of mortality. Cardiac MRI results were similar between the two patient groups, the authors added, but signs of deep venous thrombosis were much more common among patients with a history of COVID-19. Changes in total lung volume and airway resistance were also observed, and glomerular filtration rates revealed an effect on kidney function.

Pandemic-Associated Delays in Myocardial Infarction Presentation in Predominantly Rural Counties With Low COVID-19 Prevalence

American Journal of Cardiology, January 16, 2022

Fewer ST-elevation myocardial infarctions (STEMIs) presentations and increased delays in care occurred during the COVID-19 pandemic in urban areas. Whether these associations occurred in a more rural population has not been previously reported. Our objective was to evaluate the impact of COVID-19 on time-to-presentation for STEMI in rural locations. Patients presenting to a large STEMI network spanning 27 facilities and 13 predominantly rural counties between January 1, 2016 and April 30, 2020 were included. Presentation delays, defined as time from symptom onset to arrival at the first medical facility, classified as ≥12 and ≥24 hours from symptom onset were compared among patients in the pre–COVID-19 and the early COVID-19 eras. To account for patient-level differences, 2:1 propensity score matching was performed using binary logistic regression. Among 1,286 patients with STEMI, 1,245 patients presented in the pre–COVID-19 era and 41 presented during the early COVID-19 era. Presentation delays ≥12 hours (19.5% vs 4.0%) and ≥24 hours (14.6% and 0.2%) were more common in COVID-19 than pre–COVID-19 cohorts (p <0.001 for both), despite a low COVID-19 prevalence. Similar results were seen in propensity-matched comparisons (≥12 hours: 19.5% vs 2.4%, p = 0.002; ≥24 hours 14.6% vs 0.0%, p = 0.001). In a predominantly rural STEMI population, delays in seeking medical care after symptom onset were markedly more frequent during the COVID-19 era, despite low COVID-19 prevalence. Considering delays in reperfusion have multiple adverse downstream consequences, these findings may have important implications in rural communities during future pandemic resurgences.

Myocardial injury during COVID-19 hospitalization tied to mortality, long-term symptoms

Healio | Cardiology Today, January 13, 2022

Among patients hospitalized with COVID-19, myocardial injury as determined by high-sensitivity cardiac troponin T was linked to mortality and ongoing COVID-19 symptoms, researchers reported. Brittany Weber, MD, PhD, cardiologist at Brigham and Women’s Hospital and instructor in medicine at Harvard Medical School, and colleagues conducted a prospective analysis of 483 patients (median age, 63 years; 51% women) who were admitted to Brigham and Women’s Hospital for COVID-19 and had high-sensitivity cardiac troponin T measured at admission from March to May 2020. During the index hospitalization, 18.8% of patients died, 14.4% had thrombotic complications and 25.6% had CV complications, whereas at 1 year, 22.2% died, Weber and colleagues found. Cardiac injury, defined as high-sensitivity cardiac troponin T of at least 14 ng/L, occurred in 62.3% of the cohort during index hospitalization, according to the researchers. Patients with cardiac injury had higher rates of mortality at index hospitalization (28.6%) compared with those with low-level positive troponin (4.1%) and those with undetectable troponin (0%), Weber and colleagues wrote. Similar mortality rates were observed at 6 months (cardiac injury, 32.2%; low-level positive troponin, 4.9%; undetectable troponin, 0%) and at 12 months (cardiac injury, 33.2%; low-level positive troponin, 4.9%; undetectable troponin, 0%), according to the researchers. After adjustment for age, sex, CAD, hypertension, hyperlipidemia, HF and diabetes, cardiac injury was associated with elevated risk for mortality compared with undetectable troponin (HR = 13.76; 95% CI, 1.85-102.3; P = .01), but there was no difference in mortality risk between low-level positive troponin and undetectable troponin (HR = 2.31; 95% CI, 0.27-19.48; P = .44). Among the 211 patients who were alive at 6 months and had a detailed clinical assessment at that time, 37% had ongoing COVID-19-related symptoms, 16.1% had neurocognitive decline, 3.8% required increased supplemental oxygen and 19.9% had worsening functional status, according to the researchers.

Perceptions of changes in practice patterns and patient care among heart failure nurses during the COVID-19 pandemic

Heart & Lung, January 13, 2022

The Coronavirus (COVID-19) had a profound impact on the delivery of care in both hospital and outpatient settings across the United States. Patients with heart failure (HF) and healthcare providers had to abruptly adapt. Our objective was to describe how the COVID-19 pandemic affected practice patterns of HF nurses. Practicing HF nurses completed a cross-sectional, anonymous, web-based survey of perceptions of HF practice. Analyses involved descriptive and comparative statistics. Of 171 nurses who completed surveys, outpatient HF visits decreased and 63.2% added telehealth visits. Despite spending about 29 min educating patients during visits, 27.5% of nurses perceived that the pandemic decreased patients’ abilities to provide optimal self-care. Nurses reported decreased ability to collect objective data (62.4%; n = 78), although subjective assessment stayed the same (41.6%; n = 52). Conclusion: Nurses’ practice patterns provided insight into patient care changes made during COVID-19. Most core components of HF management were retained, but methods of delivery during the pandemic differed.

Usefulness of Combined Renin-Angiotensin System Inhibitors and Diuretic Treatment In Patients Hospitalized with COVID-19

American Journal of Cardiology, January 10, 2022

Antecedent use of renin-angiotensin system inhibitors (RASi) prevents clinical deterioration and protects against cardiovascular/thrombotic complications of COVID-19, for indicated patients. Uncertainty exists regarding treatment continuation throughout infection and doing so with concomitant medications. Hence, the purpose of this study is to evaluate the differential effect of RASi continuation in patients hospitalized with COVID-19 according to diuretic use. We used the Coracle registry, which contains data of hospitalized patients with COVID-19 from 4 regions of Italy. We used Firth logistic regression for adult (>50 years) cases with admission on/after February 22, 2020, with a known discharge status as of April 1, 2020. There were 286 patients in this analysis; 100 patients (35.0%) continued RASi and 186 (65%) discontinued. There were 98 patients treated with a diuretic; 51 (52%) of those continued RASi. The in-hospital mortality rates in patients treated with a diuretic and continued versus discontinued RASi were 8% versus 26% (p = 0.0179). There were 188 patients not treated with a diuretic; 49 (26%) of those continued RASi. The in-hospital mortality rates in patients not treated with a diuretic and continued versus discontinued RASi were 16% versus 9% (p = 0.1827). After accounting for age, cardiovascular disease, and laboratory values, continuing RASi decreased the risk of mortality by approximately 77% (odds ratio 0.23, 95% confidence interval 0.06 to 0.95, p = 0.0419) for patients treated with diuretics, but did not alter the risk in patients treated with RASi alone. Continuing RASi in patients concomitantly treated with diuretics was associated with reduced in-hospital mortality.

Systematic identification of ACE2 expression modulators reveals cardiomyopathy as a risk factor for mortality in COVID-19 patients

Genome Biology, January 10, 2022

Angiotensin-converting enzyme 2 (ACE2) is the cell-entry receptor for SARS-CoV-2. It plays critical roles in both the transmission and the pathogenesis of COVID-19. Comprehensive profiling of ACE2 expression patterns could reveal risk factors of severe COVID-19 illness. While the expression of ACE2 in healthy human tissues has been well characterized, it is not known which diseases and drugs might be associated with ACE2 expression. We develop GENEVA (GENe Expression Variance Analysis), a semi-automated framework for exploring massive amounts of RNA-seq datasets. We apply GENEVA to 286,650 publicly available RNA-seq samples to identify any previously studied experimental conditions that could be directly or indirectly associated with ACE2 expression. We identify multiple drugs, genetic perturbations, and diseases that are associated with the expression of ACE2, including cardiomyopathy, HNF1A overexpression, and drug treatments with RAD140 and itraconazole. Our joint analysis of seven datasets confirms ACE2 upregulation in all cardiomyopathy categories. Using electronic health records data from 3936 COVID-19 patients, we demonstrate that patients with pre-existing cardiomyopathy have an increased mortality risk than age-matched patients with other cardiovascular conditions. This study identifies multiple diseases and drugs that are associated with the expression of ACE2. The effect of these conditions should be carefully studied in COVID-19 patients. In particular, our analysis identifies cardiomyopathy patients as a high-risk group, with increased ACE2 expression in the heart and increased mortality after SARS-COV-2 infection.

Inappropriate sinus tachycardia in post-COVID-19 syndrome

Scientific Reports, January 7, 2022

Inappropriate sinus tachycardia (IST) is a common observation in patients with post-COVID-19 syndrome (PCS) but has not yet been fully described to date. To investigate the prevalence and the mechanisms underlying IST in a prospective population of PCS patients. Consecutive patients admitted to the PCS Unit between June and December 2020 with a resting sinus rhythm rate ≥ 100 bpm were prospectively enrolled in this study and further examined by an orthostatic test, 2D echocardiography, 24-h ECG monitoring (heart rate variability was a surrogate for cardiac autonomic activity), quality-of-life and exercise capacity testing, and blood sampling. To assess cardiac autonomic function, a 2:1:1 comparative sub-analysis was conducted against both fully recovered patients with previous SARS-CoV-2 infection and individuals without prior SARS-CoV-2 infection. Among 200 PCS patients, 40 (20%) fulfilled the diagnostic criteria for IST (average age of 40.1 ± 10 years, 85% women, 83% mild COVID-19). No underlying structural heart disease, pro-inflammatory state, myocyte injury, or hypoxia were identified. IST was accompanied by a decrease in most heart rate variability parameters, especially those related to cardiovagal tone: pNN50 (cases 3.2 ± 3 vs. recovered 10.5 ± 8 vs. non-infected 17.3 ± 10; p < 0.001) and HF band (246 ± 179 vs. 463 ± 295 vs. 1048 ± 570, respectively; p < 0.001). IST is prevalent condition among PCS patients. Cardiac autonomic nervous system imbalance with decreased parasympathetic activity may explain this phenomenon.

Some Patients With COVID-19 First Present With Arterial Thrombosis

Cardiology Advisor, January 6, 2022

A retrospective analysis found that some patients with COVID-19 present with arterial thrombosis as the first symptom. The study findings were published in the journal Vascular. The arterial thrombosis in COVID-19 (ARTICO-19) was an interventional registry comprising 21 centers in 9 countries in Latin America and Spain. Inpatients (N=81) with confirmed SARS-CoV-2 and arterial thrombotic complications between December 2019 and August 2020 were assessed for risk factors and outcomes. Patients had a mean age of 64.8±14.1 years; 67.9% were men; 50.0% had hypertension; 36.0% were on angiotensin-converting enzyme inhibitors or angiotensin receptor blockers; 26.6% had diabetes; 24.4% dyslipidemia; 24.1% had a history of smoking; and 14.8% were active smokers. Over a third of patients (38.3%) first presented with ischemia-related symptoms and most patients had acute limb ischemia (97.5%). The thrombus occurred above the knee (45.0%), aorta and lower limb (14.8%), upper limb (14.8%), below the knee (13.8%), abdominal aorta (5.0%), above and below the knee (3.8%), visceral above the knee (1.3%) visceral below the knee (1.3%), and thoracic aorta (1.3%). Over a third of patients (36.5%) developed acute distress respiratory syndrome, 25.7% developed pneumonia, 12.2% had mild symptoms, and 25.7% were asymptomatic. Fewer patients with severe disease received surgical interventions (11.1% vs 88.9%; P =.004). More patients with severe disease were admitted to the intensive care unit (P =.001) and died (P =.015). Overall, the study found that some patients with COVID-19 presented with arterial thrombosis, particularly acute limb ischemia before respiratory symptoms.

Q&A: How will omicron affect long COVID?

Healio | Infectious Disease, January 6, 2022

The omicron variant of SARS-CoV-2 now accounts for 95% of COVID-19 cases in the United States, CDC Director Rochelle P. Walensky, MD, MPH, said during a White House briefing on Wednesday. If omicron causes less severe disease than the delta variant, could any lasting effects of COVID-19 also be less serious? We asked Ziyad Al-Aly, MD, FASN, a physician at the VA St. Louis Health Care System who studies long COVID, to answer this and other lingering questions about the variant.

LV global longitudinal strain may predict poor outcomes in COVID-19

Healio | Cardiology Today, January 5, 2022

Left ventricular global longitudinal strain predicted death and respiratory failure in patients hospitalized with COVID-19, researchers reported in the American Journal of Cardiology. Michele Bevilacqua, MD, internal medicine resident at University Hospital of Verona, Italy, and colleagues analyzed 87 patients with COVID-19 admitted to University Hospital of Verona who had a complete echocardiography examination within 72 hours of admission. The primary outcome, mechanical ventilation by orotracheal intubation and/or mortality, occurred in 14 patients, whereas the secondary outcome, severe acute respiratory distress syndrome, defined as worsening respiratory function as indicated by a partial pressure of oxygen to fraction of inspired oxygen ratio of less than 100, occurred in 24 patients, the researchers wrote. After the researchers adjusted for risk factors and considered LV global longitudinal strain as a continuous variable, they found LV global longitudinal strain was associated with the secondary outcome (adjusted HR = 1.48; 95% CI, 1.18-1.88; P = .001) and the primary outcome (aHR = 1.63; 95% CI, 1.13-2.38; P = .012). Having LV global longitudinal strain of at least –16.1% was independently associated with risk for severe acute respiratory distress syndrome (HR = 4; 95% CI, 1.4-11.1; P = .008) and death or orotracheal intubation (HR = 7.3; 95% CI, 1.6-34.1; P = .024), according to the researchers. “LV global longitudinal strain measured at the moment of admission was a strong predictor of respiratory failure and mortality,” Bevilacqua and colleagues wrote. “Although troponin is a good biomarker of myocardial injury, in our study troponin was not a predictor of mortality.

Cardiopulmonary Exercise Testing Provides Insights on Long-Haul COVID Symptoms

Pulmonology Advisor, January 5, 2022

Patients with post-acute sequelae of SARS-CoV-2 infection (PASC), informally referred to as “long-haul COVID,” were found to have circulatory impairment, abnormal ventilatory pattern, and/or myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), according to results of a prospective study published in JACC: Heart Failure. For the analysis, researchers enrolled individuals (N=41) who developed dyspnea, or new and persistent shortness of breath, for over 3 months after recovering from a COVID-19 infection. Study participants received cardiopulmonary exercise testing (CPET) and were evaluated for ME/CFS symptoms. The participants had a mean age of 45.2±12.5 years; 23 were women; 18 were men; body mass index (BMI) was 28.3±6.4; hemoglobin was 14.0±1.3 g/dL; 9 participants had hypertension; 4 had diabetes; 2 had postural orthostatic tachycardia; 1 had prior atrial fibrillation ablation; and 1 had a history of colon cancer. During the CPET, peak oxygen consumption was 77%±21% of the predicted value. Oxygen consumption less than 80% of predicted value was observed among 24 patients who had low oxygen consumption (n=12), low oxygen consumption pulse (n=22), and/or elevated slope of minute ventilation to carbon dioxide production (n=23). Patients (41%) who had oxygen consumption greater than or equal to 80% of predicted value were considered to have normal exercise capacity but with reduced oxygen consumption pulse (n=2), respiratory rate greater than 55 breaths/min (n=3), and/or abnormal ventilatory patterns (n=12). Dysfunctional breathing was observed among 63% of study participants. The dysfunctional and normal breathers did not differ for oxygen consumption, resting end tidal pressure of carbon dioxide, maximum minute ventilation, respiratory rate, or respiratory exchange ratio. Thirty-two patients met the 1994 diagnostic criteria for ME/CFS. Excluding patients with confounding comorbidities, 46% were considered to have ME/CFS. Nearly half of this cohort (42%) also had dysfunctional breathing.

Both symptomatic and asymptomatic COVID-19 associated with increased risk of cardiovascular events

News Medical, January 4, 2022

Myocardial injury can be caused by direct injury to cardiac myocytes due to COVID-19 and as a result of secondary effects from the systemic inflammation and hypercoagulable state seen in acute infection. Therefore, COVID-19 patients with known cardiovascular disease (CVD) and other risk factors like age, hypertension, diabetes, obesity, kidney disease, and respiratory system disorders are more likely to require critical care and have a higher mortality rate. Long COVID, which is also known as post-acute COVID, is the persistence of symptoms or complications after the end of the acute phase of infection. However, the long-term impacts of COVID-19 on cardiovascular outcomes remain unknown. Furthermore, the causal role of asymptomatic and symptomatic SARS-CoV-2 infections in precipitating cardiovascular events has yet to be clarified. The objective of a recent retrospective double-cohort study was conducted at the Oregon Health & Science University (OHSU). The study was approved by the OHSU Institutional Review Board (IRB) and all results were reported using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The primary outcome was a composite of cardiovascular death, acute HF, acute coronary syndrome (ACS) including ST-Segment Elevation Myocardial Infarction (STEMI), non-STEMI (NSTEMI), or unstable angina, as well as incident stroke or transient ischemic attack, another acute or new cardiovascular outcome prompting healthcare utilization. During the study period, 99,711 COVID-19 tests were performed for 65,585 individuals. Notably, COVID-19 positive (+) patients were often younger and more likely to be non-white or Hispanic. Additionally, a higher number of COVID-19(+) patients had a history of liver disease and/or diabetes mellitus than those who tested COVID-19 negative (-), while there was no difference in CVD history between the two cohorts. The results of the study suggest that both symptomatic and asymptomatic SARS-CoV-2 infections are associated with an increased risk of late cardiovascular outcomes and have a causal effect on all-cause mortality. These findings underscore the importance of COVID-19 prevention and emphasize careful follow-up for all patients who encounter SARS-CoV-2, regardless of whether they are symptomatic or asymptomatic, to monitor for late cardiovascular events.

Arrhythmias and Intraventricular Conduction Disturbances in Patients Hospitalized With Coronavirus Disease 2019

American Journal of Cardiology, January 1, 2022

Cardiac arrhythmias have been observed in patients hospitalized with coronavirus disease (COVID-19). Most analyses of rhythm disturbances to date include cases of sinus tachycardia, which may not accurately reflect true cardiac dysfunction. Furthermore, limited data exist regarding the development of conduction disturbances in patients hospitalized with COVID-19. Hence, we performed a retrospective review and compared characteristics and outcomes for patients with versus without incident arrhythmia, excluding sinus tachycardia, as well as between those with versus without incident conduction disturbances. There were 27 of 173 patients (16%) hospitalized with COVID-19 who developed a new arrhythmia. Incident arrhythmias were associated with an increased risk of intensive care unit admission (59% vs 31%, p = 0.0045), intubation (56% vs 20%, p <0.0001), and inpatient death (41% vs 10%, p = 0.0002) without an associated increase in risk of decompensated heart failure or other cardiac issues. New conduction disturbances were found in 13 patients (8%). Incident arrhythmias in patients hospitalized with COVID-19 are associated with an increased risk of mortality, likely reflective of underlying COVID-19 disease severity more than intrinsic cardiac dysfunction. Conduction disturbances occurred less commonly and were not associated with adverse patient outcomes.

Impact of serum lactate dehydrogenase on the short-term prognosis of COVID-19 with pre-existing cardiovascular diseases

Journal of Cardiology, December 27, 2021

Patients with coronavirus disease 2019 (COVID-19) and underlying cardiovascular comorbidities have poor prognoses. Our aim was to identify the impact of serum lactate dehydrogenase (LDH), which is associated with mortality in acute respiratory distress syndrome, on the prognoses of patients with COVID-19 and underlying cardiovascular comorbidities. Among 1518 patients hospitalized with COVID-19 enrolled in the CLAVIS-COVID (Clinical Outcomes of COVID-19 Infection in Hospitalized Patients with Cardiovascular Diseases and/or Risk Factors study), 515 patients with cardiovascular comorbidities were analyzed. Patients were divided into tertiles based on LDH levels at admission [tertile 1 (T1), < 0.001]. Multivariable analysis adjusted for age, comorbidities, vital signs, and laboratory data including D-dimer and high-sensitivity troponin showed T3 was associated with an increased risk of in-hospital mortality (adjusted hazard ratio, 3.04; 95% confidence interval, 1.50–6.13; p = 0.002). High serum LDH levels at the time of admission are associated with an increased risk of in-hospital death in patients with COVID-19 and known cardiovascular disease and may aid in triage of these patients.

Antiplatelet therapy and outcome in COVID-19: the Health Outcome Predictive Evaluation Registry

BMJ Journals | Heart, December 22, 2021

Standard therapy for COVID-19 is continuously evolving. Autopsy studies showed high prevalence of platelet-fibrin-rich microthrombi in several organs. The aim of the study was therefore to evaluate the safety and efficacy of antiplatelet therapy (APT) in hospitalised patients with COVID-19 and its impact on survival. 7824 consecutive patients with COVID-19 were enrolled in a multicentre international prospective registry (Health Outcome Predictive Evaluation-COVID-19 Registry). Clinical data and in-hospital complications were recorded. Data on APT, including aspirin and other antiplatelet drugs, were obtained for each patient. During hospitalisation, 730 (9%) patients received single APT (93%, n=680) or dual APT (7%, n=50). Patients treated with APT were older (74±12 years vs 63±17 years, p<0.01), more frequently male (68% vs 57%, p<0.01) and had higher prevalence of diabetes (39% vs 16%, p<0.01). Patients treated with APT showed no differences in terms of in-hospital mortality (18% vs 19%, p=0.64), need for invasive ventilation (8.7% vs 8.5%, p=0.88), embolic events (2.9% vs 2.5% p=0.34) and bleeding (2.1% vs 2.4%, p=0.43), but had shorter duration of mechanical ventilation (8±5 days vs 11±7 days, p=0.01); however, when comparing patients with APT versus no APT and no anticoagulation therapy, APT was associated with lower mortality rates (log-rank p<0.01, relative risk 0.79, 95% CI 0.70 to 0.94). On multivariable analysis, in-hospital APT was associated with lower mortality risk (relative risk 0.39, 95% CI 0.32 to 0.48, p<0.01). APT during hospitalisation for COVID-19 could be associated with lower mortality risk and shorter duration of mechanical ventilation, without increased risk of bleeding.

The association of statins use with survival of patients with COVID-19

Journal of Cardiology, December 21, 2021

Statins are frequently prescribed for patients with dyslipidemia and diabetes mellitus. These comorbidities are highly prevalent in coronavirus disease 2019 (COVID-19) patients. Statin’s beneficial effect on mortality in COVID-19 infection has been reported in several studies. However, these findings are still inconclusive. We conducted a retrospective observational study among 6,095 patients with laboratory confirmed COVID-19 hospitalized in Mount Sinai Health System between March 1st 2020 and May 7th 2020. Patients were stratified into two groups: statin use prior to or during hospitalization (N = 2,423) versus no statins (N = 3,672). We evaluated in-hospital mortality as a primary outcome using propensity score matching and inverse probability treatment weighted (IPTW) analysis. In additional analysis, we compared continuous use of statins (N = 1,108) with no statins, continuous use of statins with discontinuation of statins (N = 644), and discontinuation of statins with no statins. Among 6,095 COVID-19 patients, statin use prior to or during hospitalization group were older (70.8 ± 12.7 years versus 59.2 ± 18.2 years, p<0.001) and had more comorbidities compared to no statins group. After matching by propensity score (1,790 pairs), there were no significant differences in-hospital mortality between patients with statins and those without [28.9% versus 31.0%, p = 0.19, odds ratio (OR) 95% confidence interval (CI): 0.91 (0.79–1.05)]. This result was confirmed by IPTW analysis [OR (95% CI): 0.96 (0.81–1.12), p = 0.53]. In the additional analysis comparing continuous use of statins with no statins group, in-hospital mortality was significantly lower in continuous use of statins compared to no statins group [26.3% versus 34.5%, p<0.001, OR (95% CI): 0.68 (0.55–0.82)] after matching by propensity score (944 pairs), as well as IPTW analysis [OR (95% CI): 0.77 (0.64–0.94), p = 0.009]. Finally, comparison of continuous use of statins with discontinuation of statins showed lower in-hospital mortality in continuous use of statins group [27.9% versus 42.1%, p<0.001, OR (95% CI): 0.53 (0.41–0.68)]. Use of statins prior to or during hospitalization was not associated with a decreased risk of in-hospital mortality; however, continuous use of statins was associated with lower in-hospital mortality compared to no statin use and discontinuation of statins.

Bradyarrhythmia in COVID-19 Patients

Cureus, December 21, 2021

The emergence of coronavirus disease 2019 (COVID-19) in 2019 has rapidly become a global health emergency. COVID-19 develops from a severe acute respiratory syndrome coronavirus (SARS-CoV) infection, which directly impacts the cardiovascular system by disrupting angiotensin-converting enzyme-2 receptors in the tissues. This leads to severe complications that cause major morbidity and mortality. Several cardiovascular complications have been reported during the pandemic, including myocardial infarction, stroke, pulmonary embolism, myocarditis, and tachyarrhythmias. Although bradyarrhythmia is another cardiac event associated with COVID-19, it has been reported in only a few cases in the medical literature. Here, we report two cases of young adult patients who were admitted because of a positive reverse transcriptase-polymerase chain reaction test of SARS-CoV-2 and presented with bradycardia detected on electrocardiogram but had an otherwise normal health condition with no history of cardiovascular illness.

AHA to fund research on long-term impact of COVID-19 on heart, brain health

Healio | Cardiology Today, December 19, 2021

The American Heart Association announced a $10 million initiative to fund studies of long-term effects of COVID-19 on heart and brain health. The grants will fund projects studying the basic mechanisms underlying cardiac, vascular and cerebrovascular complications in patients with COVID-19, as well as why some people experience effects of COVID-19 beyond the standard recovery time, according to a press release from the association. “While COVID-19 was initially thought to be a disease only of the respiratory system, it quickly became evident that its effects were not limited to any one system of the body. Cardiovascular complications in aggregate have commonly been reported among COVID-19 patients and most often include blood clots, heart inflammation known as myocarditis, disruption of the heart rhythm, heart failure and heart attacks,” Svati H. Shah, MD, MS, MHS, FAHA, professor of medicine and associate dean for genomics in the division of cardiology at Duke University School of Medicine, said in the release. “Frequently reported symptoms in patients who have effects long after their initial COVID infection have cardiovascular-related aspects including fatigue, chest pain and shortness of breath. The patients also report effects on the central nervous system, including both psychological effects such as anxiety and depression, as well as cognitive effects such as confusion and deficits of memory and concentration. But we have a lot still to learn through rigorous research to understand long COVID.” Applications are due by Feb. 1, and awards will be announced in March. Information on how to apply can be found at professional.heart.org/en/research-programs/strategically-focused-research/long-covid-cv-consequences-grant.

AHA, ADA: Diabetes harder to manage during holidays, so keep health goals on track

Healio | Cardiology Today, December 18, 2021

Nearly half of people with type 2 diabetes said it is more difficult to manage their condition during the holiday season than at other times, according to a survey from the American Heart Association and American Diabetes Association. The survey conducted on behalf of the associations’ joint initiative, Know Diabetes by Heart, included more than 1,000 U.S. adults 45 and older. Around 28% of the participants said their main concern is staying on top of their health goals during the holiday season, while 15% were concerned about finances and 14% were concerned about safe gatherings during the COVID-19 pandemic. “The holidays provide challenges to staying heart healthy for many people, but especially for those managing conditions closely tied to daily nutrition, like type 2 diabetes,” Robert Eckel, MD, FAHA, immediate past president of medicine and science for the American Diabetes Association, past president of the American Heart Association, and an endocrinologist at the University of Colorado School of Medicine, said in a press release. “Even if you don’t have diabetes yourself, it’s important to create healthy environments for our friends and family members who do,” Eckel said in the release.

Health care provider recommendation key to COVID-19 vaccine uptake

Healio, December 16, 2021

Adults who said a health care provider recommended that they receive a COVID-19 vaccine were more likely to get one, data published in MMWR show. Kimberly H. Nguyen, DrPH, a member of CDC’s COVID-19 Vaccine Task Force, and colleagues analyzed data from 340,543 U.S. adults who completed a phone survey during one of four different time periods between April 22 and Sept. 25. About 51% of the survey respondents were women, most (24.5%) were aged 50 to 64 years and 62.1% were white. The researchers reported that proportion of adults who received a provider recommendation for COVID-19 vaccination increased from 34.6% to 40.5% during the survey period. Respondents who said a health care provider recommended COVID-19 vaccination were more likely to have received at least one dose of the vaccine than those who did not receive a recommendation (77.6% vs. 61.9%, adjusted prevalence ratio [aPR] = 1.12). A COVID-19 vaccination recommendation was also associated with a respondent’s concern about COVID-19 (aPR = 1.31), thinking COVID-19 vaccines were “important to protect oneself” (aPR = 1.15), thinking COVID-19 vaccination “was very or completely safe” (aPR = 1.17) and that “many or all of their family and friends had received COVID-19 vaccination” (aPR = 1.19). The researchers noted that the survey response rate was low, and it did not measure the number of health care provider visits. The study’s cross-sectional design was also a limitation, according to Nguyen and colleagues. However, they emphasized that “provider recommendation will continue to serve an important role in motivating individual patient vaccination acceptance and completion.”

Vision and hearing impairments increase risks for poor CV outcomes in type 2 diabetes

Healio | Endocrinology, December 15, 2021

People with type 2 diabetes and a hearing or vision impairment have an elevated risk for myocardial infarction, stroke and all-cause mortality, according to study findings published in the Journal of Diabetes Investigation. “Patients with both vision and hearing impairments had the highest risk for MI and mortality,” Jung Il Moon, MD, PhD, an ophthalmologist at Yeouido St. Mary’s Hospital, The Catholic University of Korea College of Medicine in Seoul, South Korea, and colleagues wrote. “Those with only vision impairment showed higher cardiovascular risk and mortality compared with those with only hearing impairment. The present findings suggest that vision and hearing impairments are independently and synergistically important risk factors for adverse cardiovascular events and mortality in patients with type 2 diabetes.” Researchers conducted a population-based cohort study of 771,128 adults with type 2 diabetes in the Korean National Health Information Database. All patients who underwent a National Health Screening Program exam in 2009 were included in the study and followed until Dec. 31, 2018. Visual impairment was defined as having any grade of visual disability or visual acuity worse than 20/40 in both eyes. Hearing impairment was having any grade of hearing disability or having impaired hearing on pure-tone audiometric testing in at least one ear. The endpoints were any new diagnosis of MI, stroke or all-cause mortality. Participants with both a visual and hearing impairment had the highest risks for MI (adjusted HR = 1.36; 95% CI, 1.25-1.48) and all-cause mortality (aHR = 1.59; 95% CI, 1.53-1.65) and the second-highest risk for stroke (aHR = 1.29; 95% CI, 1.2-1.38) of the three impairment groups. Adults with a vision impairment had the highest risk for stroke of the three groups (aHR = 1.32; 95% CI, 1.28-1.36) and second-highest risks for MI (aHR = 1.32; 95% CI, 1.28-1.38) and all-cause mortality (aHR = 1.42; 95% CI, 1.39-1.45). Those with only a hearing impairment had lower risks for all three outcomes compared with the vision impairment only and vision impairment plus hearing impairment groups, but still had a higher risk for MI (aHR = 1.12; 95% CI, 1.07-1.17), stroke (aHR = 1.13; 95% CI, 1.09-1.18) and all-cause mortality (aHR = 1.16; 95% CI, 1.14-1.19) than those with no impairment.

Patients with long COVID-19 may have cardiac complications due to dyspnea after 1 year

Healio | Cardiology Today, December 13, 2021

Patients who were hospitalized with COVID-19 may have developed cardiac complications as they continued presenting with dyspnea 1 year after hospital discharge, according to a small study presented at EuroEcho 2021. “Our study shows that more than a third of COVID-19 patients with no history of heart or lung disease had persistent dyspnea on effort a year after discharge from hospital,” Maria-Luiza Luchian, MD, PhD student at the University Hospital Brussels, said in a press release. “When looking in detail at heart function by cardiac ultrasound, we observed subtle abnormalities that might explain the continued breathlessness.” Researchers enrolled 66 patients who were hospitalized with COVID-19 (mean age, 50 years; 67% men) from March to April 2020 at the University Hospital Brussels. All patients had no previous heart or lung disease. Participants had their lung function and possible COVID-19 sequelae assessed through spirometry and chest CT 1 year after discharge. Researchers performed transthoracic echocardiography and used myocardial work, a new imaging technique, to provide more accurate information on heart function. At 1 year after hospital discharge, 35% of patients had dyspnea during physical activity. When examining the association between cardiac imaging measures and dyspnea on year post-discharge after adjusting for age and sex, researchers observed an independent and significant association between abnormal heart function and persistent dyspnea. These associations were observed among both the global constructive work (OR = 0.998; 95% CI, 0.996-1; P = .038) and the global work index (OR = 0.998; 95% CI, 0.996-1; P = .042).

Rate of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers Use and the Number of COVID-19–Confirmed Cases and Deaths

American Journal of Cardiology, December 11, 2021

The novel coronavirus SARS-CoV-2 uses the angiotensin-converting enzyme 2 receptor as an entry point to the cell. Cardiovascular disease (CVD) is a risk factor for COVID-19 with poor outcomes. We tested the hypothesis that the rate of angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) use is associated with the rate of COVID-19–confirmed cases and deaths. We conducted a geospatial, ecological study using publicly available county-level data. The Medicare ACEI and ARB prescription rate was exposure. The COVID-19–confirmed case and death rates were outcomes. Spatial autoregression models were adjusted for the rate of births and deaths; Group Quarters population; percentage of female; percentage of Native American, Pacific Islander, Hispanic, and Black; percentage of children and older (>65 years) adults; percentage of uninsured; percentage of those living in poverty; percentage of those who are obese, smoking, admitting insufficient sleep, and those with at least some college degree; median household income; air quality index; CVD hospitalization rate in Medicare beneficiaries; and CVD death rate in a total county population. After adjustment for confounders, the ACEI use rate did not associate with COVID-19–confirmed case rate (direct county-own effect + 0.027%; 95% confidence interval [CI] −1.080 to 1.134; p = 0.962; indirect spillover effect + 0.26%; 95% CI −70.0 to 70.5; p = 0.994). Similarly, the ARB use rate was not associated with COVID-19–confirmed case rate (direct effect + 0.029%; 95% CI −0.803 to 0.862; p = 0.945; indirect effect + 0.19%; 95% CI −52.8 to 53.2; p = 0.994). In both unadjusted and adjusted Bayesian zero inflation Poisson analysis, neither ACEI nor ARB use rates were associated with COVID-19 death rates. In conclusion, ACEI and ARB use rates were not associated with COVID-19 infectivity and death rate in this ecological study.

Global Longitudinal Strain to Predict Respiratory Failure and Death in Patients Admitted for COVID-19–Related Disease

American Journal of Cardiology, December 9, 2021

Evidence of the involvement of the cardiovascular system in patients with COVID-19 is increasing. The evaluation of the subclinical cardiac involvement is crucial for risk stratification at admission, and left ventricular global longitudinal strain (LVGLS) may be useful for this purpose. A total of 87 consecutive patients admitted to the COVID Center were enrolled from December 2020 to April 2021. A complete echocardiography examination was performed within 72 hours from admission. The main outcome was the need for mechanical ventilation by way of orotracheal intubation (OTI) and mortality, and the secondary outcome was the worsening of the respiratory function during hospitalization, interpreted as a decrease of the ratio between the partial pressure of oxygen and the fraction of inspired oxygen (P/F) <100. Of 87 patients, 14 had severe disease leading to OTI or death, whereas 24 had a P/F <100. LVGLS was significantly impaired in patients with severe disease. After adjustment for risk factors, by considering LVGLS as continuous variable, the latter remained significantly associated with severe acute respiratory distress syndrome (P/F <100) (hazard ratio [HR] 1.48, 95% confidence interval [CI] 1.18 to 1.88, p = 0.001) and OTI/death (HR 1.63, 95% CI 1.13 to 2.38, p = 0.012). When using an LVGLS cutoff of −16.1%, LVGLS ≥ −16.1% was independently associated with a higher risk of severe acute respiratory distress syndrome (HR 4.0, 95% CI 1.4 to 11.1, p= 0.008) and OTI/death (HR 7.3, 95% CI 1.6 to 34.1, p = 0.024). LVGLS can detect high-risk patients at the admission, which can help to guide in starting early treatment of the admitted patients.

Blood pressure levels in US adults rose during COVID-19 pandemic

Healio | Cardiology Today, December 6, 2021

BP levels in U.S. adults increased during the COVID-19 pandemic compared with prior years, a finding that is not attributable to weight gain during lockdown, researchers reported in Circulation. Average monthly increases in BP ranged from 1.1 mm Hg to 2.5 mm Hg during the pandemic, according to the research letter. According to Luke J. Laffin, MD, co-director of the Center for Blood Pressure Disorders at Cleveland Clinic, and colleagues, “the increase in systolic BP among U.S. adults during the COVID-19 pandemic could signal a forthcoming increase in incident cardiovascular disease mortality. Reasons for pandemic-associated BP elevations are likely multifactorial, and although weight gain was not the reason, other possible reasons could include increased alcohol consumption, less physical activity, emotional stress and less ongoing medical care (including reduced medication adherence).” To assess changes in BP before and during the COVID-19 pandemic, the researchers conducted a longitudinal analysis utilizing data from an annual employer-sponsored wellness program operated by Quest Diagnostics. For the program, employees had annual BP measurements taken by trained personnel from 2018 to 2020. The present analysis included 464,585 participants (53.5% women; mean age, 45 years). Researchers observed no significant changes in BP measurements during the pre-pandemic period (2019 and January-March 2020). Changes from the preceding year in both systolic and diastolic BP showed no differences between 2019 and January to March 2020 (P for systolic = .8; P for diastolic BP = .3); however, annual BP increase was higher during the pandemic (April to December 2020) compared with pre-pandemic (P < .0001). During the pandemic period, monthly increases in BP averaged 1.1 mm Hg to 2.5 mm Hg for systolic BP and 0.14 mm Hg to 0.53 mm Hg for diastolic BP, compared with the previous year (P < .0001).

Symptoms of vaccine-related myocarditis in young people rare, mild, resolve quickly

Healio | Cardiology Today, December 6, 2021

Most young people under the age of 21 years with suspected myocarditis following COVID-19 vaccination had mild symptoms that resolved quickly, according to data published in Circulation. Most cases of suspected COVID-19 vaccine myocarditis occurred in white males and followed a messenger RNA (mRNA) vaccine, the researchers reported. “The highest rates of myocarditis following COVID-19 vaccination have been reported among adolescent and young adult males. Past research shows this rare side effect to be associated with some other vaccines, most notably the smallpox vaccine,” Jane W. Newburger, MD, MPH, FAHA, associate chair of academic affairs in the department of cardiology at Boston Children’s Hospital, the Commonwealth Professor of Pediatrics at Harvard Medical School, and member of the American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young, said in a press release issued by the AHA. “While current data on symptoms, case severity and short-term outcomes is limited, we set out to examine a large group of suspected cases of this heart condition as it relates to the COVID-19 vaccine in teens and adults younger than 21 in North America.” The retrospective analysis included 139 adolescents and young adults aged younger than 21 years with 140 episodes of suspected myocarditis within 30 days of COVID-19 vaccination who presented to 26 U.S. centers before July 4, 2021. Myocarditis was classified as confirmed (n = 49) or probable (n = 91) based on CDC definitions. “It is important for health care professionals and the public to have information about early signs, symptoms and the time course of recovery of myocarditis, particularly as these vaccines become more widely available to children,” Truong said. “Studies to determine long-term outcomes in those who have had myocarditis after COVID-19 vaccination are also planned.”

Cardiopulmonary exercise testing valuable to assess unexplained dyspnea post-COVID-19

Healio | Cardiology Today, November 30, 2021

In a small study, cardiopulmonary exercise testing identified significant abnormalities, including dysfunctional breathing, resting hypocapnia and chronic fatigue syndrome, associated with post-acute sequelae of severe SARS-CoV-2 infection. “The current clinical guidelines do not recommend cardiopulmonary exercise testing out of concern that this test could worsen the patients’ [long COVID] symptoms,” Donna M. Mancini, MD, advanced heart failure and transplant specialist at the Icahn School of Medicine at Mount Sinai, told Healio. “However, we found that cardiopulmonary exercise was able to identify reduced exercise capacity in about 46% of patients. This reduced functional capacity was from a circulatory abnormality. This may include changes involving the pulmonary or peripheral vasculature. We also found that nearly 90% of patients had ventilatory abnormalities during exercise.” Mancini and colleagues aimed to assess the utility of cardiopulmonary exercise test to define unexplained dyspnea in patients with post-acute sequelae of SARS-CoV-2 (PASC) and also assessed patients for criteria to diagnose myalgic encephalomyelitis/chronic fatigue syndrome. The researchers enrolled 41 patients with long COVID symptoms at a median of 8.9 months after infection. Of those, 18 were men and the mean age was 45 years. According to Mancini, participants in this study developed COVID-19 before vaccines were widely available. Mean left ventricular ejection fraction was 59%. In the entire cohort, average peak VO2 was 20.3 mL/kg/min, mean slope of minute ventilation to CO2 production (VE/VCO2) was 30 and average end-tidal pressure of CO2 (PetCO2) at rest was 33.5 mm Hg. Researchers reported that 58.5% of participants had a peak VO2 of less than 80% of the predicted value, all of whom experienced circulatory limitation to exercise. Among 17 patients with normal peak VO2, 15 had ventilatory abnormalities, which included a peak respiratory rate greater than 55 or dysfunctional breathing, according to the results. Eighty-eight percent of participants had ventilatory abnormalities with dysfunctional breathing, elevated VE/VCO2 and/or PetCO2 less than 35 mm Hg.

Incidence of Myopericarditis and Myocardial Injury in Coronavirus Disease 2019 Vaccinated Subjects

American Journal of Cardiology, November 28, 2021

Several recent publications have described myopericarditis cases after the coronavirus disease 2019 (COVID-19) vaccination. However, it is uncertain if these cases occurred secondary to the vaccination or more common etiologies of myopericarditis. To help determine whether a correlation exists between COVID-19 vaccination and myopericarditis, the present study compared the gender-specific cumulative incidence of myopericarditis and myocardial injury in a cohort of COVID-19 vaccinated patients at a tertiary care center in 2021 with the cumulative incidence of these conditions in the same subjects exactly 2 years earlier. We found that the age-adjusted incidence rate of myopericarditis in men was higher in the vaccinated than the control population, rate ratio 9.7 (p = 0.04). However, the age-adjusted incidence rate of myopericarditis in women was no different between the vaccinated and control populations, rate ratio 1.28 (p = 0.71). We further found that the rate of myocardial injury was higher in both men and women in 2021 than in 2019 both before and after vaccination, suggesting that some of the apparent increase in the diagnosis of myopericarditis after vaccination may be attributable to factors unrelated to the COVID-19 vaccinations. In conclusion, our study reaffirms the apparent increase in the diagnosis of myopericarditis after COVID-19 vaccination in men but not in women, although this finding may be confounded by increased rates of myocardial injury in 2021. The benefits of COVID-19 vaccination to individual and public health clearly outweigh the small potential increased risk of myopericarditis after vaccination.

Stress level up, mood and physical activity down during COVID-19 lockdown

Helio | Cardiology Today, November 22, 2021

The COVID-19 pandemic may have reduced overall mood and physical activity among study participants and increased their levels of self-reported stress, a speaker reported. According to results of the COVID-19 Health Evaluation and Cardiovascular Complications (CHECC) study presented at the American Heart Association Scientific Sessions, the changes in mood, stress and physical activity during the pandemic lockdown in Michigan may also vary by age and race. “Michigan has been one of the hardest COVID-19 hit states, with over 1.3 million cases and approximately 24,000 deaths as of November, this month,” Nirav Shah, MD, associate professor in the department of anesthesiology at the University of Michigan, said during a presentation. “We know that heart disease, hypertension and diabetes can lead to more severe disease. Also, stress, social distancing and unemployment may disrupt non-COVID-19 treatment and healthy lifestyles. With that context, [CHECC] consisted of two components.” This first component was a retrospective analysis derived from the MIPACT study that enrolled approximately 7,000 participants with wearable sensor data, including step count, activity data and ambulatory BP, combined with electronic health record and survey data (45% men; 63% white; 48% untreated hypertensive; 27% normal BMI). The second component, for which results will be presented at a later date, was a prospective analysis that enrolled student athletes and included an arm of participants with a recent COVID-19 diagnosis. Twenty-three percent of the cohort was younger than 40 years; 43% was aged 40 to 60 years; and 35% was older than 60 years. According to the presentation, the researchers observed large dips in mood scores and large spikes in stress scores in the weeks immediately following the pandemic lockdown in Michigan. These fluctuations were consistent, regardless of age group. Following the initial fluctuations, Shah reported persistent declines in mood score and increases in stress score within all age groups. After stratification by race, the changes in mood and stress were less dramatic, according to the presentation; however, Black participants’ self-reported mood scores were, on average, higher compared with other races.

Getting to the heart of COVID-19-related cardiac injury

Helio | Cardiology Today, November 19, 2021

The ability of COVID-19 to cause cardiac injury and myocarditis has been well documented since the pandemic began, and data continue to accumulate. “We certainly know that COVID-19 has a long-term effect, or ‘long COVID’, which is the systemic disease that even patients with mild COVID-19 can develop,” Howard J. Eisen, MD, senior advanced heart failure specialist at Penn State Medical Center, told Cardiology Today. “They can be fatigued, have a shortness of breath, drops in blood pressure, elevated heart rates. And a lot of that is thought to maybe be due to autoimmune phenomena and enhanced inflammation. But one thing we know is that myocarditis can, in some patients, develop into heart failure. A lot of these patients who we see who have what we call idiopathic dilated cardiomyopathy … we suspect that they have myocarditis.” As research continues and new information evolves, Cardiology Today spoke with experts in the field about COVID-19-related outcomes on the heart, the risks for myocardial injury as a result of COVID-19 and with vaccination, based on the current knowledge base, and more. In a study published in the European Heart Journal in May, myocardial injury was detected in more than half of patients hospitalized with severe COVID-19, and elevated cardiac troponin persisted months after hospital discharge. “Troponin levels are easy to obtain. While an elevated level indicates cardiac injury, it does not necessarily equate to myocarditis,” Kemna told Cardiology Today. “Myocarditis can present in many different ways. For COVID-19, cardiac inflammation may be part of a multi-organ inflammatory response or there may be endotheliitis leading to cardiac injury, and it can be challenging to distinguish between those and true myocarditis.”

Association of cardiac injury with hypertension in hospitalized patients with COVID-19 in Chin

Scientific Reports, November 17, 2021

Outbreak of global pandemic Coronavirus disease 2019 (COVID-19) has so far caused countless morbidity and mortality. However, a detailed report on the impact of COVID-19 on hypertension (HTN) and ensuing cardiac injury is unknown. Herein, we have evaluated the association between HTN and cardiac injury in 388 COVID-19 (47.5 ± 15.2 years) including 75 HTN and 313 normotension. Demographic data, cardiac injury markers, other laboratory findings, and comorbidity details were collected and analyzed. Compared to patients without HTN, hypertensive-COVID-19 patients were older, exhibited higher C-reactive protein (CRP), erythrocyte sedimentation rate, and comorbidities such as diabetes, coronary heart disease, cerebrovascular disease and chronic kidney disease. Further, these hypertensive-COVID-19 patients presented more severe disease with longer hospitalization time, and a concomitant higher rate of bilateral pneumonia, electrolyte disorder, hypoproteinemia and acute respiratory distress syndrome. In addition, cardiac injury markers such as creatine kinase (CK), myoglobin, lactic dehydrogenase (LDH), and N-terminal pro brain natriuretic peptide were significantly increased in these patients. Correlation analysis revealed that systolic blood pressure correlated significantly with the levels of CK, and LDH. Further, HTN was associated with increased LDH and CK-MB in COVID- 19 after adjusting essential variables. We also noticed that patients with elevated either high sensitivity-CRP or CRP demonstrated a significant high level of LDH along with a moderate increase in CK (p = 0.07) and CK-MB (p = 0.09). Our investigation suggested that hypertensive patients presented higher risk of cardiac injury and severe disease phenotype in COVID-19, effectively control blood pressure in HTN patients might improve the prognosis of COVID-19 patients.

Cardiac biomarker-guided corticosteroid dosing feasible, safe in COVID-19 pneumonia

Helio | Cardiology Today, November 16, 2021

An individualized, biomarker-guided approach to corticosteroid dosing utilizing C-reactive protein for COVID-19-related pneumonia reduced patients’ cumulative steroid exposure and increased the number of hospital- and oxygen-free days. This novel approach for treating pneumonia and hypoxemic respiratory failure was quickly and successfully adapted at the onset of the COVID-19 pandemic and was also safe in this population, according to Yewande Odeyemi, MD, assistant professor in the division of pulmonary and critical care at Mayo Clinic in Rochester, Minnesota. “Prior to COVID-19, corticosteroid use in community-acquired pneumonia was both controversial and undefined,” Odeyemi said during a presentation at the American Heart Association Scientific Sessions. “Our goal was to assess the feasibility and safety of an individualized, biomarker-guided corticosteroid-dosing approach utilizing C-reactive protein compared to usual care in patients with community-acquired pneumonia and acute hypoxemic respiratory failure. Our secondary goal was to assess any potential preliminary efficacy of this strategy on noncardiovascular outcomes. This was quickly adapted to include COVID-19 pneumonia at the beginning of the pandemic with the addition of cardiovascular outcomes.” The trial included patients hospitalized with community-acquired pneumonia including COVID-19 and acute hypoxemic respiratory failure (n = 44). Methylprednisolone was administered daily and dosed based on CRP levels or patients were treated with usual care. “Usual care did change as the standard of care for COVID-19 infection evolved,” Odeyemi said. “Prior to July 2020, steroids were contraindicated in COVID-19 infection. After the publication of the results of the RECOVERY trial, steroids became standard of care in a fixed-dose regimen.” The primary outcome was feasibility. Secondary noncardiovascular outcomes included cumulative steroid exposure, hospital-free days, oxygen-free days, in-hospital mortality, advanced respiratory support, hyperglycemia and delirium. Secondary CV outcomes included requirement for vasopressor therapy, new-onset or worsening arrhythmia, myocardial injury as measured by troponin or LV dysfunction, or new diagnosis of right ventricular dysfunction.

Potent Antiplatelet Not a Good Idea for Moderate COVID-19

MedPage Today, November 16, 2021

P2Y12 inhibitors did not improve outcomes for non-critically ill patients hospitalized with COVID-19, an ACTIV-4a platform trial showed.

Patients randomized to receive a potent antiplatelet, typically atop therapeutic anticoagulation with heparin, actually had numerically fewer organ support-free days through day 21 than those who received usual care without a P2Y12 inhibitor (adjusted OR 0.83, 95% CI 0.55-1.25), reported Jeffrey Berger, MD, of NYU Grossman School of Medicine in New York City, during the virtual American Heart Association meeting. In a Bayesian analysis, there was a 96% chance of futility and an 81% likelihood that P2Y12 inhibitors were worse than placebo, which prompted early termination of that portion of the trial after enrollment of 562 patients. And for the composite of death or need for organ support, the P2Y12 inhibitor also trended in the wrong direction (26% vs 22%; HR 1.19, 95% CI 0.84-1.68). “The data that you’ve seen does not support the use of these agents in context, but it will be important to address the similar question in higher-risk populations,” said study discussant Amy Towfighi, MD, of the University of Southern California in Los Angeles, at the late-breaking clinical trial session. The trial included a population with confirmed SARS-CoV-2 with at least one higher-risk criterion—elevated D-dimer, ages 60 to 84, need for more than 2 L/min oxygen, hypertension, diabetes, impaired kidney function, cardiovascular disease, or obesity—but was still a fairly low-risk group, she noted. ACTIV-4a, together with the REMAP-CAP and ATTACC multi-platform trials, had shown a relative 27% increase in organ support-free days in patients with moderate COVID-19 given therapeutic-dose levels of heparin, but no advantage in critically ill patients. Thus, nearly 90% of patients in both arms of the P2Y12 portion of ACTIV-4a received therapeutic-dose heparin.

Women with long COVID may need rehab to improve physical activit

Helio | Women’s Health & OB/GYN, November 16, 2021

Women with long COVID experience heart-rate irregularities after physical exertion, which could constrain their exercise tolerance and their free-living physical activity, according to a study published in Experimental Physiology. Since there is a greater prevalence of age-related physical disability among women than among men, these findings illustrate the need for targeted rehabilitation programs that manage persistent heart and lung problems in women with long COVID, the researchers said. “Consistent with other universities during the spring of 2020, our usual research activities involving exercise training and postmenopausal women were temporarily halted amid the emerging pandemic,” author Stephen J. Carter, MS, PhD, assistant professor in the department of kinesiology at the Indiana University School of Public Health – Bloomington, told Healio. “Since our lab has a history of studying the acute and chronic effects of exercise in women, we thought it sensible to pivot our research efforts accordingly. We felt this to be especially important, given that women are largely underrepresented in clinical work, and thus offering us a unique opportunity to explore the effects of SARS-CoV-2 on cardiopulmonary health,” Carter said. The researchers recruited 45 women for the case-controlled study. According to the researchers, 29 women (age, 54 ± 10 years; BMI, 25.6 ± 5.4 kg/m2) had a positive laboratory test for mild to moderate SARS-CoV-2 infection 4 weeks before enrolling in the study or earlier, while the control group included 16 women (age, 58 ± 11 years; BMI, 26.7 ± 4.8 kg/m2) who never tested positive. The participants with a history of SARS-CoV-2 infection had reduced total lung capacity (84% ± 8% vs. 93% ± 13%; P = .006), vital capacity (87% ± 10% vs. 93% ± 10%; P = .04), functional residual capacity (75% ± 16% vs. 88% ± 16%; P = .006) and residual volume (76% ± 18% vs. 93% ± 22%; P = .001) compared with controls.

Stemi mimicking post COVID: a case of focal myopericarditis post COVID infectio

Journal of Community Hospital of Internal Medicine Perspectives, November 15, 2021

[Case Report] Since the beginning of the coronavirus disease 2019 (COVID19) pandemic, several cases of myocarditis related to COVID-19 infection have been reported. These cases range from asymptomatic disease to fulminant heart failure or sudden cardiac death. Cardiac injury has also been found in asymptomatic patients and patients who recovered from the disease. Data regarding cardiovascular involvement due to COVID-19 infection are still limited, and the actual prevalence of myocarditis due to COVID-19 infection is still unknown. We present a case of focal myopericarditis in a patient recently recovered from COVID-19 pneumonia with electrocardiogram showing ST elevation in inferior and lateral leads. This case highlights the need for studying the long-term cardiovascular complications of COVID-19 and reinforces the use of cardiac magnetic resonance (CMR) and cardiac biomarkers in the diagnosis of COVID-19-related myocarditis.

Blood pressure control ‘decreased substantially’ during COVID-19 pandemi

Helio | Cardiology Today, November 14, 2021

BP control declined among U.S. adults in 2020 compared with 2019, due to the COVID-19 pandemic, according to a study of 24 health systems presented at the American Heart Association Scientific Sessions. “We observed large variability across health systems in blood pressure control metrics,” Alanna M. Chamberlain, PhD, MPH, FAHA, associate professor of epidemiology in the departments of cardiovascular medicine and quantitative health sciences at Mayo Clinic in Rochester, Minnesota, said during a presentation. “Our results showed suboptimal blood pressure control even before the COVID-19 pandemic, and show substantial opportunity for improvement. Blood pressure control decreased substantially during the COVID-19 pandemic, accompanied by a reduction in follow-up health care visits among persons with hypertension. Blood pressure control has not rebounded to pre-pandemic levels.” The BP Track study analyzed trends in BP control in the year before the COVID-19 pandemic and during the pandemic in patients with hypertension from 24 health systems participating in the National Patient-Centered Clinical Research Network (PCORnet). According to Chamberlain, this study “is the first use of PCORnet for national surveillance of blood pressure control and related process metrics.” She noted that “each health system transforms their data to a common data model, which is updated on a quarterly basis.” The declines in BP control and repeat visits occurred in all races and ethnicities, and BP control remained lowest in Black patients, Chamberlain said. BP control at the end of 2020 had not rebounded to 2019 levels, Chamberlain said.

Hypertension and its management in COVID-19 patients

International Journal of Cardiology Cardiovascular Risk and Prevention, November 13, 2021

Coronavirus disease 2019 (COVID-19) is suspected to mainly be more deleterious in patients with underlying cardiovascular diseases (CVD). There is a strong association between hypertension and COVID-19 severity. The binding of SARS-CoV-2 to the angiotensin-converting enzyme 2 (ACE2) leads to deregulation of the renin-angiotensin-aldosterone system (RAAS) through down-regulation of ACE2 with subsequent increment of the harmful Ang II serum levels and reduction of the protective Ang-(1–7). Both angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) are commonly used to manage hypertension. Objective was to illustrate the potential link between hypertension and COVID-19 regarding the role of angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) in hypertensive patients with COVID-19. We carried out comprehensive databases search from late December 2019 to early January 2021 by using online engines of Web of Science, Research gate, Scopus, Google Scholar, and PubMed for published and preprinted articles. The present study’s findings showed that hypertension is regarded as an independent risk factor for COVID-19 severity. Both ACEIs and ARBs are beneficial in managing hypertensive patients. This study concluded that hypertension increases COVID-19 severity due to underlying endothelial dysfunctions and coagulopathy. COVID-19 might augment the hypertensive complications due to down-regulation of ACE2. The use of ACEIs or ARBs might be beneficial in the management of hypertensive patients with COVID-19.

Common cardiac medications potently inhibit ACE2 binding to the SARS-CoV-2 Spike, and block virus penetration and infectivity in human lung cells

Scientific Reports, November 12, 2021

To initiate SARS-CoV-2 infection, the Receptor Binding Domain (RBD) on the viral spike protein must first bind to the host receptor ACE2 protein on pulmonary and other ACE2-expressing cells. We hypothesized that cardiac glycoside drugs might block the binding reaction between ACE2 and the Spike (S) protein, and thus block viral penetration into target cells. To test this hypothesis we developed a biochemical assay for ACE2:Spike binding, and tested cardiac glycosides as inhibitors of binding. Here we report that ouabain, digitoxin, and digoxin, as well as sugar-free derivatives digitoxigenin and digoxigenin, are high-affinity competitive inhibitors of ACE2 binding to the Original [D614] S1 and the α/β/γ [D614G] S1 proteins. These drugs also inhibit ACE2 binding to the Original RBD, as well as to RBD proteins containing the β [E484K], Mink [Y453F] and α/β/γ [N501Y] mutations. As hypothesized, we also found that ouabain, digitoxin and digoxin blocked penetration by SARS-CoV-2 Spike-pseudotyped virus into human lung cells, and infectivity by native SARS-CoV-2. These data indicate that cardiac glycosides may block viral penetration into the target cell by first inhibiting ACE2:RBD binding. Clinical concentrations of ouabain and digitoxin are relatively safe for short term use for subjects with normal hearts. It has therefore not escaped our attention that these common cardiac medications could be deployed worldwide as inexpensive repurposed drugs for anti-COVID-19 therapy.

COVID-19 diagnosis in patients with STEMI tied to elevated in-hospital mortality

Helio | Cardiology Today, November 9, 2021

In a cohort of patients with STEMI, a COVID-19 diagnosis significantly increased the rates of in-hospital mortality compared with patients without a COVID-19 diagnosis from the past year, according to new data. Marwan Saad, MD, PhD, FACC, FSCAI, FESC, assistant professor of medicine and director of interventional structural heart research at the Warren Alpert Medical School of Brown University, and colleagues conducted the retrospective cohort study. They included 80,449 consecutive adult patients admitted between January 2019 and December 2020 with out-of-hospital or in-hospital STEMI at 509 U.S. centers in the Vizient Clinical Database. In-hospital mortality served as the primary outcome measure. Researchers propensity-matched patients based on the likelihood of COVID-19 diagnosis, and compared patients with COVID-19 with those without COVID-19 during the previous calendar year. Overall, the out-of-hospital STEMI arm featured 76,434 patients (64% aged 51 to 74 years; 70% men), while the in-hospital STEMI arm featured 4,015 patients (58% aged 51 to 74 years; 61% men). After propensity matching, there were 551 patients with COVID-19 and 2,755 patients without COVID-19 in the out-of-hospital STEMI group, and 252 patients with COVID-19 and 756 patients without COVID-19 in the in-hospital STEMI group. Results indicated that COVID-19 status did not significantly impact the likelihood of patients with out-of-hospital STEMI receiving primary PCI. However, patients with in-hospital STEMI and COVID-19 demonstrated a significantly decreased likelihood of receiving invasive diagnostic or therapeutic coronary procedures than those without COVID-19.

Clinical outcomes of hypertensive patients with COVID-19 receiving calcium channel blockers: a systematic review and meta-analysis

Hypertension Research, November 9, 2021

We aimed to perform a systematic review and meta-analysis to determine the overall effect of the preadmission/prediagnosis use of calcium channel blockers (CCBs) on the clinical outcomes in hypertensive patients with COVID-19. A systematic literature search with no language restriction was conducted in electronic databases in July 2021 to identify eligible studies. A random-effects model was used to estimate the pooled summary measure for outcomes of interest with the preadmission/prediagnosis use of CCBs relative to the nonuse of CCBs at 95% confidence intervals (CIs). The meta-analysis revealed a significant reduction in the odds of all-cause mortality with the preadmission/prediagnosis use of CCBs relative to the nonuse of CCBs (pooled OR = 0.65; 95% CI 0.49–0.86) and a significant reduction in the odds of severe illness with preadmission/prediagnosis use of CCBs relative to the nonuse of CCBs (pooled OR = 0.61; 95% CI 0.44–0.84), and is associated with adequate evidence to reject the model hypothesis of ‘no significant difference’ at the current sample size. The potential protective effects offered by CCBs in hypertensive patients with COVID-19 merit large-scale prospective investigations.

Helio | Cardiology Today, November 8, 2021

The COVID-19 pandemic continues to challenge our health care system to deliver essential inpatient and outpatient care to infected patients while continuing to treat patients with non-COVID-19-related illnesses. All of this is occurring in a challenging environment intended to minimize spread of this virulent virus. The telehealth techniques that have proliferated to address this increased demand for medical care will have lasting and profound effects on the future practice of cardiology. Telehealth is not a new concept. Cardiologists have long made use of transtelephonic monitoring of pacemakers, and more recently use other biometric devices and cardiac imaging procedures for both live and asynchronous data transmission to our offices and hospitals for interpretation and management recommendations. With COVID-19, we quickly recognized the convenience and value of person-to-person tele-video communication with our patients outside the hospital and office settings, especially for those patients needing post-acute care or experiencing chronic illnesses such as HF and hypertension. Properly applied, televideo can improve our efficiency and deliver more and better care than many routine in-person office visits. Televideo is especially effective in providing education and individualized support, increasing patients’ compliance with both medical and lifestyle interventions, which in turn improve patients’ quality of life while avoiding the expense and inconvenience of nonessential office visits, unnecessary urgent care and avoidable hospitalization. The stress the COVID-19 pandemic has placed on our health care system has exposed deep-rooted inequities in health care delivery in our country. Socioeconomic, racial and geographic disparities extend far beyond COVID-19. The acute, chronic and worsening shortage of physicians has heightened recognition of the power of televideo communication to supplement in-person care and appreciation of the essential role nonphysician members of the health care team play in expanding productivity to bring high quality care to more patients with CVD than otherwise possible.

Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

European Heart Journal, November 4, 2021

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality. We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66–75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02–1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10–1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20–1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients. Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Takotsubo cardiomyopathy after vaccination for coronavirus disease 2019 in a patient on maintenance hemodialysis

CEN Case Reports, November 3, 2021

Coronavirus disease-2019 (COVID-19) has affected more than 220 million individuals since the global pandemic began. There is an urgent need for safe and effective vaccines, and vaccinations, such as mRNA vaccines, have been initiated worldwide. However, the adverse effects of these vaccines remain unclear. We herein present a case of an 80-year-old female on maintenance hemodialysis who developed Takotsubo cardiomyopathy 4 days after receiving the first dose of the Pfizer-BioNTech COVID-19 vaccine. There was no obvious trigger for the onset of Takotsubo cardiomyopathy other than the COVID-19 vaccination, which was the most significant event preceding her presentation. Echocardiograms obtained during her admission allowed us to monitor and show the recovery of left ventricular wall motion. We confirmed the diagnosis of Takotsubo cardiomyopathy based on the findings, including transient left ventricular dysfunction, electrocardiographic abnormalities, an elevated troponin level, and the absence of occlusive coronary artery disease. In the present case, the vaccination may have triggered emotional or physical stress. Although difficulties are associated with proving the causal relationship in the present case, the temporal relationship between the vaccination and the onset of Takotsubo cardiomyopathy is highly suggestive. The adverse effects associated with the vaccine are typical of COVID-19 vaccines administered to date, most of which are acceptable. Therefore, despite our experience of the present case, we still recommend the vaccination for COVID-19 because Takotsubo cardiomyopathy induced by the COVID-19 vaccine is extremely rare and the prognosis of the patient was good. We herein present the first case of a patient on hemodialysis who developed Takotsubo cardiomyopathy after receiving COVID-19 vaccination.

Incidence of Atrioventricular Blocks and its Association with In-Hospital Mortality and Morbidity in Patients with Coronavirus Disease 2019

Journal of Cardiology, November 1, 2021

Cardiovascular sequelae of coronavirus disease 2019 (COVID-19) infection have been explored by clinicians and researchers all over the world. The purpose of this study was to evaluate the incidence of atrioventricular block (AV) in patients hospitalized for COVID-19 and its association between in-hospital morbidity and mortality. In-hospital electrocardiograms (ECGs) of 438 patients were compared with their prior or baseline ECGs to ascertain the development of new onset AV block. Patients who developed new AV blocks were then followed at 30 and 90 days post-discharge to check for resolution of AV block. Demographic characteristics, clinical characteristics, and complications during their hospital stay were evaluated. Major complications including respiratory failure requiring oxygen supplementation and mechanical ventilation, sepsis, deep vein thrombosis, elevated troponins, hospital and intensive care unit (ICU) length of stay, as well as death were compared between those who developed new onset AV blocks and those who did not. Based on our single center study, the incidence of new onset AV blocks among patients admitted for COVID-19 during the study period was 5.5 cases per 100 patients. New onset AV blocks were not associated with longer hospital and ICU length of stay, increased intubation rates, or increased mortality. Although the development of a new onset AV block is most likely multifactorial and not solely due to COVID-19, it is still important for clinicians to be mindful about the possibility of developing symptomatic bradycardia and life-threatening arrhythmias in patients admitted for COVID-19. This can be achieved by appropriate rhythm monitoring in-patient but the need for a cardiac event monitor upon discharge is unlikely to be necessary. Careful history taking, including family and drug use history is also of great importance as emerging drug therapies for COVID-19 have potential arrhythmogenic effects.

Mild COVID Not Linked to Long-Term Cardiac Damage

MedPage Today, November 1, 2021

Cardiac parameters suggestive of myocarditis were no more common at 6 months after mild or asymptomatic COVID-19 than among people who never had the infection, a prospective case-control study found. Compared with seronegative healthcare workers, those who had generally mild SARS-CoV-2 had no differences in cardiac structure, function, MRI markers of myocarditis, or cardiac injury biomarkers 6 months later, James Moon, MD, of St. Bartholomew’s Hospital in London, and colleagues reported in JACC: Cardiovascular Imaging. The maximum prevalence of myocarditis in the type of healthcare worker population they studied may be less than 4% at 6 months, the analysis suggested. “Thus, screening in asymptomatic patients following nonhospitalized COVID-19 is currently not indicated,” the group concluded, pointing to it as yet more evidence counteracting an early but alarming finding that 78% of COVID survivors had lingering myocardial inflammation and other cardiac MRI abnormalities. Colin Berry, PhD, and Kenneth Mangion, PhD, both of the University of Glasgow, agreed in an accompanying editorial, calling the findings welcome reassurance for healthy individuals. “This is a reasonably reassuring result drawn from a healthy population,” the editorialists wrote, “however, the sample size limits the precision of this estimate, and the prevalence of cardiovascular abnormalities (e.g., myocardial scar) would be expectedly higher in an unbiased community population including individuals from less-advantaged socioeconomic circumstances (e.g., unemployed) and with pre-existing health problems.”

Evaluating Factors of Greater Patient Satisfaction with Outpatient Cardiology Telehealth Visits During the COVID-19 Pandemic

Cardiovascular Digital Health Journal, October 29, 2021

The impact of telehealth on cardiovascular care during the COVID-19 pandemic on patient satisfaction and factors associated with satisfaction are not well characterized. We conducted a non-randomized, prospective cross-sectional survey study for outpatient telehealth cardiovascular visits over a 169-day period utilizing a validated telehealth usability questionnaire. For each variable, patients were divided into two groups – one with scores above the median labeled “greater satisfaction” and the other with scores below the median labeled “less satisfaction”. 13913 outpatient telehealth encounters were successfully completed during the study period. 7327 unique patients were identified and received a survey invitation. 5993 (81.8%) patients opened the invitation, and 1034 (14.1%) patients consented and completed the survey. Overall mean and median scores were 3.15 (SD 0.74) and 3.37 (IQR 2.73–3.68) (maximum score 4.00). Greater satisfaction was noted among younger patients (mean age 63.3±14.0 years, p=0.005), female gender (46.3%, p=0.007), non-white ethnicity (24.2%, p=0.006), self-identified early adopters and innovators of new technology (49.8%, p<0.001), one-way travel time greater than 1 hour (22.3%, p<0.001), one-way travel distance greater than 10 miles (49.0%, p<0.001), patients needing child care arrangement (16.4%, p<0.001), and history of orthotopic heart transplant (OHT) (5.1%, p=0.04). Patients reported overall satisfaction with telehealth during the COVID-19 pandemic. Factors associated with patient convenience, along with female gender, younger age and non-white ethnicity correlated with greater satisfaction. Cardiovascular comorbidities did not correlate with greater satisfaction except for OHT.

Patient delay prior to care-seeking in acute myocardial infarction during the outbreak of the coronavirus SARS-CoV2 pandemic

European Journal of Cardiovascular Nursing, October 29, 2021

Our objective was to examine patient delay in seeking medical care when afflicted by an acute myocardial infarction during March–June 2020. This was a cross-sectional study in a region in Sweden during the first wave of the COVID-19 pandemic examining patients selected from the national registry (SWEDEHEART). Eligible patients were those with acute myocardial infarction, and a total of 602 patients were invited. A self-administered psychometric evaluated questionnaire, ‘Patients’ appraisal, emotions, and action tendencies preceding care-seeking in acute myocardial infarction’ (AMI), was sent to the patients, and questions regarding COVID-19 were added. A total of 326 patients answered the questionnaire. Of these, 19% hesitated to seek medical care because of the pandemic, which was related to a fear that the healthcare services were already overcrowded with patients with COVID-19, followed by a fear of becoming infected with COVID-19 in hospital. Characteristics of this cohort were significantly higher prevalences of women, immigrants, smokers, and patients with type 2 diabetes. During the outbreak and first wave of the COVID-19 pandemic, women and immigrants delayed seeking medical care for AMI because of fears about overcrowded hospitals and about becoming infected themselves. Therefore, during the COVID-19 pandemic, it is especially important to convey information about how and when to seek medical care. A collaboration involving the healthcare professionals, patient organizations, and the media would be desirable.

Hypertension and COVID-19: Potential use of beta-blockers and a call for randomized evidence

Indian Heart Journal, October 27, 2021

[Opinion Paper] Hypertension is one of the most common morbidities in COVID-19. Previous studies demonstrated that hypertension increases composite poor outcomes in patients with COVID-19. Beta-blockers is widely used as one of the most common antihypertensive agents. Beta-blockers may hold potential benefits in COVID-19 treatment, with current evidence of the potential mechanism of beta-blockers remains scarce. However, several mechanisms were suggested, including decreasing RAAS pathway activity and lowering the ACE2 levels, reducing cytokine storms, and may be beneficial in reducing mortality in ARDS related COVID-19. Further large-scale randomized clinical trials should be conducted before a definite recommendation can be drawn.

Covid-19 and Heart Damage

News Medical, October 27, 2021

The coronavirus disease 2019 (COVID-19) pandemic led to well over 200 million infections, with a fatal outcome in over 4.5 million cases. In the survivors, most recovered completely but some showed long-haul symptoms – now often called Long COVID. One important potentially long-term clinical consequence of COVID-19 seems to be heart damage. This has been recognized as far back as the Wuhan, China, outbreak. Several patients hospitalized with the disease at that time had high levels of cardiac troponin, which is a molecular biomarker of myocardial injury. Echocardiographic evaluation of these patients showed the presence of functional deficits in the heart. The obvious conclusion was that COVID-19 severity was correlated with the presence of myocardial injury. It was quite clear that people that came into the hospital sick that had heart injury were the ones that were at greatest risk of requiring mechanical ventilation and, ultimately, at the greatest risk of dying,” says Aaron Baggish, of Massachusetts General Hospital. However, the large number of asymptomatic cases coupled with a lack of focused research means that the question of how common this complication is, remains unanswered. It is also not clear whether the damage to the heart muscle is due to the systemic inflammatory reaction in COVID-19 or because of myocarditis. Most importantly, the chances of long-term injury are also unclear at this point, though it is a very significant one, considering the huge number of infections that have occurred so far.

Implantation of Cardiac Electronic Devices in Active COVID-19 Patients. Results from an International Survey

Heart Rhythm, October 26, 2021

Cardiac implantable electronic device (CIED) implantation rates, as well as the clinical and procedural characteristics and outcomes in patients with known active COVID-19 are unknown. To gather information regarding CIED procedures during active COVID-19, performed with personal protective equipment, based on an international survey. Fifty-three centers from 13 countries across 4 continents provided information on 166 patients with known active COVID-19 who underwent a CIED procedure. CIED procedure rate in 133,655 hospitalized COVID-19 patients ranged from 0 to 16.2 per 1000 patients (p<0.001). Most devices were implanted due to high degree / complete AV block (112, 67.5%) or sick sinus syndrome (31, 18.7%). Of the166 patients surveyed, the 30-day complication rate was 13.9% and the 180-day mortality rate was 9.6%. One patient had a lethal outcome as a direct result of the procedure. Differences in patient and procedural characteristics and outcomes were found between Europe and North America. An older population (76.6 vs. 66 years, p<0.001) with a non-significant higher complication rate (16.5% vs. 7.7%, p=0.2) were observed in Europe, while a higher rate of critically ill patients (3.3% vs. 33.3%, p<0.001) and mortality (5% vs. 26.9%, p=0.002) were observed in North America. CIED procedure rates during known active COVID-19 disease varied greatly from 0 to 16.2 per 1000 hospitalized COVID-19 patients worldwide. Patients with active COVID-19 infection who underwent CIED implantation had high complication and mortality rates. Operators should take into consideration these risks prior to proceeding with CIED implantation in active COVID-19 patients.

Cardiac involvement in the long-term implications of COVID-19

Nature Reviews | Cardiology, October 22, 2021

Throughout 2021, the medical and scientific communities have focused on managing the acute morbidity and mortality caused by the coronavirus disease 2019 (COVID-19) pandemic. With the approval of multiple vaccines, there is a light at the end of this dark tunnel and an opportunity to focus on the future, including managing the long-term sequelae in patients who have survived acute COVID-19. In this Perspectives article, we highlight what is known about the cardiovascular sequelae in survivors of COVID-19 and discuss important questions that need to be addressed in prospective studies to understand and mitigate these lasting cardiovascular consequences, including in post-acute COVID-19 syndrome. To provide the greatest benefit to these survivors, prospective studies should begin now, with resources made available to monitor and study this population in the coming years.

Management Strategies for COVID-19 in the General Ward of Cardiovascular Surgery: Experience From a Single Tertiary Hospital in China

The Heart Surgery Forum, October 21, 2021

Coronavirus disease 2019 (COVID-19) is a highly contagious respiratory disease that threatens global health. During the pandemic period of COVID-19, the task for prevention in the general ward of cardiovascular surgery is fairly arduous. The present study intends to summarize our experience with infection control, including ward setting, admission procedures, personnel management, health education, and so on, to provide references for clinical management.

Symptom Persistence Despite Improvement in Cardiopulmonary Health – Insights from longitudinal CMR, CPET and lung function testing post-COVID-19

EClinicalMedicine, October 20, 2021

The longitudinal trajectories of cardiopulmonary abnormalities and symptoms following infection with coronavirus disease (COVID-19) are unclear. We sought to describe their natural history in previously hospitalised patients, compare this with controls, and assess the relationship between symptoms and cardiopulmonary impairment at 6 months post-COVID-19. Fifty-eight patients and thirty matched controls (single visit), underwent symptom-questionnaires, cardiac and lung magnetic resonance imaging (CMR), cardiopulmonary exercise test (CPET), and spirometry at 3 months following COVID-19. Of them, forty-six patients returned for follow-up assessments at 6 months. At 2-3 months, 83% of patients had at least one cardiopulmonary symptom versus 33% of controls. Patients and controls had comparable biventricular volumes and function. Native cardiac T1 (marker of fibroinflammation) and late gadolinium enhancement (LGE, marker of focal fibrosis) were increased in patients at 2-3 months. Sixty percent of patients had lung parenchymal abnormalities on CMR and 55% had reduced peak oxygen consumption (pV̇O2) on CPET. By 6 months, 52% of patients remained symptomatic. On CMR, indexed right ventricular (RV) end-diastolic volume (-4·3 mls/m2, P=0·005) decreased and RV ejection fraction (+3·2%, P=0·0003) increased. Native T1 and LGE improved and was comparable to controls. Lung parenchymal abnormalities and peak V̇O2, although better, were abnormal in patients versus controls. 31% had reduced pV̇O2 secondary to symptomatic limitation and muscular impairment. Cardiopulmonary symptoms in patients did not associate with CMR, lung function, or CPET measures. In patients, cardiopulmonary abnormalities improve over time, though some measures remain abnormal relative to controls. Persistent symptoms at 6 months post-COVID-19 did not associate with objective measures of cardiopulmonary health.

Study of 1 million people finds lower risk of death from COVID-19 in statin users

Medical News Today, October 20, 2021

Statins are a group of drugs used to reduce levels of low-density lipoprotein (LDL) cholesterol in the blood, also known as “bad” cholesterol. Having high LDL cholesterol levels can lead to the hardening and narrowing of arteries and cardiovascular disease. Around 40 million people in the United States use statins to manage their cholesterol levels. Cardiovascular disease and high cholesterol levels have been linked to worsened COVID-19 outcomes. Meanwhile, other research has suggested that statins may have antiviral, anti-inflammatory, and anti-clotting effects that may be beneficial against COVID-19. This spring, a study that included 648 patients hospitalized with COVID-19 found that participants who took statins before developing COVID-19 were around 50% less likely to die in the hospital than those who did not. Until now, there has been little research on how statin use affects COVID-19 outcomes outside of hospital settings. Recently, researchers from Sweden and Australia conducted a large population study of almost 1 million people, exploring the relationship between statins and COVID-19 mortality. They found that statin use was associated with a slightly lower risk of dying from the disease. “The results were in line with our hypothesis, and some previous observational studies have shown similar results,” Rita Bergqvist, co-first author of the study and a medical student at the Karolinska Institutet, in Solna, Sweden, told Medical News Today.

Cardiac SARS-CoV-2 infection is associated with pro-inflammatory transcriptomic alterations within the heart

Cardiovascular Research, October 14, 2021

Cardiac involvement in COVID-19 is associated with adverse outcome. However, it is unclear whether cell specific consequences are associated with cardiac SARS-CoV-2 infection. Therefore, we investigated heart tissue utilizing in situ hybridization, immunohistochemistry and RNA-sequencing in consecutive autopsy cases to quantify virus load and characterize cardiac involvement in COVID-19. In this study, 95 SARS-CoV-2-positive autopsy cases were included. A relevant SARS-CoV-2 virus load in the cardiac tissue was detected in 41/95 deceased (43%). MACE-RNA-sequencing was performed to identify molecular pathomechanisms caused by the infection of the heart. A signature matrix was generated based on the single-cell dataset “Heart Cell Atlas” and used for digital cytometry on the MACE-RNA-sequencing data. Thus, immune cell fractions were estimated and revealed no difference in immune cell numbers in cases with and without cardiac infection. This result was confirmed by quantitative immunohistological diagnosis. MACE-RNA-sequencing revealed 19 differentially expressed genes (DEGs) with a q-value <0.05 (e.g. up: IFI44L, IFT3, TRIM25; down: NPPB, MB, MYPN). The upregulated DEGs were linked to interferon pathways and originate predominantly from endothelial cells. In contrast, the downregulated DEGs originate predominately from cardiomyocytes. Immunofluorescent staining showed viral protein in cells positive for the endothelial marker ICAM1 but rarely in cardiomyocytes. The GO term analysis revealed that downregulated GO terms were linked to cardiomyocyte structure, whereas upregulated GO terms were linked to anti-virus immune response. This study reveals that cardiac infection induced transcriptomic alterations mainly linked to immune response and destruction of cardiomyocytes. While endothelial cells are primarily targeted by the virus, we suggest cardiomyocyte-destruction by paracrine effects. Increased pro-inflammatory gene expression was detected in SARS-CoV-2-infected cardiac tissue but no increased SARS-CoV-2 associated immune cell infiltration was observed.

Vaccination for Respiratory Infections in Patients with Heart Failure

Journal of Clinical Medicine, September 22, 2021

Bronchopulmonary infections are a major trigger of cardiac decompensation and are frequently associated with hospitalizations in patients with heart failure (HF). Adverse cardiac effects associated with respiratory infections, more specifically Streptococcus pneumoniae and influenza infections, are the consequence of inflammatory processes and thrombotic events. For both influenza and pneumococcal vaccinations, large multicenter randomized clinical trials are needed to evaluate their efficacy in preventing cardiovascular events, especially in HF patients. No study to date has evaluated the protective effect of the COVID-19 vaccine in patients with HF. Different guidelines recommend annual influenza vaccination for patients with established cardiovascular disease and also recommend pneumococcal vaccination in patients with HF. The Heart Failure group of the French Society of Cardiology recently strongly recommended vaccination against COVID-19 in HF patients. Nevertheless, the implementation of vaccination recommendations against respiratory infections in HF patients remains suboptimal. This suggests that a national health policy is needed to improve vaccination coverage, involving not only the general practitioner, but also other health providers, such as cardiologists, nurses, and pharmacists. This review first summarizes the pathophysiology of the interrelationships between inflammation, infection, and HF. Then, we describe the current clinical knowledge concerning the protective effect of vaccines against respiratory diseases (influenza, pneumococcal infection, and COVID-19) in patients with HF and finally we propose how vaccination coverage could be improved in these patients.

COVID-19 and the Cardiovascular System: Insights into Effects and Treatments

Canadian Journal of Physiology and Pharmacology, September 21, 2021

Coronavirus disease 2019 (COVID-19), an acute and highly transmissible infectious disease has reached a pandemic level since March 11, 2020 and continues to challenge the healthcare system worldwide. The pathogenesis of COVID-19 is a complex process involving mechanisms that suppress the host antiviral and innate immune response, while triggering marked activation of coagulation and hyperinflammation leading to cytokine storm in severe COVID-19. This review summarizes current evidence related to COVID-19-associated cardiovascular severe illness and mortality, which encompasses life-threatening clinical manifestations, including myocardial injury, fulminant myocarditis, cardiac arrhythmia and ischemic stroke. The onset of hypercoagulable state is consistent with increased venous thromboembolism including deep vein thrombosis and pulmonary embolism. Thromboembolic manifestations include arterial thrombotic events such as stroke, myocardial infarction, and limb ischemia. Several treatment strategies have been investigated to mitigate COVID-19-associated cardiovascular clinical manifestations. The prevalence of thrombo-inflammatory syndrome and subsequent cardiovascular dysfunction prompted the implementation of antithrombotic therapy and strategies targeting major proinflammatory cytokines involved in COVID-19 cytokine storm. The development of new guidelines for effective treatment strategies requires concerted efforts to refine our understanding of the mechanisms underlying cardiovascular disease and large-scale clinical trials to reduce the burden of COVID-19 hospitalization and mortality.

COVID Deaths Surpass 1918 Flu Deaths

MedPage Today, September 21, 2021

U.S. COVID-19 deaths have now surpassed the 675,000 estimated deaths that occurred during the H1N1 influenza pandemic of 1918, but SARS-CoV-2 hasn’t exacted as heavy a toll as that pandemic. With a national population of around 103 million people at that time — about a third of the current total of 330 million Americans — the 1918 pandemic killed roughly 1 in 150 people in the U.S.; COVID has killed 1 in 500 Americans. Globally, the 1918 flu wrought more havoc than COVID, too, infecting about 500 million people, or a third of the world’s population at that time. It killed about 50 million people globally, according to CDC estimates. SARS-CoV-2 has infected nearly 230 million people around the world and killed some 4.7 million of them. There are many reasons for the differences in infection and mortality. The 1918 pandemic hit while the world was enmeshed in World War I and international travel was frequent; hospitals didn’t have the same medicines and technology at their disposal to treat patients; the cause of the illness was unidentifiable and therefore a test, targeted treatment, or vaccine was impossible. During the COVID-19 pandemic, global travel came to a halt and public health measures such as social distancing and masking were implemented relatively rapidly, vaccines were produced in record time, and treatments were investigated in real-time with a few proving helpful (with more still in development). Still, misinformation and disinformation campaigns stymied the effectiveness of some of those approaches in the U.S., and the virus threw humanity a curveball with the far more transmissible Delta variant.

Predictors of mortality in thrombotic thrombocytopenia after adenoviral COVID-19 vaccination: the FAPIC score

European Heart Journal, September 21, 2021

The clinical manifestation and outcomes of thrombosis with thrombocytopenia syndrome (TTS) after adenoviral COVID-19 vaccine administration are largely unknown due to the rare nature of the disease. We aimed to analyse the clinical presentation, treatment modalities, outcomes, and prognostic factors of adenoviral TTS, as well as identify predictors for mortality. PubMed, Scopus, Embase, and Web of Science databases were searched and the resulting articles were reviewed. A total of 6 case series and 13 case reports (64 patients) of TTS after ChAdOx1 nCoV-19 vaccination were included. We performed a pooled analysis and developed a novel scoring system to predict mortality. The overall mortality of TTS after ChAdOx1 nCoV-19 vaccination was 35.9% (23/64). In our analysis, age ≤60 years, platelet count <25 × 103/µL, fibrinogen <150 mg/dL, the presence of intracerebral haemorrhage (ICH), and the presence of cerebral venous thrombosis (CVT) were significantly associated with death and were selected as predictors for mortality (1 point each). We named this novel scoring system FAPIC (fibrinogen, age, platelet count, ICH, and CVT), and the C-statistic for the FAPIC score was 0.837 (95% CI 0.732–0.942). Expected mortality increased with each point increase in the FAPIC score, at 2.08, 6.66, 19.31, 44.54, 72.94, and 90.05% with FAPIC scores 0, 1, 2, 3, 4, and 5, respectively. The FAPIC scoring model was internally validated through cross-validation and bootstrapping, then externally validated on a panel of TTS patients after Ad26.COV2.S administration. Fibrinogen levels, age, platelet count, and the presence of ICH and CVT were significantly associated with mortality in patients with TTS, and the FAPIC score comprising these risk factors could predict mortality. The FAPIC score could be used in the clinical setting to recognize TTS patients at high risk of adverse outcomes and provide early intensive interventions including intravenous immunoglobulins and non-heparin anticoagulants.

The Myocardial and Neuronal Infectivity of SARS-CoV-2 and Detrimental Outcomes

Canadian Journal of Physiology and Pharmacology, September 21, 2021

The epidemiological outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), alias COVID-19, began in Wuhan, Hubei, China, in late December and eventually turned into a pandemic that has led to 3.71+ million deaths and 173+ million infected cases worldwide. In addition to respiratory manifestations, COVID-19 patients with neurological and myocardial dysfunctions exhibit a higher risk of in-hospital mortality. The immune function tends to be affected by cardiovascular risk factors and is thus indirectly related to the prognosis of COVID-19 patients. Many neurological symptoms and manifestations have been reported in COVID-19 patients. However, detailed descriptions of the prevalence and characteristic features of these symptoms are restricted due to insufficient data. It is thus advisable for clinicians to be vigilant for both cardiovascular and neurological manifestations in order to detect them at an early stage to avoid inappropriate management of COVID-19 and to address the manifestations adequately. Patients with severe COVID-19 are notably more susceptible to developing cardiovascular and neurological complications than non-severe COVID-19 patients. This review focuses on the consequential outcomes of COVID-19 on cardiovascular and neuronal functions, including other influencing factors.

Pre-medication with oral anticoagulants is associated with better outcomes in a large multinational COVID-19 cohort with cardiovascular comorbidities

Clinical Research in Cardiology, September 21, 2021

Coagulopathy and venous thromboembolism are common findings in coronavirus disease 2019 (COVID-19) and are associated with poor outcome. Timely initiation of anticoagulation after hospital admission was shown to be beneficial. In this study we aim to examine the association of pre-existing oral anticoagulation (OAC) with outcome among a cohort of SARS-CoV-2 infected patients. We analysed the data from the large multi-national Lean European Open Survey on SARS-CoV-2 infected patients (LEOSS) from March to August 2020. Patients with SARS-CoV-2 infection were eligible for inclusion. We retrospectively analysed the association of pre-existing OAC with all-cause mortality. Secondary outcome measures included COVID-19-related mortality, recovery and composite endpoints combining death and/or thrombotic event and death and/or bleeding event. We restricted bleeding events to intracerebral bleeding in this analysis to ensure clinical relevance and to limit reporting errors. A total of 1 433 SARS-CoV-2 infected patients were analysed, while 334 patients (23.3%) had an existing premedication with OAC and 1 099 patients (79.7%) had no OAC. After risk adjustment for comorbidities, pre-existing OAC showed a protective influence on the endpoint death (OR 0.62, P = 0.013) as well as the secondary endpoints COVID-19-related death (OR 0.64, P = 0.023) and non-recovery (OR 0.66, P = 0.014). The combined endpoint death or thrombotic event tended to be less frequent in patients on OAC (OR 0.71, P = 0.056). Pre-existing OAC is protective in COVID-19, irrespective of anticoagulation regime during hospital stay and independent of the stage and course of disease.

Fear of COVID-19 in Patients with Acute Myocardial Infarction

International Journal of Environmental Research and Public Health, September 18, 2021

A marked decline in myocardial infarction (AMI) hospitalizations was observed worldwide during the COVID-19 outbreak. The pandemic may have generated fear and adverse psychological consequences in these patients, delaying hospital access. The main objective of the study was to assess COVID fear through the FCV-19S questionnaire (a self-report measure of seven items) in 69 AMI patients (65 ± 11 years, mean ± SD; 59 males). Females presented higher values of each FCV-19S item than males. Older subjects (>57 years, 25th percentile) showed a higher total score with respect to those in the first quartile. The percentage of patients who responded “agree” and “strongly agree” in item 4 (“I am afraid of losing my life because of the coronavirus”) and 3 (“My hands become clammy when I think about the coronavirus”) was significantly greater in the elderly than in younger patients. When cardiovascular (CV) patients were compared to a previously published general Italian population, patients with CV disease exhibited higher values for items 3 and 4. Measures should be put in place to assist vulnerable and high CV risk patients, possibly adding psychologists to the cardiology team.

Continuous Remote Patient Monitoring Shows Early Cardiovascular Changes in COVID-19 Patients

Journal of Clinical Medicine, September 17, 2021

COVID-19 exerts deleterious cardiopulmonary effects, leading to a worse prognosis in the most affected. This retrospective multi-center observational cohort study aimed to analyze the trajectories of key vitals amongst hospitalized COVID-19 patients using a chest-patch wearable providing continuous remote patient monitoring of numerous vital signs. The study was conducted in five COVID-19 isolation units. A total of 492 COVID-19 patients were included in the final analysis. Physiological parameters were measured every 15 min. More than 3 million measurements were collected including heart rate, systolic and diastolic blood pressure, cardiac output, cardiac index, systemic vascular resistance, respiratory rate, blood oxygen saturation, and body temperature. Cardiovascular deterioration appeared early after admission and in parallel with changes in the respiratory parameters, showing a significant difference in trajectories within sub-populations at high risk. Early detection of cardiovascular deterioration of COVID-19 patients is achievable when using frequent remote patient monitoring.

Sex defining factors influence expression of ACE2 and other SARS-CoV-2 machinery

News Medical, September 17, 2021

The angiotensin-converting enzyme 2 (ACE2) has been identified as the major functional site facilitating binding and host-cell entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The evidence of multiple risk factors for the severity of coronavirus disease 2019 (COVID-19) has been described earlier, with consistent data on male sex and its association with increased hospitalizations, ICU admissions, and deaths. A possible hypothesis for why males are disproportionally affected by COVID-19 could be the location of the ACE2 gene. The ACE2 gene is located on the X chromosome. This gene has been demonstrated to be under the influence of sex hormone regulation. Several studies indicate the positive effects of estrogen to stimulate ACE2 gene transcription and its role in regulating the Renin-Angiotensin System (RAS). The activation of RAS is known to cause hypertension, kidney and cardiovascular disorders. Hence there may be a link between the sex of an individual to the severity and post-infection sequelae in COVID-19 patients. …results from this study provided evidence for the hypothesis that sex defining factors, including sex hormones and sex chromosome complement, influence the expression of ACE2 and other SARS CoV-2 machinery (ADAM17, TMPRSS2) to favor a higher residual level of cACE2 and lower local RAS activity in females than males exposed to SARS-CoV-2 S protein. This is a significant indicator that males with risk factors like diabetes, obesity, hypertension, and cardiovascular diseases will always be at a greater risk of having severe COVID-19 infection sequelae.

Left atrial appendage orifice area and morphology is closely associated with flow velocity in patients with nonvalvular atrial fibrillation

BMC Cardiovascular Disorders, September 16, 2021

Thromboembolic events are the most serious complication of atrial fibrillation (AF), and the left atrial appendage (LAA) is the most important site of thrombosis in patients with AF. During the period of COVID-19, a non-invasive left atrial appendage detection method is particularly important in order to reduce the exposure of the virus. This study used CT three-dimensional reconstruction methods to explore the relationship between LAA morphology, LAA orifice area and its mechanical function in patients with non-valvular atrial fibrillation (NVAF). A total of 81 consecutive patients with NVAF (36 cases of paroxysmal atrial fibrillation and 45 cases of persistent atrial fibrillation) who were planned to undergo catheter radiofrequency ablation were enrolled. All patients were examined by transthoracic echocardiography (TTE), TEE, and computed tomography angiography (CTA) before surgery. The LAA orifice area was obtained according to the images of CTA. According to the left atrial appendage morphology, it was divided into chicken wing type and non-chicken wing type. At the same time, TEE was performed to determine left atrial appendage flow velocity (LAAFV), and the relationship between the left atrial appendage orifice area and LAAFV was analyzed. The LAAFV in Non-chicken wing group was lower than that in Chicken wing group (36.2 ± 15.0 cm/s vs. 49.1 ± 22.0 cm/s, p-value < 0.05). In the subgroup analysis, the LAAFV in Non-chicken wing group was lower than that in Chicken wing group in the paroxysmal AF (44.0 ± 14.3 cm/s vs. 60.2 ± 22.8 cm/s, p-value < 0.05). In the persistent AF, similar results were observed (29.7 ± 12.4 cm/s vs. 40.8 ± 17.7 cm/s, p-value < 0.05). The LAAFV in persistent AF group was lower than that in paroxysmal AF group (34.6 ± 15.8 cm/s vs. 49.9 ± 20.0 cm/s, p-value < 0.001). The LAAFV was negatively correlated with left atrial dimension (R = − 0.451, p-value < 0.001), LAA orifice area (R= − 0.438, p-value < 0.001) and left ventricular mass index (LVMI) (R= − 0.624, p-value < 0.001), while it was positively correlated with LVEF (R = 0.271, p-value = 0.014). Multiple linear regression analysis showed that LAA morphology (β = − 0.335, p-value < 0.001), LAA orifice area (β = −  0.185, p-value = 0.033), AF type (β = − 0.167, p-value = 0.043) and LVMI (β = − 0.465, p-value < 0.001) were independent factors of LAAFV. Read conclusions.

Microbiota and Myopericarditis: The New Frontier in the Car-Diological Field to Prevent or Treat Inflammatory Cardiomyo-Pathies in COVID-19 Outbreak

Biomedicines, September 16, 2021

Myopericarditis is an inflammatory heart condition involving the pericardium and myocardium. It can lead to heart failure, dilated cardiomyopathy, arrhythmia and sudden death. Its pathogenesis is mainly mediated by viral infections but also can be induced by bacterial infections, toxic substances and immune mediated disorders. All these conditions can produce severe inflammation and myocardial injury, often associated with a poor prognosis. The specific roles of these different pathogens (in particular viruses), the interaction with the host, the interplay with gut microbiota, and the immune system responses to them are still not completely clear and under investigation. Interestingly, some research has demonstrated the contribution of the gut microbiota, and its related metabolites (some of which can mimic the cardiac myosin), in cardiac inflammation and in the progression of this disease. They can stimulate a continuous and inadequate immune response, with a subsequent myocardial inflammatory damage. The aim of our review is to investigate the role of gut microbiota in myopericarditis, especially for the cardiovascular implications of COVID-19 viral infection, based on the idea that the modulation of gut microbiota can be a new frontier in the cardiological field to prevent or treat inflammatory cardiomyopathies.

Heart Failure’s ‘Golden Moment’ Not Translating into Better Health

MedPage Today, September 12, 2021

Cardiology leaders complained that heart failure specialists may know how to treat their patients and to employ the latest therapies, but their actual reach is stunted by poor implementation within the wasteful U.S. healthcare system. It sounds like a tale of two cities: The COVID-19 pandemic continues to overwhelm patients and healthcare workers across the country; at the same time, heart failure patients are enjoying more therapies than ever, with new SGLT2 inhibitors hitting the market and sacubitril/valsartan (Entresto) use expanding to the historically hard-to-treat population of patients with preserved ejection fraction. Yet these advances are not being put into practice to improve the lives of many people in the U.S. “The heart failure ecosystem is full of well-intentioned people, but the way it operates, like the U.S. healthcare business in general, creates a very unusual situation where the whole is much less than the sum of its parts,” said former FDA commissioner Robert Califf, MD, now of Verily Life Sciences and Google Health, during a plenary session at the Heart Failure Society of America (HFSA) meeting held both virtually and in Denver. Califf said the heart failure field is “in one of its golden moments” amid what he called the “abject failure” of the U.S. healthcare system. “No one can argue that COVID didn’t make evidently clear the depth of health disparity in the U.S. We learned it is place that matters as much as race,” said Clyde Yancy, MD, of Northwestern University Feinberg School of Medicine in Chicago, during the HFSA session. “Achieving health equity is like treating heart failure,” Yancy said. He quoted Winston Churchill: “Success consists of going from failure to failure without loss of enthusiasm. We have done that well in heart failure. We need to do the same to achieve health equity,” he urged.

Resistant hypertension and COVID-19: tip of the iceberg?

Journal of Human Hypertension, September 10, 2021

Since the outbreak of COVID-19 pandemic many epidemiological studies revealed that common cardiovascular risk factors are frequently seen in these patients, but it was not clear which of them represented an independent predictor of adverse outcomes including mortality. Data coming from China indicated that arterial hypertension might be responsible for worse outcome irrespective of other risk factors and comorbidities, including age, diabetes, coronary artery disease, and renal dysfunction. However, this was not confirmed in studies and some authors claimed that this relationship was a consequence of other confounding factors that frequently meet in hypertensive patients, including antihypertensive treatment, which was at the early stage of pandemic considered responsible for increased admissions in intensive care unit and even higher mortality. This mainly referred to angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor II blockers (ARBs). However, many studies and meta-analysis that followed the first false alarm dismissed any relation between the aforementioned drug classes and cardiac injury and adverse outcomes in COVID-19 patients. Moreover, investigations showed the beneficial effect of ACEIs and ARBs on the outcome in COVID-19 patients. Many questions still remained unanswered. In this issue of the Journal, Işik et al. investigated the influence of resistant arterial hypertension on in-hospital mortality in large cohort of COVID-19 patients. The authors used the definition of the American Heart Association for resistant arterial hypertension. Therefore, resistant hypertension was diagnosed in all patients with blood pressure (BP) ≥ 130/80 mmHg who were treated with three antihypertensive drugs including a diuretic or reached <130/80 mmHg with at least four antihypertensive medications. The influence of resistant hypertension on outcomes in COVID-19 patients has not been investigated so far. In the present study the mortality of COVID-19 was surprisingly high (18.7%) in the whole population of 1897 patients. Interestingly, there were no many significant differences in demographic and clinical characteristics between regulated and resistant hypertensive patients. The patients with resistant hypertension had higher prevalence of heart failure and, by definition, higher percentage of different antihypertensive medications than their controlled counterparts.

Heart transplantation in the era of COVID-19 pandemic: delirium, post-transplant depression and visitor restrictions The role of liaison and inpatient psychosomatic treatment. A case report

European Heart Journal – Case Reports, September 9, 2021

Heart transplant recipients show a high risk of developing major depression with an increased risk of post-transplant morbidity and mortality. Heart transplant specialists and patients face unprecedented challenges during the COVID-19 pandemic, which have enormous clinical implications such as increased risk of COVID-19 as well as visitor restrictions with social isolation during the post-transplant inpatient treatment. We present a case of a 64-year-old woman with end-stage heart failure caused by noncompaction cardiomyopathy who received an orthotopic heart transplant (OHT) without any intraoperative complications. Postoperatively, she showed acute psychotic symptoms in the ICU with improvement after switching intravenous tacrolimus treatment to an oral intake. Furthermore, the patient developed severe depressive symptoms with malnutrition and had a prolonged hospitalization. Standard medical care was complemented by intensive psychocardiological treatment to overcome the crisis. High complexity of the post-transplant management after OHT underlines the importance of multidisciplinary teamwork, involving heart transplant specialist and allied mental health professionals. This collaboration led to an excellent long-term result. Facing the COVID-19 pandemic, the hospital visitor policies may be scrutinized, carefully looking at the role of social isolation, postoperative experience in the ICU, and medical complications after OHT.

Case Report of Cardiogenic Shock Secondary to Covid-19 Myocarditis: Peculiarities on Diagnosis, Histology and Treatment

European Heart Journal – Case Reports, September 9, 2021

The year 2020 was dramatically characterized by SARS-CoV-2 pandemic outbreak. COVID-19-related heart diseases and myocarditis have been reported. A 45-year-old healthy male was admitted to the intensive care unit of our hospital because of cardiogenic shock. A diagnosis of COVID-19 infection and myocarditis was done. We present here several peculiarities about diagnostic workup, myocardial histological findings, choice of treatment and the patient clinical course at three and eight-months of follow-up. COVID-19 myocardial damage and myocarditis are mainly linked to the cytokine storm with mild myocardial inflammatory infiltrate and very unusual platelet microclots in the setting of the microvascular obstructive thrombo-inflammatory syndrome. Counteracting the inflammatory burden with an interleukine-1 inhibitor appeared safe and led to a dramatic and stable improvement of cardiac function.

Metoprolol in Critically Ill Patients With COVID-19

Journal of the American College of Cardiology, September 7, 2021

Severe COVID-19 can progress to an acute respiratory distress syndrome (ARDS), which involves alveolar infiltration by activated neutrophils. The beta-blocker metoprolol has been shown to ameliorate exacerbated inflammation in the myocardial infarction setting. The purpose of this study was to evaluate the effects of metoprolol on alveolar inflammation and on respiratory function in patients with COVID-19–associated ARDS. A total of 20 COVID-19 patients with ARDS on invasive mechanical ventilation were randomized to metoprolol (15 mg daily for 3 days) or control (no treatment). All patients underwent bronchoalveolar lavage (BAL) before and after metoprolol/control. The safety of metoprolol administration was evaluated by invasive hemodynamic and electrocardiogram monitoring and echocardiography. Metoprolol administration was without side effects. At baseline, neutrophil content in BAL did not differ between groups. Conversely, patients randomized to metoprolol had significantly fewer neutrophils in BAL on day 4 (median: 14.3 neutrophils/µl [Q1, Q3: 4.63, 265 neutrophils/µl] vs median: 397 neutrophils/µl [Q1, Q3: 222, 1,346 neutrophils/µl] in the metoprolol and control groups, respectively; P = 0.016). Metoprolol also reduced neutrophil extracellular traps content and other markers of lung inflammation. Oxygenation (PaO2:FiO2) significantly improved after 3 days of metoprolol treatment (median: 130 [Q1, Q3: 110, 162] vs median: 267 [Q1, Q3: 199, 298] at baseline and day 4, respectively; P = 0.003), whereas it remained unchanged in control subjects. Metoprolol-treated patients spent fewer days on invasive mechanical ventilation than those in the control group (15.5 ± 7.6 vs 21.9 ± 12.6 days; P = 0.17). In this pilot trial, intravenous metoprolol administration to patients with COVID-19–associated ARDS was safe, reduced exacerbated lung inflammation, and improved oxygenation. Repurposing metoprolol for COVID-19–associated ARDS appears to be a safe and inexpensive strategy that can alleviate the burden of the COVID-19 pandemic.

Prevalence of right ventricular dysfunction and impact on all-cause death in hospitalized patients with COVID-19: a systematic review and meta-analysis

Scientific Reports, September 7, 2021

The Coronavirus Disease (COVID-19) pandemic imposed a high burden of morbidity and mortality. In COVID-19, direct lung parenchymal involvement and pulmonary microcirculation dysfunction may entail pulmonary hypertension (PH). PH and direct cardiac injury beget right ventricular dysfunction (RVD) occurrence, which has been frequently reported in COVID-19 patients; however, the prevalence of RVD and its impact on outcomes during COVID-19 are still unclear. This study aims to evaluate the prevalence of RVD and associated outcomes in patients with COVID-19, through a Systematic Review and Meta-Analysis. MEDLINE and EMBASE were systematically searched from inception to 15th July 2021. All studies reporting either the prevalence of RVD in COVID-19 patients or all-cause death according to RVD status were included. The pooled prevalence of RVD and Odds Ratio (OR) for all-cause death according to RVD status were computed and reported. Subgroup analysis and meta-regression were also performed. Among 29 studies (3813 patients) included, pooled prevalence of RVD was 20.4% (95% CI 17.1–24.3%; 95% PI 7.8–43.9%), with a high grade of heterogeneity. No significant differences were found across geographical locations, or according to the risk of bias. Severity of COVID-19 was associated with increased prevalence of RVD at meta-regression. The presence of RVD was found associated with an increased likelihood of all-cause death (OR 3.32, 95% CI 1.94–5.70). RVD was found in 1 out of 5 COVID-19 patients, and was associated with all-cause mortality. RVD may represent one crucial marker for prognostic stratification in COVID-19; further prospective and larger are needed to investigate specific management and therapeutic approach for these patients.

Spatio-temporal hybrid neural networks reduce erroneous human “judgement calls” in the diagnosis of Takotsubo syndrome

EClinicalMedicine, September 4, 2021

We investigate whether deep learning (DL) neural networks can reduce erroneous human “judgment calls” on bedside echocardiograms and help distinguish Takotsubo syndrome (TTS) from anterior wall ST segment elevation myocardial infarction (STEMI). We developed a single-channel (DCNN[2D SCI]), a multi-channel (DCNN[2D MCI]), and a 3-dimensional (DCNN[2D+t]) deep convolution neural network, and a recurrent neural network (RNN) based on 17,280 still-frame images and 540 videos from 2-dimensional echocardiograms in 10 years (1 January 2008 to 1 January 2018) retrospective cohort in University of Iowa (UI) and eight other medical centers. Echocardiograms from 450 UI patients were randomly divided into training and testing sets for internal training, testing, and model construction. Echocardiograms of 90 patients from the other medical centers were used for external validation to evaluate the model generalizability. A total of 49 board-certified human readers performed human-side classification on the same echocardiography dataset to compare the diagnostic performance and help data visualization. The DCNN (2D SCI), DCNN (2D MCI), DCNN(2D+t), and RNN models established based on UI dataset for TTS versus STEMI prediction showed mean diagnostic accuracy 73%, 75%, 80%, and 75% respectively, and mean diagnostic accuracy of 74%, 74%, 77%, and 73%, respectively, on the external validation. DCNN(2D+t) (area under the curve [AUC] 0·787 vs. 0·699, P = 0·015) and RNN models (AUC 0·774 vs. 0·699, P = 0·033) outperformed human readers in differentiating TTS and STEMI by reducing human erroneous judgement calls on TTS. Spatio-temporal hybrid DL neural networks reduce erroneous human “judgement calls” in distinguishing TTS from anterior wall STEMI based on bedside echocardiographic videos.

Association of renin–angiotensin system blockers with COVID-19 diagnosis and prognosis in patients with hypertension: a population-based study

Clinical Kidney Journal, September 3, 2021

The effect of renin-angiotensin (RAS) blockade either by angiotensin-converting enzyme inhibitors (ACEi) or angiotensin-receptor blockers (ARBs) on coronavirus disease 2019(COVID-19) susceptibility, mortality and severity is inadequately described. We examined the association between renin-angiotensin system (RAS) blockade and COVID-19 diagnosis and prognosis in a large population-based cohort of patients with hypertension. This is a cohort study using regional health records. We identified all individuals aged 18-95 years from 87 health care reference areas of the main health provider in Catalonia (Spain), with a history of hypertension from primary care records. Data were linked to COVID-19 test results, hospital, pharmacy and mortality records from 1 March 2020 to 14 August 2020. We defined exposure to RAS blockers as the dispensation of ACEi/ARBs during the three months before COVID-19 diagnosis or 1 March 2020. Primary outcomes were: COVID-19 infection, and severe progression in hospitalized patients with COVID-19(the composite of need for invasive respiratory support or death). For both outcomes and for each exposure of interest (RAAS blockade, ACEi or ARB) we estimated associations in age-sex-area-propensity matched samples. From a cohort of 1,365,215 inhabitants we identified 305,972 patients with hypertension history. Recent use of ACEi/ARBs in patients with hypertension was associated with a lower 6 month-cumulative incidence of COVID-19 diagnosis (3.78% [95% CI: 3.69% – 3.86%] vs 4.53% [95% CI: 4.40% – 4.65%]; p < 0.001). In the 12,344 patients with COVID-19 infection, the use of ACEi/ARBs was not associated with a higher risk of hospitalization with need for invasive respiratory support or death (OR = 0.91 (0.71 – 1.15); p = 0.426).

Mobile health and cardiac arrhythmias: patient self-management in digital care pathways

European Journal of Cardiovascular Nursing, September 2, 2021

The use of technology in cardiovascular care has emerged significantly over the last decade. This includes telemedicine and cardiac monitoring devices to remotely monitor and manage cardiac conditions, as well as the use of activity trackers and educational applications to support a healthy lifestyle and to activate and support patients in self-management of their condition. The COVID-19 global pandemic accelerated the uptake of these technologies, given that numerous interventions and models of care delivery were converted from face-to-face into virtual and remote models of care using digital healthcare solutions. Patient roles have changed from passively receiving treatment, to actively being involved in their care process, treatment decisions and being an active member of the treatment team. Co-design methodologies are required to develop novel approaches incorporating the aims and requirements from the perspective of healthcare professionals but equally important, the needs, values, and preferences of the patients involved in this. In clinical practice, such co-design methodologies are referred to as shared decision-making, which plays an important role in the management of patients with chronic conditions such as atrial fibrillation (AF). A recent study published in the European Journal of Cardiovascular Nursing, stated that patients with symptomatic AF may experience severe symptoms such as palpitations, shortness of breath, and chest pain, which can be scary, and the emotional stress may even worsen or trigger episodes of AF. This study included 821 women who had symptomatic palpitations were provided a handheld electrocardiogram (ECG), which was connected to their smartphone for a 60-day period. Participants were instructed to record an ECG twice a day and in case of symptoms and received immediate responses based on an automated algorithm interpretation. Most recordings demonstrated sinus rhythm or premature atrial/ventricular contractions, and only 6% demonstrated AF. Using validated questionnaires, it was demonstrated that anxiety and depression levels decreased significantly. Interestingly and contrastingly, the frequency and severity of symptoms improved, which resulted in the improved quality of life. This demonstrates the huge potential of technology on the wellbeing of patients by providing direct feedback on heart rate and rhythm as an integrated part of a comprehensive care approach.

COVID-19 pandemic and cardiovascular disease: the double sentence

European Journal of Preventive Cardiology, September 1, 2021

Coronavirus disease 2019 (COVID-19) pandemic affected every level of our healthcare systems, especially hospitals, which faced a huge human and logistical burden. To face the exponential growth of COVID-19 patients, national or local authorities declared lockdowns and urged people to avoid seeking medical care for unnecessary situations. This translated into reductions of hospital admissions, including for acute problems such as myocardial infarctions. During the first lockdown, for instance, studies reported a ∼20–30% decrease in admissions for myocardial infarction in France or Denmark. In New Zealand, despite a low incidence rate of COVID-19 infections during the first wave, hospitalizations for acute coronary syndrome also decreased by 28%, especially due to fewer admissions for non-ST-segment elevation acute coronary syndromes. It is also noteworthy that rates of admission for acute coronary syndromes during COVID-19 pandemic were comparable to pre-pandemic levels in countries that established strict controls of the epidemics. Reasons for the reduction in admissions for acute coronary syndromes are probably multifactorial, but less engagement in stressful situations due to lockdown is a frequently proposed explanation. Beyond admission rates during a pandemic situation, there remains the question of the fate of patients still admitted, especially those hospitalized with cardiovascular diseases that account for a large proportion of admissions. Cannata et al. report in the Journal the results of a meta-analysis comprising studies investigating in-hospital mortality of people admitted with cardiovascular disease but without severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during the first wave of the pandemic compared to a pre-pandemic period. Comprising data from more than 27 000 individuals, their study showed a 62% higher risk (relative risk) of in-hospital mortality during the pandemic period. In absolute numbers, mortality amounted to 10.4% during the COVID-19 first wave compared to 5.7% during the pre-pandemic period.

Types of myocardial injury and mid-term outcomes in patients with COVID-19

European Heart Journal – Quality of Care and Clinical Outcomes, August 30, 2021

Our aim was to evaluate the acute and chronic patterns of myocardial injury among patients with coronavirus disease-2019 (COVID-19), and their mid-term outcomes. Patients with laboratory-confirmed COVID-19 who had a hospital encounter within the Mount Sinai Health System (New York City) between 27 February 2020 and 15 October 2020 were evaluated for inclusion. Troponin levels assessed between 72 h before and 48 h after the COVID-19 diagnosis were used to stratify the study population by the presence of acute and chronic myocardial injury, as defined by the Fourth Universal Definition of Myocardial Infarction. Among 4695 patients, those with chronic myocardial injury (n = 319, 6.8%) had more comorbidities, including chronic kidney disease and heart failure, while acute myocardial injury (n = 1168, 24.9%) was more associated with increased levels of inflammatory markers. Both types of myocardial injury were strongly associated with impaired survival at 6 months [chronic: hazard ratio (HR) 4.17, 95% confidence interval (CI) 3.44–5.06; acute: HR 4.72, 95% CI 4.14–5.36], even after excluding events occurring in the first 30 days (chronic: HR 3.97, 95% CI 2.15–7.33; acute: HR 4.13, 95% CI 2.75–6.21). The mortality risk was not significantly different in patients with acute as compared with chronic myocardial injury (HR 1.13, 95% CI 0.94–1.36), except for a worse prognostic impact of acute myocardial injury in patients <65 years of age (P-interaction = 0.043) and in those without coronary artery disease (P-interaction = 0.041). Chronic and acute myocardial injury represent two distinctive patterns of cardiac involvement among COVID-19 patients. While both types of myocardial injury are associated with impaired survival at 6 months, mortality rates peak in the early phase of the infection but remain elevated even beyond 30 days during the convalescent phase.

Risk prediction in patients with COVID-19 based on haemodynamic assessment of left and right ventricular function

European Heart Journal – Cardiovascular Imaging, August 28, 2021

Cardiovascular involvement is common in COVID-19. We sought to describe the haemodynamic profiles of hospitalized COVID-19 patients and determine their association with mortality. Consecutive hospitalized patients diagnosed with COVID-19 infection underwent clinical evaluation using the Modified Early Warning Score (MEWS) and a full non-invasive echocardiographic haemodynamic evaluation, irrespective of clinical indication, as part of a prospective predefined protocol. Patients were stratified based on filling pressure and output into four groups. Multivariable Cox-Hazard analyses determined the association between haemodynamic parameters with mortality. Among 531 consecutive patients, 44% of patients had normal left ventricular (LV) and right ventricular (RV) haemodynamic status. In contrast to LV haemodynamic parameters, RV parameters worsened with higher MEWS stage. While RV parameters did not have incremental risk prediction value above MEWS, LV stroke volume index, E/e′ ratio, and LV stroke work index were all independent predictors of outcome, particularly in severe disease. Patients with LV or RV with high filling pressure and low output had the worse outcome, and patients with normal haemodynamics had the best (P < 0.0001). In hospitalized patients with COVID-19, almost half have normal left and right haemodynamics at presentation. RV but not LV haemodynamics are related to easily obtainable clinical parameters. LV but not RV haemodynamics are independent predictors of mortality, mostly in patients with severe disease.

Comparison of Outcomes in Patients with COVID-19 and Thrombosis vs. Those Without Thrombosis

American Journal of Cardiology, August 28, 2021

Venous thromboembolism (VTE) in coronavirus disease 2019 (COVID-19) has been established. We sought to evaluate the clinical impact of thrombosis in COVID-19-positive patients over the span of the pandemic to date. We analyzed COVID-19-positive patients with the diagnosis of thrombosis who presented to the MedStar Health system (11 hospitals in Washington, DC, and Maryland) during the pandemic (March 1, 2020 – March 31, 2021). We compared clinical course and outcomes based on the presence or absence of thrombosis and then, specifically, cardiac thrombosis. The cohort included 11,537 COVID-19-positive admitted patients. Of these patients, 1,248 had non-cardiac thrombotic events and 1,009 had cardiac thrombosis (myocardial infarction) during their hospital admission. Of the non-cardiac thrombotic events, 562 (45.0%) were pulmonary embolism, 480 (38.5%) were deep venous thromboembolism, and 347 (27.8%) were stroke. In the thrombosis arm, the cohort’s mean age was 64.5 ± 15.3 years, 53.3% were men, and a majority were African American (64.9%). Patients with thrombosis tended to be older, with more co-morbidities. In-hospital mortality was significantly higher (16.0%) in COVID-19-positive patients with concomitant thrombosis versus those without thrombosis (7.9%; p <0.001) but lower than in COVID-19-positive patients with cardiac thrombosis (24.7%; p <0.001). In conclusion, COVID-19 patients with thrombosis are at higher risk for in-hospital mortality. However, this prognosis is not as grim as cardiac thrombosis. Efforts should focus on early recognition, evaluation, and intensifying antithrombotic management of these patients.

COVID-19 and ROS Storm: What is the Forecast for Hypertension

American Journal of Hypertension, August 25, 2021

As of 12 May 2021, the Center for Disease Control data tracker reports that more than 32 million Americans were infected with the SARS-CoV-2 virus. The death toll of the ongoing COVID-19 pandemic has surpassed the mark of 580,000, and despite the recent availability of vaccines, it continues to increase on American soil, though at a lower rate. Unfortunately, the full impact of the disease is not yet reflected in many countries, such as Brazil and India, where all victims may not be fully accounted for, and which are battling the virus and witnessing a disproportional toll on their citizens. While our understanding of COVID-19 has drastically improved since its first case in Wuhan (Hubei Province, China), there is still a myriad of open questions regarding the pathophysiology of this disease. Cumulative evidence, however, suggests that patients with cardiometabolic diseases are at a greater risk of developing the severe form of COVID-19, but the specific contribution of each disrupted pathway is unclear. Previous studies highlighted the significance of a cytokine storm to the severity of SARS-CoV-2 infection, and more recently, the possibility of another storm, the bradykinin one, also contributing to the widespread tissue damage observed in some COVID-19 patients, involving those with hypertension comorbidity. Under these unprecedented conditions, there is yet, another equally relevant, still overlooked, storm on the forecast for hypertension: the reactive oxygen species (ROS) storm. ROS are signaling molecules that exert critical biological roles. Conversely, dysregulated ROS production, leading to oxidative stress, contributes to the pathophysiology of several diseases, including hypertension. While different mechanisms could trigger the generation of ROS, it is widely accepted that NADPH oxidase is a main source of these molecules, and not surprisingly, the expression levels of this enzyme are altered during hypertension.

Arterial Hypertension and Diabetes Mellitus in COVID-19 Patients: What Is Known by Gender Differences?

Journal of Clinical Medicine, August 23, 2021

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has infected >160 million people around the world. Hypertension (HT), chronic heart disease (CHD), and diabetes mellitus (DM) increase susceptibility to SARS-CoV-2 infection. Aims. We designed this retrospective study to assess the gender differences in hypertensive diabetic SARS-CoV-2 patients. We reported data, by gender differences, on the inflammatory status, on the hospital stays, intensive care unit (ICU) admission, Rx and CT report, and therapy. Methods. We enrolled 1014 patients with confirmed COVID-19 admitted into different Hospitals of Campania from 26 March to 30 June, 2020. All patients were allocated into two groups: diabetic-hypertensive group (DM-HT group) that includes 556 patients affected by diabetes mellitus and arterial hypertension and the non-diabetic- non-hypertensive group (non-DM, non-HT group) comprising 458 patients. The clinical outcomes (i.e., discharges, mortality, length of stay, therapy, and admission to intensive care) were monitored up to June 30, 2020. Results. We described, in the DM-HT group, higher proportion of cardiopathy ischemic (CHD) (47.5% vs. 14.8%, respectively; p < 0.0001) and lung diseases in females compared to male subjects (34.8% vs. 18.5%, respectively; p < 0.0001). In male subjects, we observed higher proportion of kidney diseases (CKD) (11% vs. 0.01%, respectively; p < 0.0001), a higher hospital stay compared to female subjects (22 days vs. 17 days, respectively, p < 0.0001), a higher admission in ICU (66.9% vs. 12.8%, respectively, p < 0.0001), and higher death rate (17.3% vs. 10.7%, respectively, p < 0.0001). Conclusion. These data confirm that male subjects, compared to female subjects, have a higher hospital stay, a higher admission to ICU, and higher death rate.

The Effects of Reduced Physical Activity on the Lipid Profile in Patients with High Cardiovascular Risk during COVID-19 Lockdown

International Journal of Environmental Research and Public Health, August 23, 2021

The COVID-19 pandemic is a serious global health problem. In Italy, to limit the infections, the government ordered lockdown from March 2020. This measure, designed to contain the virus, led to serious limitations on the daily life of the individuals it affected, and in particular in the limitation of physical exercise. The aim of this study was to evaluate the effects of reduced physical activity on the lipid profile in patients with high cardiovascular risk. We enrolled 38 dyslipidemic patients, 56% male, with an age range of 44–62 years, considered to be at high cardiovascular risk. All patients were prescribed statin drug therapy (atorvastatin 40 mg) and a vigorous physical activity program four times a week, 1 h per session. In addition, a personalized Mediterranean diet was prescribed to all the patients. Total cholesterol, LDL, HDL and triglycerides were measured in patients at T0 before lockdown and at T1 during lockdown. Data showed a significant increase (p < 0.01) in total cholesterol (+6,8%) and LDL (+15,8%). Furthermore, the analysis of the data revealed a reduction in HDL (−3%) and an increase in triglycerides (+3,2%), although both were not significant (p > 0.05). Our study showed that the reduction in physical activity during lockdown led to an increase in LDL levels, and therefore, in the risk of ischemic heart disease in dyslipidemic patients with high cardiovascular risk.

Prevalence and Prognostic Value of Myocardial Injury in the Initial Presentation of SARS-CoV-2 Infection among Older Adults

Journal of Clinical Medicine, August 23, 2021

Myocardial involvement during SARS-CoV-2 infection has been reported in many prior publications. We aim to study the prevalence and the clinical implications of acute myocardial injury (MIN) during SARS-CoV-2 infection, particularly in older patients. The method includes a longitudinal observational study with all consecutive adult patients admitted to a COVID-19 unit between March–April 2020. Those aged ≥65 were considered as older adult group. MIN was defined as at least 1 high-sensitive troponin (hs-TnT) concentration above the 99th percentile upper reference limit with different sex-cutoff. Results. Among the 634 patients admitted during the period of observation, 365 (58%) had evidence of MIN, and, of them, 224 (61%) were older adults. Among older adults, MIN was associated with longer time to recovery compared to those without MIN (13 days (IQR 6-21) versus 9 days (IQR 5-17); p < 0.001, respectively. In-hospital mortality was significantly higher in older adults with MIN at admission versus those without it (71 (31%) versus 11 (12%); p < 0.001). In a logistic regression model adjusting by age, sex, severity, and Charlson Comorbidity Index, the OR for in-hospital mortality was 2.1 (95% CI: 1.02–4.42; p = 0.043) among those older adults with MIN at admission. Older adults with acute myocardial injury had greater time to clinical recovery, as well as higher odds of in-hospital mortality.

COVID-19 and Cardiovascular Disease: a Global Perspective

Current Cardiology Reports, August 19, 2021

It has already been more than one year since the novel coronavirus disease 2019 (COVID-19), officially known as SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2), pandemic has started, and surely it has become a remarkable challenge for healthcare systems around the world. This review aims to assess the global impact of the COVID-19 pandemic on the cardiovascular diseases (CVDs), trying to assess the possible future trajectory of the CVDs and their management. The COVID-19 pandemic has had a deleterious impact on the CV risk factors, with an increase in both sedentary and unhealthy food habits. The fear of contagion has decreased the access to the emergency systems with an increase in out-of-hospital-cardiac-arrests and late presentation of acute myocardial infarctions. The closure of the non-urgent services has delayed cardiac rehabilitation programmes and chronic clinical care. As a result of the COVID-19 pandemic impact on the population habits and on the management of CVDs, we will probably face an increase in CVD and heart failure cases. It is crucial to use all the non-traditional approaches, such as telemonitoring systems, in order to overcome the difficulties raised by the pandemic.

The use of remote monitoring of cardiac implantable devices during the COVID-19 pandemic: an EHRA physician survey

EP Europace, August 19, 2021

It is unclear to what extent the COVID-19 pandemic has influenced the use of remote monitoring (RM) of cardiac implantable electronic devices (CIEDs). The present physician-based European Heart Rhythm Association (EHRA) survey aimed to assess the influence of the COVID-19 pandemic on RM of CIEDs among EHRA members and how it changed the current practice. The survey comprised 27 questions focusing on RM use before and during the pandemic. Questions focused on the impact of COVID-19 on the frequency of in-office visits, data filtering, reasons for initiating in-person visits, underutilization of RM during COVID-19, and RM reimbursement. A total of 160 participants from 28 countries completed the survey. Compared to the pre-pandemic period, there was a significant increase in the use of RM in patients with pacemakers (PMs) and implantable loop recorders (ILRs) during the COVID-19 pandemic (PM 24.2 vs. 39.9%, P = 0.002; ILRs 61.5 vs. 73.5%, P = 0.028), while there was a trend towards higher utilization of RM for cardiac resynchronization therapy-pacemaker (CRT-P) devices during the pandemic (44.5 vs. 55%, P = 0.063). The use of RM with implantable cardioverter-defibrillators (ICDs) and CRT-defibrillator (CRT-D) did not significantly change during the pandemic (ICD 65.2 vs. 69.6%, P = 0.408; CRT-D 65.2 vs. 68.8%, P = 0.513). The frequency of in-office visits was significantly lower during the pandemic (P < 0.001). Nearly two-thirds of participants (57 out of 87 respondents), established new RM connections for CIEDs implanted before the pandemic with 33.3% (n = 29) delivering RM transmitters to the patient’s home address, and the remaining 32.1% (n = 28) activating RM connections during an in-office visit. The results of this survey suggest that the crisis caused by COVID-19 has led to a significant increase in the use of RM of CIEDs.

Epicardial ablation of ventricular tachycardia in patients with structural heart disease: a single-centre experience over 12 years

EP Europace, August 18, 2021

Epicardial ablation has risen to an essential part of the treatment of ventricular tachycardias (VTs). In this study, we report the efficacy, risks, and current trends of epicardial ablation in structural heart disease as reported in a tertiary single centre over a 12-year period. Two hundred and thirty-six patients referred for VT ablation underwent a successful epicardial access and were included in the analysis (89% non-ischaemic cardiomyopathy, 90% males, mean age 60 years, mean left ventricular ejection fraction 38.4%). After performing epicardial ablation the clinical VTs were eliminated in 87% of the patients and 71% of the cohort achieved freedom from VT during 22-month follow-up. Twelve patients (5%) suffered major procedure-related complications. Until the end of follow-up 47 (20%) patients died, 9 (4%) underwent a left ventricular assist device implantation and 10 (4%) patients received a heart transplantation. Antiarrhythmic drugs at baseline and during follow-up were independent predictors of VT recurrence. Atrial fibrillation, renal dysfunction, worse New York Heart Association class, and antiarrhythmic drugs at follow-up were associated with worse survival in our cohort. In this large tertiary single-centre experience, percutaneous epicardial access was feasible in the large majority of the cohort with acceptably low complications rates. A combined endo-/epicardial approach resulted in 87% acute and 71% long-term success. Further studies are needed to clarify the role of routine combined endo-/epicardial ablation in these complex cardiomyopathies.

Cardiovascular Disease Complicating COVID-19 in the Elderly

Medicina, August 17, 2021

SARS-CoV-2, a single-stranded RNA coronavirus, causes an illness known as coronavirus disease 2019 (COVID-19). The highly transmissible virus gains entry into human cells primarily by the binding of its spike protein to the angiotensin-converting enzyme 2 receptor, which is expressed not only in lung tissue but also in cardiac myocytes and the vascular endothelium. Cardiovascular complications are frequent in patients with COVID-19 and may be a result of viral-associated systemic and cardiac inflammation or may arise from a virus-induced hypercoagulable state. This prothrombotic state is marked by endothelial dysfunction and platelet activation in both macrovasculature and microvasculature. In patients with subclinical atherosclerosis, COVID-19 may incite atherosclerotic plaque disruption and coronary thrombosis. Hypertension and obesity are common comorbidities in COVID-19 patients that may significantly raise the risk of mortality. Sedentary behaviors, poor diet, and increased use of tobacco and alcohol, associated with prolonged stay-at-home restrictions, may promote thrombosis, while depressed mood due to social isolation can exacerbate poor self-care. Telehealth interventions via smartphone applications and other technologies that document nutrition and offer exercise programs and social connections can be used to mitigate some of the potential damage to heart health.

Clinical Characteristics and Outcomes of Hypertensive Patients Infected with COVID-19: A Retrospective Study

International Journal of General Medicine, August 17, 2021

Hypertension has been reported as the most prevalent comorbidity in patients with coronavirus disease 2019 (COVID-19). This retrospective study aims to compare the clinical characteristics and outcomes in COVID-19 patients with or without hypertension. A total of 944 hospitalized patients with laboratory-confirmed COVID-19 were included from January to March 2020. Information from the medical record, including clinical features, radiographic and laboratory results, complications, treatments, and clinical outcomes, were extracted for the analysis. A total of 311 (32.94%) patients had comorbidity with hypertension. In COVID-19 patients with hypertension, the coexistence of type 2 diabetes (56.06% vs 43.94%), coronary heart disease (65.71% vs 34.29%), poststroke syndrome (68.75% vs 31.25%) and chronic kidney diseases (77.78% vs 22.22%) was significantly higher, while the coexistence of hepatitis B infection (13.04% vs 86.96%) was significantly lower than in COVID-19 patients without hypertension. Computed tomography (CT) chest scans show that COVID-19 patients with hypertension have higher rates of pleural effusion than those without hypertension (56.60% vs 43.40%). In addition, the levels of blood glucose [5.80 (IQR, 5.05– 7.50) vs 5.39 (IQR, 4.81– 6.60)], erythrocyte sedimentation rate (ESR) [28 (IQR, 17.1– 55.6) vs 21.8 (IQR, 11.5– 44.1), P=0.008], C-reactive protein (CRP) [17.92 (IQR, 3.11– 46.6) vs 3.15 (IQR, 3.11– 23.4), P=0.013] and serum amyloid A (SAA) [99.28 (IQR, 8.85– 300) vs 15.97 (IQR, 5.97– 236.1), P=0.005] in COVID-19 patients with hypertension were significantly higher than in patients without hypertension. It is common for patients with COVID-19 to have the coexistence of hypertension, type 2 diabetes, coronary heart disease and so on, which may exacerbate the severity of COVID-19.

COVID-19 may affect long-term ‘fight or flight’ response in young adults

Medical News Today, August 16, 2021

Around a third of otherwise healthy people who have recovered from mild COVID-19 experience the lingering symptoms of long COVID. The most common symptoms include fatigue and shortness of breath, but some individuals also report heart palpitations. This may be a sign that their “autonomic nervous system” is out of balance. The two wings of the autonomic nervous system act together automatically to regulate vital functions such as heart rate and breathing. When the body perceives a life threatening situation, the sympathetic nervous system increases heart rate and breathing rate, a reaction that people call the “fight-or-flight response.” By contrast, the parasympathetic nervous system restores the body to a more stable, restful state, known as “rest and digest.” Individuals with hypertension (high blood pressure), diabetes, and obesity often have increased activity in their sympathetic nervous system, which COVID-19 may exacerbate. For the first time, researchers have now assessed sympathetic nerve activity in otherwise healthy young people recovering from the infection. They ran a series of tests on 16 individuals aged approximately 20 years old who had tested positive for SARS-CoV-2, the virus that causes COVID-19, around 35 days previously. Before the pandemic, the scientists carried out identical tests on an age-matched group of 14 healthy volunteers, who served as controls. The tests revealed changes in the sympathetic nervous system of people recovering COVID-19, both at rest and in response to a stress test. There were also differences in heart rate and sympathetic nerve activity in a test designed to simulate standing up. The researchers believe that the same changes in older adults could have adverse effects on their cardiovascular health. “This is because, with aging, we tend to lose some of the compensatory mechanisms in place to offset the blood-pressure-raising effects of high sympathetic activity,” said senior author Dr. Abigail Stickford, from the department of health and exercise science at Appalachian State University in Boone, NC. “Ultimately, this could also place more strain on the heart,” she told Medical News Today.

FDA Authorizes COVID Booster Shots for Certain Populations

MedPage Today, August 13, 12021

After weeks of speculation, the FDA amended the emergency use authorizations (EUAs) for Pfizer and Moderna’s COVID-19 vaccines to include an additional booster dose for certain immunocompromised people, the agency said late Thursday. These populations include solid-organ transplant recipients or others diagnosed with conditions “considered to have a similar level of immunocompromise” who previously received one of the two mRNA vaccines. After weeks of speculation, the FDA amended the emergency use authorizations (EUAs) for Pfizer and Moderna’s COVID-19 vaccines to include an additional booster dose for certain immunocompromised people, the agency said late Thursday. These populations include solid-organ transplant recipients or others diagnosed with conditions “considered to have a similar level of immunocompromise” who previously received one of the two mRNA vaccines. The FDA kept the language purposely vague, as clinical considerations are set to be defined Friday during CDC’s Advisory Committee on Immunization Practices (ACIP) meeting. FDA merely added that individuals immunocompromised “in a manner similar” to those who underwent solid-organ transplantation have a reduced ability to fight disease and are vulnerable to infections, such as COVID-19.

Cardiac MRI in Patients with Prolonged Cardiorespiratory Symptoms after Mild to Moderate COVID-19 Infection

Radiology, August 10, 2021

Myocardial injury and inflammation on cardiac MRI in patients suffering from coronavirus disease 19 (COVID-19) have been described in recent publications. Concurrently, a chronic COVID-19 syndrome (CCS) after COVID-19 infection has been observed manifesting with symptoms like fatigue and exertional dyspnea. To explore the relationship between CCS and myocardial injury and inflammation as an underlying cause of the persistent complaints in previously healthy individuals. In this prospective study from January 2021 to April 2021, study participants without known cardiac or pulmonary diseases prior to COVID-19 infection with persisting CCS symptoms like fatigue or exertional dyspnea after convalescence and healthy control participants underwent cardiac MRI. Cardiac MRI protocol included T1 and T2 relaxation times, extracellular volume (ECV), T2 signal intensity ratio, and late gadolinium enhancement (LGE). Student t test, Mann-Whitney U test, and χ2 test were used for statistical analysis. 41 participants with CCS (39±13 years; 18 men) and 42 control participants (39±16 years; 26 men) were evaluated. Median time between initial mild to moderate COVID-19 disease without hospitalization and cardiac MRI was 103 days (interquartile range: 88-158). Troponin T levels were normal. Parameters indicating myocardial inflammation and edema were comparable between participants with CCS and control participants: T1 relaxation time (978±23 ms vs 971±25 ms; P=.17), T2 relaxation time (53±2 ms vs 52±2 ms; P=.47), T2 signal intensity ratio (1.6±0.2 vs 1.6±0.3; P=.10). Visible myocardial edema was present in none of the participants. Three of 41 (7%) participants with CCS demonstrated non-ischemic LGE compared to none in the control group (0 of 42 [0%]; P=.07). None of the participants fulfilled the 2018 Lake Louise criteria for the diagnosis of myocarditis. Individuals without hospitalization for COVID-19 and with CCS did not demonstrate signs of active myocardial injury or inflammation on cardiac MRI.

Prognostic Value of Electrocardiographic QRS Diminution in Patients Hospitalized With COVID-19 or Influenza

American Journal of Cardiology, August 8, 2021

During the clinical care of hospitalized patients with COVID-19, diminished QRS amplitude on the surface electrocardiogram was observed to precede clinical decompensation, culminating in death. This prompted investigation into the prognostic utility and specificity of low QRS complex amplitude (LoQRS) in COVID-19. We retrospectively analyzed consecutive adults admitted to a telemetry service with SARS-CoV-2 (n=140) or influenza (n=281) infection with a final disposition – death or discharge. LoQRS was defined as a composite of QRS amplitude <5mm or <10 mm in the limb or precordial leads, respectively, or a ≥50% decrease in QRS amplitude on follow-up ECG during hospitalization. LoQRS was more prevalent in patients with COVID-19 than influenza (24.3% vs 11.7%, p=0.001), and in patients who died than survived with either COVID-19 (48.1% vs 10.2%, p<0.001) or influenza (38.9% vs 9.9%, p<0.001). LoQRS was independently associated with mortality in patients with COVID-19 when adjusted for baseline clinical variables (OR 11.5, 95%CI 3.9-33.8, p<0.001), presenting and peak troponin, D-dimer, C-reactive protein, albumin, intubation, and vasopressor requirement (OR 13.8, 95% CI 1.3-145.5, p=0.029). The median time to death in COVID-19 from the first ECG with LoQRS was 52 hours (IQR 18-130). Dynamic QRS amplitude diminution is a strong independent predictor of death over not only the course of COVID-19 infection, but also Influenza infection. In conclusion, this finding may serve as a pragmatic prognostication tool reflecting evolving clinical changes during hospitalization, over a potentially actionable time interval for clinical reassessment.

Prognostic utility of pulmonary artery and ascending aorta diameters derived from computed tomography in COVID-19 patients

Echocardiography, August 6, 2021

Chest computed tomography (CT) imaging plays a diagnostic and prognostic role in Coronavirus disease 2019 (COVID-19) patients. This study aimed to investigate and compare predictive capacity of main pulmonary artery diameter (MPA), ascending aorta diameter (AAo), and MPA-to-AAo ratio to determine in-hospital mortality in COVID-19 patients. This retrospective study included 255 hospitalized severe or critical COVID-19 patients. MPA was measured at the level of pulmonary artery bifurcation perpendicular to the direction of the vessel through transverse axial images and AAo was measured by using the same CT slice at its maximal diameter. MPA-to-AAo ratio was calculated by division of MPA to AAo. Multivariate logistic regression model yielded MPA ≥29.15 mm (OR: 4.95, 95% CI: 2.01–12.2, p = 0.001), MPA (OR: 1.28, 95% CI: 1.13–1.46, p < 0.001), AAo (OR: .90, 95% CI: .81–.99, p = 0.040), and MPA-to-AAo ratio ≥.82 (OR: 4.67, 95% CI: 1.86–11.7, p = 0.001) as independent predictors of in-hospital mortality. Time-dependent multivariate Cox-proportion regression model demonstrated MPA ≥29.15 mm (HR: 1.96, 95% CI: 1.03–3.90, p = 0.047) and MPA (HR: 1.08, 95% CI: 1.01–1.17, p = 0.048) as independent predictors of in-hospital mortality, whereas AAo and MPA-to-AAo ratio did not reach statistical significance. Pulmonary artery enlargement strongly predicts in-hospital mortality in hospitalized COVID-19 patients. MPA, which can be calculated easily from chest CT imaging, can be beneficial in the prognostication of these patients.

Prognostic implications of biventricular strain measurement in COVID-19 patients by speckle-tracking echocardiography

Clinical Cardiology, August 6 2021

Recent reports have indicated the beneficial role of strain measurement in COVID-19 patients. To determine the association between right and left global longitudinal strain (RVGLS, LVGLS) and COVID-19 patients’ outcomes. Hospitalized COVID-19 patients between June and August 2020 were included. Two-dimensional echocardiography and biventricular global longitudinal strain measurement were performed. The outcome measure was defined as mortality, ICU admission, and need for intubation. Appropriate statistical tests were used to compare different groups. In this study 207 patients (88 females) were enrolled. During 64 ± 4 days of follow-up, 22 (10.6%) patients died. Mortality, ICU admission, and intubation were significantly associated with LVGLS and RVGLS tertiles. LVGLS tertiles could predict poor outcome with significant odds ratios in the total population (OR = 0.203, 95% CI: 0.088–0.465; OR = 0.350, 95% CI: 0.210–0.585; OR = 0.354, 95% CI: 0.170–0.736 for mortality, ICU admission, and intubation). Although odds ratios of LVGLS for the prediction of outcome were statistically significant among hypertensive patients, these odds ratios did not reach significance among non-hypertensive patients. RVGLS tertiles revealed significant odds ratios for the prediction of mortality (OR = 0.322, 95% CI: 0.162–0.640), ICU admission (OR = 0.287, 95% CI: 0.166–0.495), and need for intubation (OR = 0.360, 95% CI: 0.174–0.744). Odds ratios of RVGLS remained significant even after adjusting for hypertension when considering mortality and ICU admission. RVGLS and LVGLS can be acceptable prognostic factors to predict mortality, ICU admission, and intubation in hospitalized COVID-19 patients. However, RVGLS seems more reliable, as it is not confounded by hypertension.

What lies behind the pandemic’s inequitable impact on Black men

American Medical Association, August 4, 2021

COVID-19’s profound impact on Black men has been well documented, but the virus’s deeply inequitable impact has not necessarily been well explained. The answer might be found in the pandemic’s convergence of chronic disease epidemics intersecting with social factors such as structural racism. The pandemic “has surfaced that minoritized communities, communities of color, or low-income communities, have all been disproportionately impacted by the virus,” said Christopher S. Holliday, PhD, MPH, the director of population health and clinical-community linkages at the AMA. “But then, when you parse those numbers out, Black men tend to—again—fall toward the bottom of those disparities.” Holliday co-wrote a commentary published in Public Health Reports that explores how COVID-19 combined with the concurring (or co-occurring) epidemics of heart disease, obesity , hypertension, diabetes and drug overdoses to create a “syndemic.” Syndemics are defined as “two or more epidemics interacting synergistically in ways that exacerbate health consequences because of their interaction.” In the commentary, “Using Syndemics and Intersectionality to Explain the Disproportionate COVID-19 Mortality Among Black Men,” Holliday and his colleagues from Vanderbilt, Georgetown and George Washington universities use syndemics to “identify how the clustering of structural forces precipitates clustering of disease in specific populations, moving beyond the assumption that these phenomena are separate or coincidental.”

Myocarditis Following COVID-19 Vaccination

Radiology, August 3, 2021

A healthy 15-year-old boy received his second vaccination dose and the following day he developed fever, myalgia, and intermittent tachycardia. At presentation to the hospital, his electrocardiogram showed ST-segment elevation in the left precordial leads. High-sensitive cardiac troponin and C-reactive protein levels were elevated. Serology tests for cardiotropic viruses were negative. Transthoracic echocardiography showed normal myocardial function without wall motion abnormalities. Cardiac MRI at 1.5 T showed a normal left ventricular size, normal left ventricular ejection fraction and a small pericardial effusion. T2-weighted short TI inversion recovery sequences displayed focal myocardial edema involving the lateral wall, most emphasized in the basal inferolateral segment. Corresponding subepicardial enhancement was detected by late gadolinium enhancement imaging indicating inflammatory necrosis. Cardiac MRI characteristics of vaccine-induced hypersensitivity myocarditis are similar to other virus-induced causes of myocarditis. This case shows that clinicians should be aware of vaccine-induced myocarditis as a possible adverse effect in children with thoracic/cardiovascular complaints after mRNA SARS-CoV-2-vaccination. As children are now scheduled to be vaccinated in many countries, cases of vaccine-induced myocarditis will have been noted in association with mRNA vaccines. Vaccine associated myocarditis is rare, but more common in the young population, especially in males (e.g. incidence of 40.6 cases per million second doses of mRNA SARS-CoV-2 vaccinations in males aged 12-29 years).

Cardiac magnetic resonance in recovering COVID-19 patients. Feature tracking and mapping analysis to detect persistent myocardial involvement

IJC Heart & Vasculature, August 3, 2021

Post-COVID-19 patients may incur myocardial involvement secondary to systemic inflammation. Our aim was to detect possible oedema/diffuse fibrosis using cardiac magnetic resonance imaging (CMR) mapping and to study myocardial deformation of the left ventricle (LV) using feature tracking (FT). Prospective analysis of consecutively recruited post-COVID-19 patients undergoing CMR. T1 and T2 mapping sequences were acquired and FT analysis was performed using 2D steady-state free precession cine sequences. Statistical significance was set to p<0.05. Included were 57 post-COVID-19 patients and 20 healthy controls, mean age 59±15 years, men 80.7%. The most frequent risk factors were hypertension (33.3%) and dyslipidaemia (36.8%). The contact-to-CMR interval was 81±27 days. LV ejection fraction (LVEF) was 61±10%. Late gadolinium enhancement (LGE) was evident in 26.3% of patients (19.3%, non-ischaemic). T2 mapping values (suggestive of oedema) were higher in the study patients than in the controls (50.9±4.3 ms vs 48±1.9 ms, p<0.01). No between-group differences were observed for native T1 nor for circumferential strain (CS) or radial strain (RS) values (18.6±3.3% vs 19.2±2.1% (p=0.52) and 32.3±8.1% vs 33.6±7.1% (p=0.9), respectively). A sub-group analysis for the contact-to-CMR interval (<8 weeks vs ≥8 weeks) showed that FT-CS (15.6±2.2% vs 18.9±2.6%, p<0.01) and FT-RS (24.9±5.8 vs 33.5±7.2%, p<0.01) values were lower for the shorter interval. Post-COVID-19 patients compared to heathy controls had raised T2 values (related to oedema), but similar native T1, FT-CS and FT-RS values. FT-CS and FT-RS values were lower in post-COVID-19 patients undergoing CMR after <8 weeks compared to ≥8 weeks.

Troponin elevation in COVID-19 patients: An important stratification biomarker with still some open questions

International Journal of Cardiology, August 2, 2021

[Editorial] The SARS-CoV-2 infection determines a disease predominantly affecting lungs. Its clinical spectrum is wide, including asymptomatic infection, mild upper respiratory tract illness and severe viral pneumonia leading to respiratory failure and death. However, heart and vessels can represent other targets of the virus. On this level, SARS-CoV-2 has been associated to many Cardiovascular (CV) disorders such as myocardial injury, acute coronary syndrome, pulmonary embolism, myocarditis and arrhythmias. Focusing on myocardial injury, which is defined as a sudden raise in troponin levels over the 99th percentile, its incidence as a COVID-19 related complication ranges from 7.2% to 36%. The article published in this issue of the International Journal of Cardiology by Maino et al. entitled “Prevalence and characteristics of myocardial injury during COVID-19 pandemic: a new role for high-sensitive troponin” provides new data about the link between SARS-CoV2 infection and the damage exerted over cardiomyocites. Designed as a retrospective single-centre study, in this work the authors analysed 189 patients from the emergency room of “Fondazione Policlinico Universitario A. Gemelli IRCCS” in Rome (Italy) with a COVID-19 diagnosis, in which high-sensitive troponin I levels were measured within the first 24 h from admission. Results confirmed a high prevalence of myocardial damage (16%), which is more common among COVID-19 patients reporting more frequently features of frailty (older age, greater burden of CV comorbidities) and presenting a prominent inflammatory state (higher biochemical levels of inflammation). Furthermore, the multivariate analysis confirmed troponin as one of the most significant determinants of disease severity: higher levels of this biomarker appeared to be in connection with higher prevalence of intensive care unit admission, increased need of endotracheal intubation and higher mortality rate, resulting in a worse intercourse of disease and a poorer outcome. From the present study and the previously published one, three questions arise.

Deceleration capacity is associated with acute respiratory distress syndrome in COVID-19

Heart & Lung, August 2, 2021

Acute respiratory distress syndrome (ARDS) is considered the main cause of COVID-19 associated morbidity and mortality. Early and reliable risk stratification is of crucial clinical importance in order to identify persons at risk for developing a severe course of disease. Deceleration capacity (DC) of heart rate as a marker of cardiac autonomic function predicts outcome in persons with myocardial infarction and heart failure. We hypothesized that reduced modulation of heart rate may be helpful in identifying persons with COVID-19 at risk for developing ARDS. We prospectively enrolled 60 consecutive COVID-19 positive persons presenting at the University Hospital of Tuebingen. Arterial blood gas analysis and 24h-Holter ECG recordings were performed and analyzed at admission. The primary end point was defined as development of ARDS with regards to the Berlin classification. 61.7% (37 of 60 persons) developed an ARDS. In persons with ARDS DC was significantly reduced when compared to persons with milder course of infection (3.2 ms vs. 6.6 ms, p < 0.001). DC achieved a good discrimination performance (AUC = 0.76) for ARDS in COVID-19 persons. In a multivariate analysis, decreased DC was associated with the development of ARDS. Our data suggest a promising role of DC to risk stratification in COVID-19.

The Effect of COVID-19 on Adult Cardiac Surgery in the United States in 717,103 Patients

The Annals of Thoracic Surgery, July 31, 2021

COVID-19 has changed the world as we know it, and the United States continues to accumulate the largest number of COVID-related deaths worldwide. There exists a paucity of data regarding the effect of COVID-19 on adult cardiac surgery trends and outcomes on regional and national levels. The STS Adult Cardiac Surgery Database was queried from January 1, 2018 to June 30, 2020. The Johns Hopkins COVID-19 database was queried from February 1, 2020 to January 1, 2021. Surgical and COVID-19 volumes, trends, and outcomes were analyzed on a national and regional level. Observed-to-expected ratios were used to analyze risk-adjustable mortality. 717,103 adult cardiac surgery patients and over 20 million COVID-19 patients were analyzed. Nationally, there was 52.7% reduction in adult cardiac surgery volume, and 65.5% reduction in elective cases. The Mid-Atlantic region was most affected by the first COVID-19 surge, with 69.7% reduction in overall case volume and 80.0% reduction in elective cases. In the Mid-Atlantic and New England regions, the observed-to-expected mortality for isolated coronary bypass increased as much as 1.48 times (148% increase) pre-COVID rates. After the first COVID-19 surge, nationwide cardiac surgical case volumes did not return to baseline, indicating a COVID-19-associated deficit of cardiac surgery patients. This is the largest analysis of COVID-19 related impact on adult cardiac surgery volume, trends, and outcomes. During the pandemic, cardiac surgery volume suffered dramatically, particularly in the Mid-Atlantic and New England regions during the first COVID-19 surge, with a concurrent increase in observed-to-expected 30-day mortality.

COVID-19 may have stirred a silent killer. Find out what to do.

American Medical Association, July 30, 2021

Your patients could have no signs, no symptoms. They might not feel different at all. Or they could get headaches or nosebleeds, but they might never connect the dots. In other words, hypertension is easy to miss. And if left unchecked, high blood pressure can increase your patients’ risk of life-threatening conditions, including heart disease and stroke. Which is why it has been so important during the COVID-19 pandemic for patients with high blood pressure to continue to work together with their primary care physicians—to keep it under control. Early in the pandemic, in addition to the health risks directly related to COVID-19, serious concerns surfaced about what the indirect impact from the COVID-19 pandemic might be due to the disruption of health care-related services. “What would be the toll of deferring treatment for acute cardiovascular conditions like chest pain, heart attacks, heart failure exacerbations and strokes?” said Michael Rakotz, MD, vice president of improving health outcomes at the AMA. The effects were, in fact, dramatic. How prepared were we to remotely manage conditions like high blood pressure without in-person visits? According to research published this year based on data from 2019 pre-pandemic, nearly 70% of health professionals recommended the use of self-measured blood pressure (SMBP) monitoring to their patients with hypertension. And, more than 60% of patients with hypertension reported measuring their blood pressure outside of the office. The problem is that only about 7% reported sharing their readings with their health professionals via the internet or email, which is an important strategy to improve hypertension control. Read more to see key steps physicians can take to overcome the challenges.

The Role of Statins in COVID-19, With a Focus on Patients With Cardiovascular Risk Factors

Cardiology Advisor, July 30, 2021

A recent study suggests that patients taking statin medications have a significantly lower risk for in-hospital death from COVID-19. The findings, published in PLOS ONE, demonstrated that the use of statins prior to admission was associated with a 41% reduction of in-hospital death and a greater than 25% reduction in risk of developing a severe outcome, after adjusting for age, sex, other medical conditions, insurance status, and hospital site. “We also found, in a propensity-matched analysis, that most of this benefit was seen in patients with a history of prior heart disease or high blood pressure. For patients without those underlying conditions, there was the suggestion of benefit (16% lower odds of death). However, the results were not statistically significant,” said the lead study author Lori Daniels, MD, professor and director of the cardiovascular intensive care unit at University of California San Diego Health, San Diego, California. Study findings revealed that outpatient use of statins (alone or with antihypertensive agents) was associated with a reduced risk for death (adjusted odds ratio [aOR,] 0.59; 95% CI, 0.50-0.69), after adjusting for demographic characteristics, insurance status, hospital site, and concurrent medications. The use of statins and/or antihypertensive agents was associated with a reduced risk for death among patients with a history of CVD and/or hypertension (aOR, 0.68; 95% CI, 0.58-0.81) in propensity-matched analyses.

Long-term effects of coronavirus disease 2019 on the cardiovascular system, CV COVID registry: A structured summary of a study protocol

PLOS ONE, July 29, 2021

Patients presenting with the coronavirus-2019 disease (COVID-19) may have a high risk of cardiovascular adverse events, including death from cardiovascular causes. The long-term cardiovascular outcomes of these patients are entirely unknown. We aim to perform a registry of patients who have undergone a diagnostic nasopharyngeal swab for SARS-CoV-2 and to determine their long-term cardiovascular outcomes. This is a multicenter, observational, retrospective registry to be conducted at 17 centers in Spain and Italy (ClinicalTrials.gov number: NCT04359927). Consecutive patients older than 18 years, who underwent a real-time reverse transcriptase-polymerase chain reaction (RT-PCR) for SARS-CoV2 in the participating institutions, will be included since March 2020, to August 2020. Patients will be classified into two groups, according to the results of the RT-PCR: COVID-19 positive or negative. The primary outcome will be cardiovascular mortality at 1 year. The secondary outcomes will be acute myocardial infarction, stroke, heart failure hospitalization, pulmonary embolism, and serious cardiac arrhythmias, at 1 year. Outcomes will be compared between the two groups. Events will be adjudicated by an independent clinical event committee. The results of this registry will contribute to a better understanding of the long-term cardiovascular implications of the COVID19.

Cardiovascular Adverse Events Reported from COVID-19 Vaccines: A Study Based on WHO Database

International Journal of General Medicine, July 27, 2021

Thirteen COVID-19 vaccines are granted emergency approval. It is crucial to monitor their adverse events post vaccination. The present study focuses on cardiovascular adverse events post-COVID-19 vaccination and aims to determine adverse events with the administered vaccine. The cardiovascular (CVS) adverse events were extracted for three broad headings (SOCs) – cardiac disorders, vascular disorders, and investigations. Descriptive statistics were reported in the form of percentage and frequency, and the disproportionality analysis was conducted. For the cardiovascular system, 4863 adverse events (AEs) were reported from BNT162b2 Pfizer, 1222 AstraZeneca, Moderna, and other COVID-19 vaccines. Common adverse events observed with vaccines under study were tachycardia (16.41%), flushing (12.17%), hypertension (5.82%), hypotension (3.60%) and peripheral coldness (2.41%). Based on disproportionality analysis (IC025 values), acute myocardial infarction, cardiac arrest, and circulatory collapse were linked to the vaccines in the age group > 75 years. Hypertension, severe hypertension, supraventricular tachycardia, sinus tachycardia, and palpitations were associated across all age groups and either gender. Amongst the investigations, abnormal ECG findings raised C-reactive protein, elevated D dimer, and troponin were reported in specific age groups or gender or all subjects. Although cardiovascular events have been reported with the COVID-19 vaccines, the causality is yet to be established because such CVS AEs are also usually associated with the general public even without intervention. Hence, people should be administered these vaccines, and sustained monitoring of these AEs should be done.

Algorithm developed for managing suspected ACS in patients hospitalized with COVID-19

Helio | Cardiology Today, July 25, 2021

Diagnosis of ACS in concomitant COVID-19 infection can be made difficult due to an overlap of symptoms, fewer patients presenting to the hospital and a lack of guidance diagnosing hospitalized patients, a speaker reported. At the virtual American Society for Preventive Cardiology Congress on CVD Prevention, Amit Khera, MD, MSc, FACC, FAHA, FASPC, immediate past president of the ASPC and professor of medicine, director of preventive cardiology and the Dallas Heart Ball chair in hypertension and heart disease at UT Southwestern Medical Center, discussed the etiologies of ACS and COVID-19 infection and the importance of patient education. “At every one of my patient visits over last year, I always remind people that if you have a symptom, the hospital is safe. You must present. Hopefully, we are on the tail end of all this, but there are variants and other lessons learned that may come up in the future,” Khera said. “But communication to our patients is key. How do we avoid having this increase of ACS-related COVID-19? Vaccination. People know that quite well. We have all seen clinical trial data. This is real world data.” According to a study published in the American Journal of Preventive Cardiology, patients with atherosclerotic CVD who contract COVID-19 experienced greater relative risk for COVID-19 related ACS compared with individuals without ASCVD (RR = 5.9). Researchers reported even greater relative risk among patients with COVID-19 and familial hypercholesterolemia vs. those without FH (RR = 14.3). For patients with COVID-19 and suspected ACS, Khera said that point-of-care ultrasound may be able to rule other explanations such as myocarditis, congestive HF, pulmonary embolism, right ventricular dysfunction and stress cardiomyopathy. “Point-of-care ultrasound has been a godsend at our institution and many others in that we can get quick data, it avoids exposure,” Khera said.

Predictive Value of Neutrophil/Lymphocyte Ratio (NLR) on Cardiovascular Events in Patients with COVID-19

International Journal of General Medicine, July 24, 2021

The research on the association between coronavirus disease 2019 (COVID-19) and cardiovascular disease (CVD) is still insufficient. This study aimed to investigate the association between neutrophil/lymphocyte ratio (NLR) and risk of cardiovascular events in patients with COVID-19. Our study included 159 patients with COVID-19 who were measured for NLR value within the first 24 hours of admission. They were followed up for 6 months after discharge and then the relationship between levels of NLR and risk of cardiovascular events was assessed. In all included patients with COVID-19, NLR values in patients with cardiovascular events [16.28 (4.95– 45.18)] were significantly higher than patients without cardiovascular events [4.75 (2.60– 7.47)]. A multivariate logistic regression model revealed that elevated NLR value [increased per SD, 2.41 (1.43– 4.29), P< 0.001; increased 1 of NLR, 2.05 (1.33–4.01), P=0.010] was significantly and independently associated with increased risk of CVD history on admission after adjustment of related confounding factors. Cox regression analysis revealed that elevated NLR value had a significant association with increased risk of cardiovascular events [increased per SD, 2.36 (1.42– 4.36), P< 0.001; Increased 1 of NLR, 2.00 (1.30– 3.97), P=0.014] after adjustments of these same confounding factors. Furthermore, the ROC curve suggested that NLR value (AUC=0.803, 95% CI=0.731– 0.875, P< 0.001, sensitivity 81.2%, and specificity 82.6%) has a good predictive value for cardiovascular events during follow-up.

Epidemiological and Clinical Characteristics of Deceased COVID-19 Patients

International Journal of General Medicine, July 24, 2021

Fatalities due to COVID-19 continue to increase, and information on the epidemiological and clinical characteristics of deceased patients who were hospitalized with COVID-19 is limited in the Arab region. The current study aimed to address this gap. Three hundred and four Saudi patients in Jazan Region, Saudi Arabia, who died after being hospitalized with COVID-19, were analyzed in this retrospective cohort study. A greater proportion of male patients (59%), compared to female patients (41%), died due to COVID-19. Just over half (55%) of the deaths due to COVID-19 affected patients aged ≥ 65 years. More than two-thirds of the deceased COVID-19 patients had diabetes (70%) and hypertension (69%); other comorbidities were obesity (30%), heart disease (30%), and chronic kidney disease (14%). Dyspnea (91%), cough (80%), and fever (70%) were the most frequently reported clinical symptoms. Eighty-five per cent of COVID-19 deaths occurred in patients admitted to the intensive care unit (ICU), and 90% of the patients required mechanical ventilation. Typically, lymphopenia, and neutrophilia were observed on admission and 24 hours prior to death. Creatinine and serum ferritin levels and erythrocyte sedimentation rate and D-dimer plasma levels increased significantly following infection with COVID-19. Lung infiltrates and pulmonary opacity (83%) were the most common findings on chest X-ray. Respiratory failure (70%) and acute respiratory distress syndrome (52%) were the leading complications to death. Logistic and Cox regression revealed that a higher age, smoking, high creatinine and aspartate transaminase levels, and respiratory failure were significantly associated with the risk of mortality during the early stay in hospitals. The proportion of comorbidities was high in deceased patients who were hospitalized with COVID-19 in Jazan region, Saudi Arabia. A higher age, smoking, and respiratory failure were significant predictors of mortality during the early stay in hospitals.

Dapagliflozin in patients with cardiometabolic risk factors hospitalised with COVID-19 (DARE-19): a randomised, double-blind, placebo-controlled, phase 3 trial

The Lancet, July 21, 2021

COVID-19 can lead to multiorgan failure. Dapagliflozin, a SGLT2 inhibitor, has significant protective benefits for the heart and kidney. We aimed to see whether this agent might provide organ protection in patients with COVID-19 by affecting processes dysregulated during acute illness. DARE-19 was a randomised, double-blind, placebo-controlled trial of patients hospitalised with COVID-19 and with at least one cardiometabolic risk factor. Patients critically ill at screening were excluded. Patients were randomly assigned 1:1 to dapagliflozin (10 mg daily orally) or matched placebo for 30 days. Dual primary outcomes were assessed in the intention-to-treat population: the outcome of prevention (time to new or worsened organ dysfunction or death), and the hierarchial composite outcome of recovery (change in clinical status by day 30). Safety outcomes, in patients who received at least one study medication dose, included serious adverse events, adverse events leading to discontinuation, and adverse events of interest. Between April 22, 2020 and Jan 1, 2021, 1250 patients were randomly assigned with 625 in each group. The primary composite outcome of prevention showed organ dysfunction or death occurred in 70 patients (11·2%) in the dapagliflozin group, and 86 (13·8%) in the placebo group (hazard ratio [HR] 0·80, 95% CI 0·58–1·10; p=0·17). For the primary outcome of recovery, 547 patients (87·5%) in the dapagliflozin group and 532 (85·1%) in the placebo group showed clinical status improvement, although this was not statistically significant (win ratio 1·09, 95% CI 0·97–1·22; p=0·14). There were 41 deaths (6·6%) in the dapagliflozin group, and 54 (8·6%) in the placebo group (HR 0·77, 95% CI 0·52–1·16). Serious adverse events were reported in 65 (10·6%) of 613 patients treated with dapagliflozin and in 82 (13·3%) of 616 patients given the placebo. In patients with cardiometabolic risk factors who were hospitalised with COVID-19, treatment with dapagliflozin did not result in a statistically significant risk reduction in organ dysfunction or death, or improvement in clinical recovery, but was well tolerated.

Epicardial adipose tissue and severe Coronavirus Disease 19

Cardiovascular Diabetology, July 20, 2021

Both visceral adipose tissue and epicardial adipose tissue (EAT) have pro-inflammatory properties. The former is associated with COVID-19 severity. We aimed to investigate whether an association also exists for EAT. We retrospectively measured EAT volume using computed tomography (CT) scans (semi-automatic software) of inpatients with COVID-19 and analyzed the correlation between EAT volume and anthropometric characteristics and comorbidities. We then analyzed the clinicobiological and radiological parameters associated with severe COVID-19 (O2 ≥≥ 6 l/min), intensive care unit (ICU) admission or death, and 25% or more CT lung involvement, which are three key indicators of COVID-19 severity. We included 100 consecutive patients; 63% were men, mean age was 61.8 ± 16.2 years, 47% were obese, 54% had hypertension, 42% diabetes, and 17.2% a cardiovascular event history. Severe COVID-19 (n = 35, 35%) was associated with EAT volume (132 ± 62 vs 104 ± 40 cm3, p = 0.02), age, ferritinemia, and 25% or more CT lung involvement. ICU admission or death (n = 14, 14%) was associated with EAT volume (153 ± 67 vs 108 ± 45 cm3, p = 0.015), hypertension and 25% or more CT lung involvement. The association between EAT volume and severe COVID-19 remained after adjustment for sex, BMI, ferritinemia and lung involvement, but not after adjustment for age. Instead, the association between EAT volume and ICU admission or death remained after adjustment for all five of these parameters. Our results suggest that measuring EAT volume on chest CT scans at hospital admission in patients diagnosed with COVID-19 might help to assess the risk of disease aggravation.

Cardiac Abnormalities Depicted with MRI in COVID-19: Ongoing Concern for Myocardial Injury

Radiology, July 20, 2021

[Editorial, Review and Commentary] COVID-19 is a systemic disease induced by the SARS-CoV-2 virus affecting the endothelium of different vascular beds throughout the entire human body. The magnitude of pulmonary parenchymal and vascular involvement in large part defines overall prognosis and the probability of severe outcomes in COVID-19, including death. By extension, it also determines the need for hospitalization in the majority of patients admitted for standard and critical care. Yet, the extent of involvement of other organ systems in patients without potentially significant pulmonary disease remains largely unknown. Prior studies suggest that myocardial involvement is associated with unfavorable prognosis in patients with COVID-19, but clinically significant myocardial injury is currently believed to occur in a subgroup of patients with symptoms requiring hospitalization. However, recent MRI studies suggest the presence of cardiac sequelae not only in hospitalized patients with COVID-19 but also in outpatients, including elite athletes. Thus, the clinical significance of myocardial alterations identified in convalescing patients with COVID-19 remains incompletely understood. In the May 2021 issue of Radiology, Li et al, demonstrated myocardial extracellular volume expansion and reduced myocardial strain in a group of convalescing patients with COVID-19 hospitalized with severe or moderate pulmonary disease, compared with age- and sex-matched healthy control participants. In this prospective observational cohort study, the median extracellular volume was 31.4%, 29.7%, and 25.0% (P < .001) for comparisons of both patients with severe and moderate COVID-19 versus control participants. The corresponding mean global longitudinal strain values were less negative (representing reduced cardiac function) in both participants with severe and moderate COVID-19 compared with control participants (severe and moderate COVID-19 [both −12.5%] vs healthy control participants [−15.4%]; [P = .002 and P = .001, respectively]).

Cardiomyocytes Recruit Monocytes upon SARS-CoV-2 Infection by Secreting CCL2

Stem Cell Reports, July 20, 2021

Heart injury has been reported in up to 20% of COVID-19 patients, yet the cause of myocardial histopathology remains unknown. Here, using an established in vivo hamster model, we demonstrate that SARS-CoV-2 can be detected in cardiomyocytes of infected animals. Furthermore, we found damaged cardiomyocytes in hamsters and COVID-19 autopsy samples. To explore the mechanism, we show that both human pluripotent stem cell-derived cardiomyocytes (hPSC-derived CMs) and adult cardiomyocytes (CMs) can be productively infected by SARS-CoV-2, leading to secretion of the monocyte chemoattractant cytokine CCL2 and subsequent monocyte recruitment. Increased CCL2 expression and monocyte infiltration was also observed in the hearts of infected hamsters. Although infected CMs suffer damage, we find that the presence of macrophages significantly reduces SARS-CoV-2 infected CMs. Overall, our study provides direct evidence that SARS-CoV-2 infects CMs in vivo and suggests a mechanism of immune-cell infiltration and histopathology in heart tissues of COVID-19 patients.

Myocarditis Associated with mRNA COVID-19 Vaccination

Radiology, July 20, 2021

[Research Letter] In this retrospective, IRB approved HIPPA compliant study, cardiac MRI exams performed at our institution between 1/1/2021-5/25/2021 were reviewed for MRI findings of myocarditis/pericarditis. Subsequently, electronic health records were reviewed, and all patients who received COVID-19 vaccine preceding cardiac MRI were included (consecutive sample). Informed consent was waived per IRB protocol. Patients with a history of prior COVID were excluded. Cardiac MRI was performed at 1.5T/3T (GE Healthcare) and evaluated as recently described. Clinical radiology reports were reviewed by three cardiovascular radiologists (7-27 years of experience; initials blinded for review) in consensus. Demographic and clinical data including COVID-19 vaccination, 12-lead electrocardiogram (ECG), and serum markers of cardiac injury were documented. Five patients (4:1 male:female, age range 17-38 years) were identified who had abnormal MRI findings and were vaccinated against COVID-19 prior to MRI. Cardiac troponin and ECG were abnormal in all patients. All patients were hospitalized due to acute onset of chest pain with diagnosis of acute myocarditis. Patients 1-3 received their second dose of BNT162b2 vaccine two, three and two days, respectively, before onset of chest pain; Patients 4 and 5 both received their second dose of mRNA-1273 three days before onset of chest pain. In all patients, MRI showed myocarditis-like findings including non-ischemic pattern of late gadolinium enhancement, corresponding signal abnormalities on T2-weighted images, and pericardial enhancement. Diagnostic considerations included pulmonary embolus or acute coronary event with additional imaging-based testing (Table). Ipsilateral axillary lymphadenopathy to the vaccination site was identified in four patients. COVID-19 testing at the time of diagnosis (and history of prior COVID-19) were negative. No respiratory symptoms, prodrome or skin rash were present prior to vaccination. Further, medical history did not reveal any pre-existing cardiac disease in these patients.

Clinical characteristics and outcomes of patients with heart failure admitted to the intensive care unit with coronavirus disease 2019 (COVID-19): A multicenter cohort study

American Heart Journal Plus: Cardiology Research and Practice, July 19, 2021

Patients with underlying heart failure (HF) in the setting of COVID-19 who require admission to the intensive care unit (ICU) might present with a unique set of challenges. This study aims to extensively describe the characteristics and outcomes of patients with HF who were admitted to ICU with COVID-19. We conducted a multicenter retrospective analysis for all adult patients with HF and an objectively confirmed diagnosis of COVID-19 who were admitted to ICUs between March 1 and August 31, 2020, in Saudi Arabia. A total of 723 critically ill patients with COVID-19 were admitted into ICUs during the study period: 59 patients with HF and 664 patients with no HF before admission to ICU. Patients with HF had statistically significant more comorbidities, including diabetes mellitus, hypertension, dyslipidemia, atrial fibrillation, and acute coronary syndrome. Moreover, higher baseline severity scores (APACHE II & SOFA score) and nutritional risk (NUTRIC score) were observed in HF patients. Overall, patients with HF had more in-hospital and ICU deaths in comparison to patients without HF: (64.3% vs. 44.6%, P-value < 0.01) and (54.5% vs. 39%, P-value = 0.02), respectively. Patients with HF had a similar incidence of thrombosis, ICU length of stay, duration of mechanical ventilation, and hospital length of stay compared to patients with no HF.

Atrial fibrillation in patients with SARS-CoV-2 infection

Medicina Clínica, July 19, 2021

The SARS-CoV-2 infection ranges from asymptomatic to critical forms and several prognostic factors have been described. Atrial fibrillation (AF) is common in acute situations where it is linked with more complications and mortality. We aimed to evaluate the prognostic information of AF in this population. This was a retrospective analysis of a cohort of 517 patients consecutively admitted in a tertiary hospital due to SARS-CoV-2 infection. We divided the patients in two groups according the development of AF and compared the main features of both groups. An univariable and multivariable analysis of mortality were also performed. Among 517 patients with SARS-CoV-2 infection admitted in a tertiary center, 54 (10.4%) developed AF. These patients are older (81.6 vs 66.5 years old, p < 0.001) and present more hypertension (74% vs 47%, p < 0.001), cardiomyopathy (9% vs 1%, p = 0.002), previous heart failure admission (9% vs 0.4%, p < 0.001), previous episodes of AF (83% vs 1%, p < 0.001) and bigger left atrium (47.8 vs 39.9 mm, p < 0.001). AF COVID-19 patients present more acute respiratory failure (72% vs 40%, p < 0.001) and higher in-hospital mortality (50% vs 22%, p < 0.001). Predictors of AF development are age and previous AF. AF is not an independent predictor of in-hospital mortality. Predictors are age, creatinine > 1.5 mg/dL at admission, LDH > 250 UI/L at admission and acute respiratory failure. According to the results, AF appears in 10% of hospitalized patients with SARS-CoV-2 infection. These patients present more comorbidities and two-fold increase in hospital mortality. Atrial fibrillation is not an independent prognostic factor.

Statin Use Linked to Reduced Death Risk in Hospitalized COVID-19 Patients

Cardiology Advisor, July 19, 2021

Statin use appears to reduce the risk of severe COVID-19 disease or death among hospitalized patients, particularly in those with a history of cardiovascular disease and/or hypertension, according to research published in The Public Library of Science (PLOS) ONE. To evaluate the relationship between the use of statins and COVID-19 outcomes, study authors analyzed data from 10,541 hospitalized patients with active COVID-19 disease who were enrolled in the American Heart Association’s COVID-19 Cardiovascular Disease (CVD) Registry from January 2020 to September 2020. Prior to admission, 42% (n=4449) of patients used statins, with 7% of patients using statins alone and 35% using statins plus antihypertensives. “Because the use of statins and [antihypertensives] is strongly linked to the underlying high-risk conditions for which they are prescribed, we used propensity score matching techniques to investigate the use of these medications, separately for patients with and without a history of CVD and/or hypertension,” the study authors reported. They used logistic regression to adjust for demographic characteristics, insurance status, hospital site, and concurrent medications. The primary outcome of the study was in-hospital all-cause death or discharge to hospice care.

Admission Rates During a Second COVID-19 Lockdown

American Heart Journal, July 15, 2021

Societal lockdowns during the first wave of the COVID-19 pandemic were associated with decreased admission rates for acute cardiovascular conditions worldwide. In this nationwide Danish study of the first five weeks of a second pandemic lockdown, incidence of new-onset heart failure and atrial fibrillation remained stable, but there was a significant drop in new-onset ischemic heart disease and ischemic stroke during the fourth week of lockdown, which normalized promptly. The observed drops were lower compared to the first Danish lockdown in March 2020; thus, our data suggest that declines in acute CVD admission rates during future lockdowns are avoidable.

Effects of Renin-Angiotensin-Aldosterone Inhibitors on Early Outcomes of Hypertensive COVID-19 Patients: A Randomized Triple-Blind Clinical Trial

American Journal of Hypertension, July 15, 2021

The role of angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs) has been addressed in some studies related to the current coronavirus disease-2019 (COVID-19) pandemic with possible higher severity and mortality in patients with hypertension. A triple-blind randomized controlled trial was designed to evaluate the effects of these medications on the COVID-19 progression. Patients were enrolled in this trial between April and September 2020. They were randomized in two groups. The former dosage of ACEis/ARBs was continued in one group while in another group, the ACEis/ARBs were replaced by amlodipine ± carvedilol according to the dose equivalents. The primary outcomes were length of stay in hospitals and intensive care units. Other outcomes include mechanical ventilation, non-invasive ventilation, readmission, and COVID-19 symptoms after discharge. We randomized 64 patients with COVID-19 into two groups. Most patients were aged 66-80 and 46-65 years-old, 33 (51.6%) and 27 (42.2%), respectively. The study groups were nearly similar in baseline vital signs and characteristics. In addition, there was no significant difference in terms of recorded systolic and diastolic blood pressure measurements between groups. Furthermore, we did not find a significant difference between the days of intensive care unit or ward admission, the discharge rate, or readmission rates between the two groups.

More than 1 in 3 cardiology professionals reported burnout during COVID-19 pandemic

Cardiology Today, July 15, 2021

The COVID-19 pandemic has increased burnout among CV professionals, with many surveyed citing their basic, emotional and safety needs were not well supported by health care organizations, which, for some, led to a desire to change careers. The prevalence of burnout among all CV professionals nearly doubled after the start of the COVID-19 pandemic, from 20% in 2019 to 38% during the pandemic, according to data from the American College of Cardiology 2020 Well Being Study, a survey sent to ACC members in fall 2020. Looking closer at the overall respondents, among U.S. cardiologists, peak COVID-19 burnout rates increased to 40% from a pre-pandemic rate of 27% and among international cardiologists, burnout doubled to 21% from a pre-pandemic rate of 10%. Burnout rates rose to 43%, from 21% in 2019, among U.S. fellows in training. The largest increase was reported by U.S. CV team members — a 139% increase, from 23% in 2019 to 55% during the pandemic. “The issue of burnout has been simmering for years and was brought to a boil by mounting changes in the health care system — most predominantly, the widespread institution of electronic health records and performance metrics,” Cardiology Today Editorial Board Member Laxmi Mehta, MD, noninvasive cardiologist, Sarah Ross Soter Endowed Chair in Women’s Cardiovascular Health and professor of medicine in the division of cardiovascular medicine at The Ohio State University, said during a presentation. “COVID-19 has had a devastating health, social and economic effect worldwide. The impact of COVID-19 on the well-being of CV professionals has not been reported. The potential long-term psychological effects are real and concerning.” These new results come on the heels of 2019 survey data from the ACC, which found that the prevalence of burnout in cardiology increased by 32% since 2015, especially among women and mid-career cardiologists, despite efforts to alleviate job-related pressures. The increase in the prevalence of burnout was 90% from 2019 to 2020.

Cardiac Pathology in COVID-19: A Single Center Autopsy Experience

Cardiovascular Pathology, July 14, 2021

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is commonly associated with myocardial injury and heart failure. The pathophysiology behind this phenomenon remains unclear, with many diverse and multifaceted hypotheses. To contribute to this understanding, we describe the underlying cardiac findings in fifty patients who died with coronavirus disease 2019 (COVID-19). Included were autopsies performed on patients with a positive SARS-CoV-2 reverse-transcriptase-polymerase-chain reaction test from the index hospitalization. In the case of out-of-hospital death, patients were included if post-mortem testing was positive. Complete autopsies were performed according to a COVID-19 safety protocol, and all patients underwent both macroscopic and microscopic examination. If available, laboratory findings and echocardiograms were reported. The median age of the decedents was 63.5 years. The most common comorbidities included hypertension (90.0%), diabetes (56.0%) and obesity (50.0%). Lymphocytic inflammatory infiltrates in the heart were present in eight (16.0%) patients, with focal myocarditis present in two (4.0%) patients. Acute myocardial ischemia was observed in eight (16.0%) patients. The most common findings were myocardial fibrosis (80.0%), hypertrophy (72.0%), and microthrombi (66.0%). The most common causes of death were COVID-19 pneumonia in 18 (36.0%), COVID-19 pneumonia with bacterial superinfection in 12 (24.0%), and COVID-19 pneumonia with pulmonary embolism in 10 (20.0%) patients.

Post congress highlights in acute cardiovascular care: a report from the ACC scientific sessions 2021

European Heart Journal. Acute Cardiovascular Care, July 13, 2021

Two studies evaluated novel therapeutic interventions in the setting of hospitalized COVID-19. These studies established the feasibility of performing randomized controlled trials even in the midst of a pandemic. The DARE-19 trial included 1250 patients with cardiometabolic risk factors hospitalized with active COVID-19 infection and oxygen saturation ≥94% while receiving ≤5 L/min of oxygen. Patients were randomized in a 1:1 ratio to receive dapagliflozin 10 mg/day or matching placebo. Although not statistically significant, time to organ failure or death was numerically lower with dapagliflozin (86 vs. 70 events) and the drug was well tolerated with similar rates of discharge and length of stay. Finally, the ACTION trial enrolled 615 hospitalized COVID-19 patients with elevated D-dimer levels. Stable patients were randomized to rivaroxaban 20 mg daily or standard of care, while unstable patients were randomized to enoxaparin 1 mg/kg twice daily versus standard of care. The test strategy did not improve the primary composite endpoint (hierarchical analysis of mortality, duration of hospitalization and duration of oxygen therapy through 30 days) and was associated with increased risk of International Society on Thrombosis and Haemostasis (ISTH) major or clinically relevant non-major bleeding [8.4 vs. 2.3%, relative risk 3.64 (1.61–8.27)].

The prognostic value of myocardial injury in COVID-19 patients and associated characteristics

Immunity, Inflammation and Disease, July 9, 2021

Since December 2019, coronavirus disease 2019 (COVID-19) has emerged as an international pandemic. COVID-19 patients with myocardial injury might need special attention. However, an understanding on this aspect remains unclear. This study aimed to illustrate clinical characteristics and the prognostic value of myocardial injury to COVID-19 patients. This retrospective, single-center study finally included 304 hospitalized COVID-19 cases confirmed by real-time reverse-transcriptase polymerase chain reaction from January 11 to March 25, 2020. Myocardial injury was determined by serum high-sensitivity troponin I (Hs-TnI). The primary endpoint was COVID-19-associated mortality. Of 304 COVID-19 patients (median age, 65 years; 52.6% males), 88 patients (27.3%) died (61 patients with myocardial injury, 27 patients without myocardial injury on admission). COVID-19 patients with myocardial injury had more comorbidities (hypertension, chronic obstructive pulmonary disease, cardiovascular disease, and cerebrovascular disease); lower lymphocyte counts, higher C-reactive protein (CRP; median, 84.9 vs. 28.5 mg/L; p < .001), procalcitonin levels (median, 0.29 vs. 0.06 ng/ml; p < .001), inflammatory and immune response markers; more frequent need for noninvasive ventilation, invasive mechanical ventilation; and was associated with higher mortality incidence (hazard ratio [HR] = 7.02; 95% confidence interval [CI], 4.45–11.08; p < .001) than those without myocardial injury. Myocardial injury (HR = 4.55; 95% CI, 2.49–8.31; p < .001), senior age, CRP levels, and novel coronavirus pneumonia types on admission were independent predictors to mortality in COVID-19 patients. COVID-19 patients with myocardial injury on admission is associated with more severe clinical presentation and biomarkers. Myocardial injury and higher Hs-TnI are both strongest independent predictors to COVID-19-related mortality after adjusting confounding factors.

9 ways to reduce inequity in hypertension treatment and control

American Medical Association, July 2, 2021

COVID-19 did not create disparities in hypertension management and control, but it did exacerbate preexisting inequities, especially among people without health insurance and difficulty accessing care. Steps have been identified that can be taken to promote a more equitable health system and better BP control. That was a conclusion drawn by a diverse expert panel of clinicians and researchers that convened virtually during the 4th Annual University of Utah Translational Hypertension Symposium to discuss environmental and socioeconomic factors contributing to disparities. Their discussion was summarized in an open-access report, “Inequities in Hypertension Control in the United States Exposed and Exacerbated by COVID‐19 and the Role of Home Blood Pressure and Virtual Health Care During and After the COVID‐19 Pandemic” published in the Journal of the American Heart Association. “COVID-19 has also reminded us that when we design interventions, it is important to consider health equity from the beginning rather than as an afterthought,” lead author Adam Bress, Pharm.D., University of Utah School of Medicine associate professor of population health science, said in a news release. “Too often, individuals are blamed for their health care conditions, without considering the multiple levels of social factors and context that contribute to persistent and pervasive health inequities,” added Bress, who is also an investigator at the VA Salt Lake City Health Care System.

Absence of Both Right and Left Main Coronary in a COVID Survivor

Diagnostics, July 1, 2021

The prevalence of isolated right coronary artery (RCA) absence ranges from 0.014% to 0.066% in the general population, but its combination with an absent left main (dual ostium left anterior descending [LAD] and super-dominant left circumflex [LCx]) has not been previously described. We report the case of a rare coronary artery anomaly: an absent RCA with LAD and LCx coronary arteries arising separately from the left coronary sinus. A 53-year-old male with recent COVID-19 infection was referred to our service for coronary computed tomography angiography (CCTA) due to the recent onset of atypical chest pain. The RCA was absent, with no vessel leaving the right or non-coronary sinus. The LAD and LCx emerged from the left coronary sinus, with a “double-barrel” appearance. The LAD was unremarkable, with small, non-stenosed calcified plaque. The LCx had a 3 mm diameter, arching downward in the left atrioventricular groove, passing through the crux cordis, continuing into the right atrioventricular groove, and ending as a left acute artery and sinonodal artery. No significant stenosis was found on any of the vessels, ruling out atherosclerotic coronary disease.

Patients With Acute Myocarditis Following mRNA COVID-19 Vaccination

JAMA Cardiology, June 29, 2021

Vaccine-associated myocarditis is an unusual entity that has been described for the smallpox vaccine, but only anecdotal case reports have been described for other vaccines. Whether COVID-19 vaccination may be linked to the occurrence of myocarditis is unknown. Our objective was to describe a group of 7 patients with acute myocarditis over 3 months, 4 of whom had recent messenger RNA (mRNA) COVID-19 vaccination. All patients referred for cardiovascular magnetic resonance imaging at Duke University Medical Center were asked to participate in a prospective outcomes registry. Two searches of the registry database were performed: first, to identify patients with acute myocarditis for the 3-month period between February 1 and April 30 for 2017 through 2021, and second, to identify all patients with possible vaccine-associated myocarditis for the past 20 years. Once patients with possible vaccine-associated myocarditis were identified, data available in the registry were supplemented by additional data collection from the electronic health record and a telephone interview. In the 3-month period between February 1 and April 30, 2021, 7 patients with acute myocarditis were identified, of which 4 occurred within 5 days of COVID-19 vaccination. Three were younger male individuals (age, 23-36 years) and 1 was a 70-year-old female individual. All 4 had received the second dose of an mRNA vaccine (2 received mRNA-1273 [Moderna], and 2 received BNT162b2 [Pfizer]). All presented with severe chest pain, had biomarker evidence of myocardial injury, and were hospitalized. Coincident testing for COVID-19 and respiratory viruses provided no alternative explanation. Cardiac magnetic resonance imaging findings were typical for myocarditis, including regional dysfunction, late gadolinium enhancement, and elevated native T1 and T2.

Portable single-lead electrocardiogram device is accurate for QTc evaluation in hospitalized patients

Heart Rhythm O2, June 28, 2021

The objective of the study was to assess the impact of diabetes, hypertension and cardiovascular diseases on inpatient mortality from COVID-19, and its relationship to ethnicity and social deprivation. This retrospective, single-centre observational study in Birmingham, UK, consisted of 907 hospitalised patients with laboratory-confirmed COVID-19 from a multi-ethnic community, admitted between 1 March 2020 and 31 May 2020. The primary analysis was an evaluation of cardiovascular conditions and diabetes in relation to ethnicity and social deprivation, with the end-point of inpatient death or death within 30 days of discharge. A multivariable logistic regression model was used to calculate HRs while adjusting for confounders. 361 of 907 (39.8%) died in hospital or within 30 days of discharge. The presence of diabetes and hypertension together appears to confer the greatest mortality risk (OR 2.75; 95% CI 1.80 to 4.21; p < 0.001) compared with either condition alone. Age > 65 years (OR 3.32; 95% CI 2.15 to 5.11), male sex (OR 2.04; 95% CI 1.47 to 2.82), hypertension (OR 1.69; 95% CI 1.10 to 2.61) and cerebrovascular disease (OR 1.87; 95% CI 1.31 to 2.68) were independently associated with increased risk of death. The mortality risk did not differ between the quintiles of deprivation. High-sensitivity troponin I was the best predictor of mortality among biomarkers (OR 4.43; 95% CI 3.10 to 7.10). Angiotensin-receptor blockers (OR 0.57; 95% CI 0.33 to 0.96) and ACE inhibitors (OR 0.65; 95% CI 0.43 to 0.97) were not associated with adverse outcome. The Charlson Index of Comorbidity scores were significantly higher in non-survivors. The combined prevalence of hypertension and diabetes appears to confer the greatest risk, where diabetes may have a modulating effect. Hypertension and cerebrovascular disease had a significant impact on inpatient mortality.

Hypertension is the major predictor of poor outcomes among inpatients with COVID-19 infection in the UK: a retrospective cohort study

BMJ Open, June 26, 2021

The objective of the study was to assess the impact of diabetes, hypertension and cardiovascular diseases on inpatient mortality from COVID-19, and its relationship to ethnicity and social deprivation. This retrospective, single-centre observational study in Birmingham, UK, consisted of 907 hospitalised patients with laboratory-confirmed COVID-19 from a multi-ethnic community, admitted between 1 March 2020 and 31 May 2020. The primary analysis was an evaluation of cardiovascular conditions and diabetes in relation to ethnicity and social deprivation, with the end-point of inpatient death or death within 30 days of discharge. A multivariable logistic regression model was used to calculate HRs while adjusting for confounders. 361 of 907 (39.8%) died in hospital or within 30 days of discharge. The presence of diabetes and hypertension together appears to confer the greatest mortality risk (OR 2.75; 95% CI 1.80 to 4.21; p < 0.001) compared with either condition alone. Age > 65 years (OR 3.32; 95% CI 2.15 to 5.11), male sex (OR 2.04; 95% CI 1.47 to 2.82), hypertension (OR 1.69; 95% CI 1.10 to 2.61) and cerebrovascular disease (OR 1.87; 95% CI 1.31 to 2.68) were independently associated with increased risk of death. The mortality risk did not differ between the quintiles of deprivation. High-sensitivity troponin I was the best predictor of mortality among biomarkers (OR 4.43; 95% CI 3.10 to 7.10). Angiotensin-receptor blockers (OR 0.57; 95% CI 0.33 to 0.96) and ACE inhibitors (OR 0.65; 95% CI 0.43 to 0.97) were not associated with adverse outcome. The Charlson Index of Comorbidity scores were significantly higher in non-survivors. The combined prevalence of hypertension and diabetes appears to confer the greatest risk, where diabetes may have a modulating effect. Hypertension and cerebrovascular disease had a significant impact on inpatient mortality.

Pulmonary adverse drug event data in hypertension with implications on COVID-19 morbidity

Scientific Reports, June 25, 2021

Hypertension is a recognized comorbidity for COVID-19. The association of antihypertensive medications with outcomes in patients with hypertension is not fully described. However, angiotensin-converting enzyme 2 (ACE2), responsible for host entry of the novel coronavirus (SARS-CoV-2) leading to COVID-19, is postulated to be upregulated in patients taking angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs). Here, we evaluated the occurrence of pulmonary adverse drug events (ADEs) in patients with hypertension receiving ACEIs/ARBs to determine if disparities exist between individual drugs within the respective classes using data from the FDA Spontaneous Reporting Systems. For this purpose, we proposed the proportional reporting ratio to provide a statistical summary for the commonality of an ADE for a specific drug as compared to the entire database for drugs in the same or other classes. In addition, a statistical procedure, multiple logistic regression analysis, was employed to correct hidden confounders when causative covariates are underreported or untrusted to correct analyses of drug-ADE combinations. To date, analyses have been focused on drug classes rather than individual drugs which may have different ADE profiles depending on the underlying diseases present. A retrospective analysis of thirteen pulmonary ADEs showed significant differences associated with quinapril and trandolapril, compared to other ACEIs and ARBs. Specifically, quinapril and trandolapril were found to have a statistically significantly higher incidence of pulmonary ADEs compared with other ACEIs as well as ARBs (P < 0.0001) for group comparison (i.e., ACEIs vs. ARBs vs. quinapril vs. trandolapril) and (P ≤ 0.0007) for pairwise comparison (i.e., ACEIs vs. quinapril, ACEIs vs. trandolapril, ARBs vs. quinapril, or ARBs vs. trandolapril). This study suggests that specific members of the ACEI antihypertensive class (quinapril and trandolapril) have a significantly higher cluster of pulmonary ADEs.

Investigating the implications of COVID-19 outbreak on systems of care and outcomes of STEMI patients: A systematic review and meta-analysis

Indian Heart Journal, June 25, 2021

There has been a concern whether the decrease in ST-segment elevation myocardial infarction (STEMI) cases during the COVID-19 pandemic era is related to unsatisfactory performance of STEMI systems of care as well as worsening of the clinical outcomes in STEMI patients. Thus, our meta-analysis was conducted to evaluate this matter. We compared the predetermined variables in this meta-analysis during the early and late pandemic. Using a combination of adapted search terms to fit the requirements of several search engines (PubMed, EuropePMC, SCOPUS, ProQuest, and EBSCOhost), we reviewed all observational studies citing our outcomes of interest before and during the outbreak. Thirty-five records comprising a total of 62,244 participants were identified. Overall, our meta-analysis showed that there was a huge reduction of nearly 80% for STEMI admission during the outbreak (n=10,263) in contrast to before the outbreak period (n=51,984). STEMI patients who were admitted during the outbreak received less primary PCI and had longer symptom-to-FMC (first medical contact) time along with prolonged door-to-balloon time. A decrease in the achievement of final TIMI 3 flow after primary PCI was also observed in this study. However, the number of in-hospital mortality was similar between two groups.

FDA Authorizes IL-6 Inhibitor for Severe COVID-19 Patients

MedPage Today, June 25, 2021

Tocilizumab (Actemra), an interleukin-6 (IL-6) inhibitor, was authorized to treat certain hospitalized COVID-19 patients, the FDA announced late on Thursday. The drug received emergency use authorization (EUA) for hospitalized patients ages 2 and up who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO). It is not authorized for outpatients, the agency said. “Providing additional therapies for those who do become hospitalized is an important step in combating this pandemic,” said Patrizia Cavazzoni, MD, director of the FDA’s Center for Drug Evaluation and Research, in a statement. Tocilizumab is an IL-6 inhibitor given by intravenous infusion, which is approved to treat inflammatory diseases such as rheumatoid arthritis, and is used in certain hematologic cancers to quell cytokine release syndrome following CAR T-cell therapy. Results of early trials in COVID-19 patients were mixed, but the FDA pointed to the results of four randomized trials, two of which showed either a mortality benefit or an improvement in composite clinical outcomes. Chief among them was the UK’s pragmatic RECOVERY trial, which found a significantly lower risk of death by day 28 compared to usual care (31% vs 35%, respectively) among patients with COVID-19 pneumonia treated with tocilizumab. The tocilizumab group also had a shorter hospital stay (19 vs 28 days). The agency also noted results of the EMPACTA trial, where a significantly lower proportion of COVID-19 patients treated with tocilizumab progressed to mechanical ventilation or died by day 28 versus those receiving only usual care (12% vs 19%).

FDA to Add Warning on Rare Myocarditis Risk After COVID Vaccination

MedPage Today, June 23, 2021

Given the reported cases of myocarditis in young people who received mRNA COVID-19 vaccines, FDA will include a warning statement about the risks and characteristics of this rare condition, an agency representative said at CDC’s Advisory Committee on Immunization Practices (ACIP) meeting on Wednesday. Data presented by CDC staff estimated a rate of 12.6 cases per million within 3 weeks of a second dose of either Pfizer’s or Moderna’s mRNA vaccine for individuals ages 12 to 39. Rates were highest among boys and younger men. The side effect was rare, but when it occurred, it was typically within a week of vaccination. FDA liaison representative, Doran Fink, MD, PhD, noted the agency will add a warning about the risk of myocarditis or pericarditis following vaccination that states “these events have occurred in some recipients following dose 2, onset of symptoms was several days to a week” and based on limited follow-up, “most cases had a resolution of symptoms.” The warning would also advise anyone experiencing these symptoms to “seek medical attention” and state that information on long-term sequelae with the condition is limited. CDC staff said they would update their vaccine fact sheets with more comprehensive information in the coming days. While there was no vote scheduled during the ACIP meeting, the committee seemed to agree with CDC staff that the benefits of COVID-19 vaccination continue to outweigh the risks of vaccination in people ages 12 and older.

Researchers find losartan is not effective in reducing hospitalization from mild COVID-19

Science Daily, June 18, 2021

University of Minnesota Medical School researchers determined that the common blood pressure medication, losartan, is not effective in reducing hospitalization for mildly-ill COVID-19 outpatients. In the multicenter, randomized, double-blinded clinical trial, non-hospitalized patients recently diagnosed with COVID-19 were given either losartan or a placebo and monitored for 15 days. The study’s results, which were published in EClinicalMedicine, showed that although losartan does not reduce the likelihood of hospitalization, the medication does not appear to worsen symptoms of COVID-19 or have any significant or harmful side effects on patients with mild COVID-19. “Based on our results, there is no benefit to starting losartan for newly diagnosed outpatients with COVID-19, but those who are already taking the medication for pre-existing health conditions should feel safe continuing it,” said Michael Puskarich, MD, an associate professor in the Department of Emergency Medicine at the U of M Medical School and co-principal investigator of this study. He is also an emergency physician at Hennepin Healthcare. “Given SARS-CoV-2 binding with ACE2 there has been significant research interest into the utility of ACE and AT1R blocking agents to combat COVID-19. This study provides insight that for patients with mild COVID-19, who do not require hospital admission, that there is no benefit or harm from such agents,” said co-principal investigator Christopher Tignanelli, MD, MS, an assistant professor in the Department of Surgery at the U of M Medical School and critical care surgeon with M Health Fairview.

Decline in CV testing at start of pandemic varied by region

Healio | Cardiology Today, June 17, 2021

At the beginning of the COVID-19 pandemic, diagnostic CV volumes declined, but the drops varied by U.S. region, according to data from the INCAPS-COVID registry. “Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for CVD morbidity and mortality,” Cole B. Hirschfeld, MD, internal medicine resident at Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, and colleagues wrote in JACC: Cardiovascular Imaging. “We compared laboratory characteristics, practices and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States.” The researchers analyzed 1.3 million imaging studies from the INCAPS-COVID registry of 909 centers in 108 countries, including 155 centers in 40 U.S. states. They compared data from April 2020, at the start of the COVID-19 pandemic, with data from March 2019. Diagnostic CV procedures fell in April 2020 across the globe, at rates similar in and outside of the U.S. (U.S., 68%; non-U.S., 63%; P = .237), according to the researchers. However, they found, invasive coronary angiography procedures declined more sharply in the U.S. compared with elsewhere (69% vs. 53%; P < .001). U.S. centers were more likely than non-U.S. centers to report increased use of telehealth (90% vs. 65%; P < .001), of temperature checks for on-site patients (87% vs. 77%; P = .008), of symptom screening (97% vs. 86%; P < .001) and of COVID-19 testing (46% vs. 26%; P < .001). In the U.S., reduction in diagnostic CV procedure volume varied by region, with the decline higher in the Northeast (76%) and Midwest (74%) than in the South (62%) and the West (44%), according to the researchers.

Cardiovascular biomarkers in COVID-19

European Heart Journal: Acute Cardiovascular Care, June 14, 2021

Although primarily a respiratory infectious disease that may be complicated with acute respiratory distress syndrome (ARDS), cardiovascular involvement is common in COVID-19. Cardiovascular complications are commonly observed in hospitalized patients with COVID-19, and individuals with pre-existing cardiovascular disease are disproportionately affected. Accordingly, cardiovascular biomarkers, including markers of myocardial injury (cardiac troponins), haemodynamic stress (B-type natriuretic peptides), and fibrin degradation products (D-dimer), are commonly elevated in proportion to disease severity in COVID-19. The frequency of myocardial injury is particularly high in critically ill patients with ARDS, those requiring mechanical ventilation and in non-survivors. Notably, the range of myocardial injury in COVID-19 is wide, and most patients demonstrate lower levels than commonly observed in acute myocardial infarction. A variety of mechanisms may contribute to myocardial injury in COVID-19. In addition to pre-existing chronic myocardial injury, these include direct viral injury to the myocardium, i.e. viral myocarditis, and acute myocardial infarction. However, these complications are considered to be relatively rare in COVID-19. COVID-19 may also be associated with a pronounced pro-inflammatory state reflected in increased levels of C-reactive protein and IL6, sometimes alluded to as a cytokine storm, which may also cause myocardial injury reflected in rise in cardiac troponin levels. Biomarkers that provide information from different pathophysiological axes, such as growth differentiation factor 15 (GDF-15), may provide particularly strong prognostic information. COVID-19 is also associated with a prothrombotic state. As a result, platelet and clotting factor consumption is reflected in a lower platelet count and increased D-dimer. Direct viral effects in the bone marrow and interactions with platelets, may also contribute to thrombocytopenia.

COVID-19 related cardiac complications – from clinical evidences to basic mechanisms. Opinion paper of the ESC Working Group on Cellular Biology of the Heart

Cardiovascular Research, June 12, 2021

The pandemic of Coronavirus disease (COVID)-19 is a global threat, causing high mortality, especially in the elderly. The main symptoms and the primary cause of death are related to interstitial pneumonia. Viral entry also into myocardial cells mainly via the angiotensin converting enzyme type 2 (ACE2) receptor and excessive production of pro-inflammatory cytokines, however, also make the heart susceptible to injury. In addition to the immediate damage caused by the acute inflammatory response, the heart may also suffer from long-term consequences of COVID-19, potentially causing a post-pandemic increase in cardiac complications. Although the main cause of cardiac damage in COVID-19 remains coagulopathy with micro- (and to a lesser extent macro-) vascular occlusion, open questions remain about other possible modalities of cardiac dysfunction, such as direct infection of myocardial cells, effects of cytokines storm, and mechanisms related to enhanced coagulopathy. In this opinion paper, we focus on these lesser appreciated possibilities and propose experimental approaches that could provide a more comprehensive understanding of the cellular and molecular bases of cardiac injury in COVID-19 patients. We first discuss approaches to characterize cardiac damage caused by possible direct viral infection of cardiac cells, followed by formulating hypotheses on how to reproduce and investigate the hyperinflammatory and pro-thrombotic conditions observed in the heart of COVID-19 patients using experimental in vitro systems. Finally, we elaborate on strategies to discover novel pathology biomarkers using omics platforms.

FDA Approves Third COVID-19 Antibody Treatment for Emergency Use

Pulmonology Advisor, June 11, 2021

[Press Release] A third antibody treatment designed to keep high-risk COVID-19 patients from being hospitalized was approved for emergency use by the U.S. Food and Drug Administration on Wednesday. Importantly, in lab tests, the newly authorized drug, dubbed sotrovimab, neutralized the highly infectious virus variant that is crippling India, as well as variants first spotted in Britain, South Africa, Brazil, California, and New York. “With the authorization of this monoclonal antibody treatment, we are providing another option to help keep high-risk patients with COVID-19 out of the hospital,” Patrizia Cavazzoni, M.D., director of the FDA Center for Drug Evaluation and Research, said in an agency news release. “It is important to expand the arsenal of monoclonal antibody therapies that are expected to retain activity against the circulating variants of COVID-19 in the United States.” Developed by GlaxoSmithKline, in concert with the American company Vir Biotechnology, the drug should become available to Americans “in the coming weeks,” company officials said in a statement. “Sotrovimab is a critical new treatment option in the fight against the current pandemic and potentially for future coronavirus outbreaks as well,” said George Scangos, Ph.D., Vir’s chief executive officer. GSK and Vir’s treatment is a single drug, designed to mimic the antibodies generated when the immune system fights off the coronavirus. Its emergency use authorization was based on a study of 583 volunteers who had started experiencing symptoms within the previous five days. The study showed that those who received the GSK-Vir treatment had an 85 percent reduction in their risk for hospitalization or death compared with those who received placebo.

AMA survey: 96% of physicians fully vaccinated against COVID-19

Healio | Primary Care, June 11, 2021

Most practicing physicians in the United States who were surveyed reported being fully vaccinated against COVID-19, with no significant differences in vaccination by gender, age or geographic location, according to the AMA. The organization administered the survey from June 3 to 8. About 300 physicians responded to the survey; half of them were primary care physicians. Of the 11 non-vaccinated physicians who participated in the survey, five said that they plan on receiving the COVID-19 vaccine. The AMA said that the most common reason for not being vaccinated was that the COVID-19 vaccine is “too new and has unknown long-term effects.” With more than 96% of physicians reporting to be fully vaccinated, the data yield a 20% increase in vaccinated physicians compared with a poll conducted by Medscape last month, according to an AMA press release. “Practicing physicians across the country are leading by example, with an amazing uptake of the COVID-19 vaccines,” AMA President Susan R. Bailey, MD, said in the release. “Physicians and clinicians are uniquely positioned to listen to and validate patient concerns, and one of the most powerful anecdotes a physician can offer is that they themselves have been vaccinated.”

Improving heart health may reduce the severity of COVID-19 disease

European Society of Cardiology, June 10, 2021

[Press Release] High blood pressure, smoking, obesity, heart disease and diabetes are associated with worse outcomes in patients with COVID-19, according to a study published today in European Heart Journal – Quality of Care and Clinical Outcomes, a journal of the European Society of Cardiology (ESC). “Many of the cardiovascular risk factors associated with more severe consequences from COVID-19 are potentially modifiable,” said study author Dr. Stephanie Harrison of the University of Liverpool, UK. “Clinicians and policy makers should consider that strategies which improve cardiovascular health may also improve outcomes for people following COVID-19.” Emerging evidence has suggested that COVID-19 patients with heart disease may be more likely to need hospitalisation or ventilation or die from COVID-19 compared to those without heart disease. Studies have also examined whether risk factors for cardiovascular disease such as high blood pressure and smoking may be linked with poor outcomes from COVID-19. Many reviews have been conducted to consolidate the research linking cardiovascular disease and COVID-19. The aim of this study, commissioned by Public Health England, was to summarise the evidence in these reviews – i.e. a review of reviews – to address two questions: 1) What is the association between cardiovascular risk factors or cardiovascular disease and outcomes for patients with COVID-19? 2) What is the impact of COVID-19 on cardiovascular health? The authors identified the highest quality reviews – a total of 32 reviews including studies of up to ~45,000 patients with COVID-19. The factors associated with a higher likelihood of worse outcomes from COVID-19 were high blood pressure, current or past smoking, obesity, diabetes, previous stroke or pre-existing cardiovascular disease, liver disease, and kidney disease. Heart disease was linked with a nearly four-fold odds of severe COVID-19, while the odds were more than doubled for hypertension and diabetes, and 80% higher in smokers compared to non-smokers”

Cardiovascular risk factors, cardiovascular disease, and COVID-19: an umbrella review of systematic reviews

European Heart Journal – Quality of Care and Clinical Outcomes, June 9, 2021

Our aims were to consolidate evidence to determine (i) the association between cardiovascular risk factors and health outcomes with coronavirus 2019 (COVID-19); and (ii) the impact of COVID-19 on cardiovascular health. An umbrella review of systematic reviews was conducted. Fourteen medical databases and pre-print servers were searched from 1 January 2020 to 5 November 2020. The review focused on reviews rated as moderate or high-quality using the AMSTAR 2 tool. Eighty-four reviews were identified; 31 reviews were assessed as moderate quality and one was high-quality. The following risk factors were associated with higher mortality and severe COVID-19: renal disease [odds ratio (OR) (95% confidence interval) for mortality 3.07 (2.43–3.88)], diabetes mellitus [OR 2.09 (1.80–2.42)], hypertension [OR 2.50 (2.02–3.11)], smoking history [risk ratio (RR) 1.26 (1.20–1.32)], cerebrovascular disease [RR 2.75 (1.54–4.89)], and cardiovascular disease [OR 2.65 (1.86–3.78)]. Liver disease was associated with higher odds of mortality [OR 2.81 (1.31–6.01)], but not severe COVID-19. Current smoking was associated with a higher risk of severe COVID-19 [RR 1.80 (1.14–2.85)], but not mortality. Obesity associated with higher odds of mortality [OR 2.18 (1.10–4.34)], but there was an absence of evidence for severe COVID-19. In patients hospitalized with COVID-19, the following incident cardiovascular complications were identified: acute heart failure (2%), myocardial infarction (4%), deep vein thrombosis (7%), myocardial injury (10%), angina (10%), arrhythmias (18%), pulmonary embolism (19%), and venous thromboembolism (25%). Many of the risk factors identified as associated with adverse outcomes with COVID-19 are potentially modifiable. Primary and secondary prevention strategies that target cardiovascular risk factors may improve outcomes for people following COVID-19.

COVID-19 Increases Health Inequities in Patients With Hypertension

Cardiology Advisor, June 8, 2021

Among individuals with high blood pressure, COVID-19 has disproportionately affected underserved racial, ethnic, and socioeconomic groups, according to a report recently published in the Journal of the American Heart Association. This report draws on the work of several sources, including a diverse group of experts that discussed this matter as well as rectification strategies at the recent Fourth Annual University of Utah Translational Hypertension Symposium. The results of a nationwide blood pressure study of more than 50,000 adults show that a decrease in the numbers of people with healthy blood pressure levels is linked with inadequate health care and insurance. From 2017 to 2018, 40% to 46% of insured Americans had healthy blood pressure, compared with 22% of those who were uninsured. Compared with White adults, Black adults had a 12% lower likelihood for healthy blood pressure. The threshold for high blood pressure in this study was above 140/90 mmHg. Lifestyle modifications, a lack of in-person visits, and poor medication adherence are challenges to healthy blood pressure. During the COVID-19 pandemic, hospitalizations for stroke, heart attack, and heart failure decreased, but out-of-hospital deaths increased by 20%. Other researchers showed that bias among health care professionals resulted in differing care quality and clinical inertia, both of which affect blood pressure management. A concerning trend, according to investigators, is distrust of health care professionals by people of color. Trust can be improved through community intervention programs such as the successful BARBER trial in Los Angeles. A low percentage of health care researchers and medical school students are from under-resourced communities. The study researchers concluded that “COVID-19 has disproportionately affected people from different racial and ethnic groups, those who are from under-resourced populations and communities that face historic or systemic disadvantages.”

Vaccine-induced Thrombotic Thrombocytopenia (VITT) and COVID-19 Vaccines: What Cardiovascular Clinicians Need to Know

American College of Cardiology, June 8, 2021

Organized in an FAQ format for easy navigation, this guidance is summarized from more extensive documents and approved by the ACC Science and Quality Committee. This FAQ is intended to be topical, not comprehensive. In extremely rare cases, the Johnson & Johnson/Jansen and Astra Zeneca COVID-19 vaccinations may cause vaccine-induced thrombotic thrombocytopenia (VITT), a condition characterized by simultaneous acute thrombosis and thrombocytopenia. The condition is similar to heparin-induced thrombocytopenia. Specific risk factors for VITT have yet to be determined given the extremely low case count, though presentation seems to appear between 5-28 days post vaccination. Patients should be reassured that the benefits of vaccination against COVID-19 far outweigh any potential risk. Diagnostic, therapeutic, and patient communication recommendations are included.

Improved Outcomes With Methylprednisolone in Hospitalized Hypoxic Patients With COVID-19

Cardiology Advisor, June 4, 2021

Treatment with methylprednisolone led to significantly greater improvements in clinical status and shortened hospital length of stay than treatment with dexamethasone in hospitalized COVID-19 patients with hypoxia, according to the results of a study published in BMC Infectious Diseases. This prospective trial included 86 hospitalized patients with COVID-19 in Iran. Participants were randomly assigned to either methylprednisolone 2 mg/kg/d (n=44) or dexamethasone 6 mg/kg/d (n=42). Treatment was administered in conjunction with standard of care for 10 days. The primary endpoint was 28-day mortality rate and clinical status at 5 and 10 days. The data were examined using a 9-point World Health Organization (WHO) ordinal scale ranging from uninfected (point 0) to death (point 8). Secondary endpoints included intensive care unit admission and the need for invasive mechanical ventilation. No significant differences were observed between the treatment groups in terms of demographic variables, comorbid diseases, or disease severity at time of admission. At day 5, however, patients treated with methylprednisolone reached a significantly better clinical status compared with patients who received dexamethasone (4.02 vs 5.21, respectively; P =.002). Patients in the methylprednisolone group also had better clinical status at day 10 (2.90 vs 4.71; P =.001). Patients in the methylprednisolone group had a significantly better overall mean 9-point WHO score (3.909 vs 4.873; P =.004). The use of methylprednisolone was also associated with a significantly shorter mean length of hospital stay (7.43±3.64 vs 10.52±5.47 days; P =.015). A lower proportion of patients in the methylprednisolone group required a ventilator during hospitalization (18.2% vs 38.1%; P =.040).

COVID-19 may increase risk for MI in patients with ASCVD, familial hypercholesterolemia

Healio | Cardiology Today, June 4, 2021

Adults with preexisting atherosclerotic CVD and/or familial hypercholesterolemia have increased risk for acute MI if infected with COVID-19, according to an analysis published in the American Journal of Preventive Cardiology. “CVD, hypertension and heart failure are associated with higher rates of COVID-19-related morbidity and mortality,” Kelly D. Myers, BS, chief technology officer at the FH Foundation and CEO of Atomo Inc. in Austin, Texas, and colleagues wrote. “However, studies have documented fewer individuals presenting to hospital with acute MI during the pandemic.” Researchers assessed laboratory data and diagnostic, procedural and prescription claims from Symphony Health from May 2012 to June 2020. In total, 55,441,462 adults who were evaluated or treated for CVD with valid demographic data and at least one record before COVID-19 and one after the pandemic were analyzed. Acute MI rates for all individuals were assessed through COVID-19 status and history. Individuals with and without COVID-19 were then categorized into groups and matched based on the presence or lack of comorbidities before COVID-19: ASCVD (176,946 with COVID-19; 12,051,757 without COVID-19); familial hypercholesterolemia (FH; 1,216 with COVID-19; 121,396 without COVID-19); probable FH (3,369 with COVID-19; 334,724 without COVID-19); FH and ASCVD (1,399 with COVID-19; 89,396 without COVID-19); probable FH and ASCVD (3,833 with COVID-19; 253,449 without COVID-19); and no FH nor ASCVD (447,192 with COVID-19; 41,956,785 without COVID-19). According to the researchers, there were increased rates of acute MI among individuals with COVID-19 compared with matched individuals without COVID-19 in the group with ASCVD (1.4% vs. 0.46%; P < .0002), in the group with FH (0.41% vs. 0.12%; P = .003), in the group with probable FH (0.5% vs. 0.12%; P < .0002), in the group with FH and ASCVD (1.57% vs. 0.56%; P < .0002), in the group with probable FH and ASCVD (2.09% vs. 0.5%; P < .0002) and in the group with neither disease (0.34% vs. 0.11%; P < .0002).

Inverse association between hypertension treatment and COVID-19 prevalence in Japan

International Journal of Infectious Diseases, June 3, 2021

Cell entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) depends on angiotensin-converting enzyme II (ACE2). ACE2 is homologous with, but acts antagonistically to, angiotensin-converting enzyme (ACE), and has the critical function of protecting the lungs. ACE inhibitors are major antihypertensive agents. Thus, we aimed to analyze the impact of the prevalence of preexisting hypertension on the local spread of coronavirus disease 2019. Data on SARS-CoV-2 infection and the estimated number of patients who received medical treatment based on disease classification using the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, in each prefecture were obtained from the official Japanese notifications database. We analyzed the association between the proportion of patients with each disease and SARS-CoV-2-infection prevalence. The ratio of patients treated for diseases of the circulatory system, especially hypertensive disorders, per population demonstrated the most significant negative correlation with SARS-CoV-2-infection prevalence (Spearman’s rank correlation, p < 0.01). Age group analysis revealed a significant negative correlation in age groups 35–44, 45–54, 55–64, 75–84, and ≥85. Our findings suggest that hypertension treatment may play a protective role against the local spread of SARS-CoV-2 infection.

Hypertension, renin-angiotensin-aldosterone-system-blocking agents, and COVID-19

Clinical Hypertension, June 1, 2021

There have been concerns regarding the safety of renin-angiotensin-aldosterone-system (RAAS)-blocking agents including angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) during the coronavirus disease 2019 (COVID-19) pandemic. This study sought to evaluate the impact of hypertension and the use of ACEI/ARB on clinical severity in patients with COVID-19. A total of 3,788 patients aged 30 years or older who were confirmed with COVID-19 with real time reverse transcription polymerase chain reaction were identified from a claims-based cohort in Korea. The primary study outcome was severe clinical events, a composite of intensive care unit admission, need for ventilator care, and death. Patients with hypertension (n = 1,190, 31.4 %) were older and had higher prevalence of comorbidities than those without hypertension. The risk of the primary study outcome was significantly higher in the hypertension group, even after multivariable adjustment (adjusted odds ratio [aOR], 1.67; 95 % confidence interval [CI], 1.04 to 2.69). Among 1,044 patients with hypertensive medical treatment, 782 (74.9 %) were on ACEI or ARB. The ACEI/ARB subgroup had a lower risk of severe clinical outcomes compared to the no ACEI/ARB group, but this did not remain significant after multivariable adjustment (aOR, 0.68; 95 % CI, 0.41 to 1.15).

Dysrhythmias in Patients With COVID-19

Cardiology Advisor, May 27, 2021

A 76-year-old man who was diagnosed with COVID-19 and discharged from the emergency department (ED) 2 days prior, returns to the ED with worsening shortness of breath, fatigue, and nonproductive cough. The patient has no associated fevers, chest pain, or gastrointestinal symptoms. An electrocardiogram (ECG) reveals new-onset atrial fibrillation (AF) with a ventricular rate of 115 beats per minute and elevated troponin level. The patient’s oxygen saturation is 80% on room air. He is initially placed on a nonrebreather mask, which is quickly escalated to a high-flow oxygen therapy via nasal cannula. Oxygen saturation improves to 93% with 80% fraction of inspired oxygen on 35 L/min flow. He is admitted for COVID-19 pneumonia and initiated on dexamethasone, remdesivir, empiric IV antibiotics, and enoxaparin for venous thromboembolism prophylaxis. Cardiology and pulmonology are consulted. Laboratory results of note include elevated white blood cell count (14,300/µL), neutrophil (1000/µL), troponin (0.52 ng/mL), creatine kinase (642 U/L), C-reactive protein (289.8 mg/dL), D-dimer (3.82 µg/mL), and N-terminal pro-BNP (brain natriuretic peptide; 700 pg/mL) levels. Mild decreases in sodium (133 mEq/L), chloride (97 mEq/L), and albumin (2.7 g/dL) are also noted. The remainder of the basic metabolic panel, liver panel, complete blood count, and coagulation studies are within normal limits. The patient’s chest radiograph reveals bilateral interstitial pneumonitis. An echocardiogram reveals severe aortic stenosis and normal ejection fraction with moderate aortic regurgitation. Pulmonary computed tomography angiogram does not demonstrate pulmonary emboli but does show evidence of COVID-19 infection, noting bilateral ground-glass opacities with possible underlying pulmonary fibrosis.

Prevalence of Clinical and Subclinical Myocarditis in Competitive Athletes With Recent SARS-CoV-2 Infection: Results From the Big Ten COVID-19 Cardiac Registry

JAMA Cardiology, May 27, 2021

Myocarditis is a leading cause of sudden death in competitive athletes. Myocardial inflammation is known to occur with SARS-CoV-2. Different screening approaches for detection of myocarditis have been reported. The Big Ten Conference requires comprehensive cardiac testing including cardiac magnetic resonance (CMR) imaging for all athletes with COVID-19, allowing comparison of screening approaches. The objective was to determine the prevalence of myocarditis in athletes with COVID-19 and compare screening strategies for safe return to play. For athletes with myocarditis, presence of cardiac symptoms and details of cardiac testing were recorded. Myocarditis was categorized as clinical or subclinical based on the presence of cardiac symptoms and CMR findings. Subclinical myocarditis classified as probable or possible myocarditis based on other testing abnormalities. Myocarditis prevalence across universities was determined. The utility of different screening strategies was evaluated. Representing 13 universities, cardiovascular testing was performed in 1597 athletes (964 men [60.4%]). Thirty-seven (including 27 men) were diagnosed with COVID-19 myocarditis (overall 2.3%; range per program, 0%-7.6%); 9 had clinical myocarditis and 28 had subclinical myocarditis. If cardiac testing was based on cardiac symptoms alone, only 5 athletes would have been detected (detected prevalence, 0.31%). Cardiac magnetic resonance imaging for all athletes yielded a 7.4-fold increase in detection of myocarditis (clinical and subclinical). Follow-up CMR imaging performed in 27 (73.0%) demonstrated resolution of T2 elevation in all (100%) and late gadolinium enhancement in 11 (40.7%).

Acute myocarditis related to Covid-19 infection: 2 cases report

Annals of Medicine & Surgery, May 26, 2021

Since COVID 19 was described for the first time in December 2019, we have not stopped discovering its different clinical manifestations. Despite the respiratory complication, which is the most common symptomatology, multi-organ dysfunction, and multiple cardiovascular complications were described such as acute myocarditis, heart failure and even arrhythmias. Two patients aged 26 and 56 year-old, developed acute myocarditis related to Covid-19 infection but with different symptomatology. Case 1 presented to the emergency room with digestive symptomatology, Covid-19 infection was confirmed by a positive chest CT scan and positive COVID-19 serology testing. Clinical, biological, radiological findings allowed making the diagnosis of a Covid-19 infection with a bacterial superinfection complicated by a fulminant myocarditis. Case 2 presented to the emergency department with a chest pain, dyspnoea, paroxistic cough, myalgia and fever. A Covid-19 infection was confirmed. The electrocardiogram showed a diffuse ST elevation, echocardiography showed normal systolic function and the high-sensitivity cardiac troponin I level was high. Invasive coronary angiography was performed, revealing angiographically normal coronary arteries. Our 2 cases was treated differently, case 1 received antibiotherapy because of the bacterial superinfection and inotropic support for the septic and cardiogenic choc. Contrarily to case 2 who received inotropic support, immunoglobulin and corticosteroid. With a total recovery for both patients.

Takotsubo syndrome during the COVID-19 pandemic, state-of -the- art review

CJC Open, May 26, 2021

The current coronavirus disease 2019 (COVID-19) presents an ongoing medical challenge with multiple organs involvement, including the cardiovascular system. Takotsubo syndrome (TTS) has been described in the context of COVID-19 in two different scenarios: as a direct complication of the infection, and as an indirect outcome secondary to psychological burden of quarantine and social isolation (i.e., stress induced cardiomyopathy). Confirming the diagnosis of TTS in COVID-19 may be challenging due to the limited use of coronary angiography consistent with the recommended guidelines aimed to minimize contact with infected individuals. The use of natriuretic peptide as a diagnostic and prognostic marker in this context may not be reliable since this peptide is already elevated in severe cases of COVID-19 regardless of TTS diagnosis. A relatively high incidence of complications has been reported in these cases, probably related to the severity of the underlying infectious disease. Although quarantine-induced stress cardiomyopathy is a reasonable outcome of the powerful stress during the current pandemic, conflicting results have been reported, and further studies are encouraged to determine the true incidence.

Classification of COVID-19 electrocardiograms by using hexaxial feature mapping and deep learning

BMC Medical Informatics and Decision Making, May 25, 2021

Coronavirus disease 2019 (COVID-19) has become a pandemic since its first appearance in late 2019. Deaths caused by COVID-19 are still increasing day by day and early diagnosis has become crucial. Since current diagnostic methods have many disadvantages, new investigations are needed to improve the performance of diagnosis. A novel method is proposed to automatically diagnose COVID-19 by using Electrocardiogram (ECG) data with deep learning for the first time. Moreover, a new and effective method called hexaxial feature mapping is proposed to represent 12-lead ECG to 2D colorful images. Gray-Level Co-Occurrence Matrix (GLCM) method is used to extract features and generate hexaxial mapping images. These generated images are then fed into a new Convolutional Neural Network (CNN) architecture to diagnose COVID-19. Two different classification scenarios are conducted on a publicly available paper-based ECG image dataset to reveal the diagnostic capability and performance of the proposed approach. In the first scenario, ECG data labeled as COVID-19 and No-Findings (normal) are classified to evaluate COVID-19 classification ability. According to results, the proposed approach provides encouraging COVID-19 detection performance with an accuracy of 96.20% and F1-Score of 96.30%. In the second scenario, ECG data labeled as Negative (normal, abnormal, and myocardial infarction) and Positive (COVID-19) are classified to evaluate COVID-19 diagnostic ability. The experimental results demonstrated that the proposed approach provides satisfactory COVID-19 prediction performance with an accuracy of 93.00% and F1-Score of 93.20%. Furthermore, different experimental studies are conducted to evaluate the robustness of the proposed approach.

Despite being fully vaccinated, transplant recipients remain at greater risk for COVID-19

Helio | Nephrology News & Issues, May 24, 2021

After a second dose of either the Moderna or Pfizer-BioNTech COVID-19 vaccine, solid organ transplant recipients failed to achieve an antibody response against SARS-CoV-2 comparable to the general population. According to a related press release, this study continues research that the team from Johns Hopkins School of Medicine conducted earlier in 2021, which showed 17% of transplant recipients “produced sufficient antibodies” after one dose of the two-dose regimen. “While there was an increase in those with detectable antibodies — 54% overall — after the second shot, the number of transplant recipients in our second study whose antibody levels reached high enough levels to ward off a SARS-CoV-2 infection was still well below what’s typically seen in people with healthy immune systems,” Brian J. Boyarsky, MD, PhD, said in the release. “Based on our findings, we recommend that transplant recipients and other immunocompromised patients continue to practice strict COVID-19 safety precautions, even after vaccination.” For the study, Boyarsky and colleagues included 658 transplant recipients who completed a two-dose vaccine regimen between December 2020 and March 2021. Researchers found the first dose led to a detectable antibody response in 15% of transplant recipients; the response occurred at a median of 21 days after the first dose was administered. After the second dose, an antibody response was detectable in 54% of participants, occurring a median of 29 days later (46% had no response after either dose).

Inequities in Hypertension Care Magnified by the COVID-19 Pandemic

Cardiology Advisor, May 24, 2021

During the 4th Annual University of Utah Translational Hypertension Symposium, there was a discussion about the inequities in health care for the diagnosis and management of hypertension in the United States and how these inequities have been exacerbated by the COVID-19 pandemic. A synopsis of this discussion was published in the Journal of the American Heart Association. As of March of 2021, more than half a million Americans have died from COVID-19. Due to the increased burden on the healthcare system the management of chronic conditions has been interrupted for many patients and this disruption will likely have long-term consequences. This is particularly concerning for hypertension, as it is one of the leading causes of cardiovascular disease. During the conference, clinicians described that they had substantially reduced or completely discontinued in-person outpatient hypertension consultations. During telemedicine visits, it was apparent that most patients did not have access to validated at-home blood pressure monitors, as only 15% on the market are validated. During the few years before the pandemic, there has been a trend for blood pressure control rates to be on the decline. This pattern has been more pronounced among minority populations in the United States, likely due to disparities in healthcare access. Inadequate control of blood pressure has been associated with healthcare disparities, lack of physical activity, poor access to healthy foods, low health literacy, and distrust of the healthcare system. Addressing inequalities in hypertension health care must include national and state health policies, local community outreach, the healthcare organization and practice, the clinical team, and the individual patient and support network.

COVID-19 vaccine benefits still outweigh risks, despite possible rare heart complications

American Heart Association, May 23, 2021

Late last week, the U.S. Centers for Disease Control and Prevention (CDC) alerted health care professionals that they are monitoring the Vaccine Adverse Events Reporting System (VAERS) and the Vaccine Safety Datalink (VSD) for cases of young adults developing the rare heart-related complication myocarditis, after receiving a COVID-19 vaccine manufactured by Pfizer-BioNTech or Moderna. The COVID-19 Vaccine Safety Technical Work Group (VaST) of the CDC’s Advisory Committee on Immunization Practices (ACIP) is reviewing several dozen cases of myocarditis that have been reported in adolescents and young adults: more often in males rather than females; more frequently after the second dose rather than the first dose of either the Pfizer-BioNTech or Moderna vaccine; and typically appearing within 4 days of vaccination. The benefits of COVID-19 vaccination enormously outweigh the rare, possible risk of heart-related complications, including inflammation of the heart muscle, or myocarditis. The American Heart Association/American Stroke Association, a global force for longer, healthier lives, urges all adults and children ages 12 and older in the U.S. to receive a COVID vaccine as soon as they can

Echocardiographic Correlates of In-Hospital Death in Patients with Acute COVID-19 Infection: The World Alliance Societies of Echocardiography (WASE-COVID) Study

Journal of the American Society of Echocardiography, May 20, 2021

The novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus which has led to the global Coronavirus disease-2019 (COVID-19) pandemic is known to adversely affect the cardiovascular system through multiple mechanisms. In this international, multi-center study conducted by the World Alliance Societies of Echocardiography (WASE), we aim to determine the clinical and echocardiographic phenotype of acute cardiac disease in COVID-19 patients, to explore phenotypic differences in different geographic regions across the world, and to identify parameters associated with in-hospital mortality. We studied 870 patients with acute COVID-19 infection from 13 medical centers in four world regions (Asia, Europe, United States, Latin America) who had undergone transthoracic echocardiograms (TTEs). Clinical and laboratory data were collected, including patient outcomes. Anonymized echocardiograms were analyzed with automated, machine learning-derived algorithms to calculate left ventricular (LV) volumes, ejection fraction (EF), and LV longitudinal strain (LS). Right-sided echocardiographic parameters that were measured included right ventricular (RV) LS, RV free wall strain (FWS), and RV basal diameter (RVBD). Multivariate regression analysis was performed to identify clinical and echocardiographic parameters associated with in-hospital mortality. Significant regional differences were noted in terms of patient co-morbidities, severity of illness, clinical biomarkers, and LV and RV echocardiographic metrics. Overall in-hospital mortality was 21.6%. Parameters associated with mortality in a multivariate analysis were age (OR 1.12 [1.05, 1.22], p = 0.003), previous lung disease (OR 7.32 [1.56, 42.2], p = 0.015), LVLS (OR 1.18 [1.05, 1.36], p = 0.012), lactic dehydrogenase (LDH) (OR 6.17 [1.74, 28.7], p = 0.009), and RVFWS (OR 1.14 [1.04, 1.26], p = 0.007).

Cardiologists making strides in COVID-19 research

Helio | Cardiology Today, May 19, 2021

COVID-19 is predominantly considered an infectious and respiratory disease, but it is intertwined with the CV system as well. That means cardiologists have a lot to contribute to battle it, especially in the area of pathophysiology. Because COVID-19 is often considered an ICU issue and an infectious disease, cardiologists have at times been left on the sideline during the pandemic. But we now know that there are many CV implications of COVID-19. There have been cases of myocarditis, although not as many as initially thought. There are many patients with elevation of biomarkers of cardiomyocyte injury (high-sensitivity cardiac troponin T or I). There have been a lot of cases of right HF, often from pulmonary embolism and many with thrombophlebitis. We have learned that the pathways that lead to HF and even CAD — the inflammatory pathways and the cytokine pathways that produce HF — are some of the same pathways that we see in COVID-19. This is an aspect of the disease that is not discussed in infectious disease or pulmonary journals. The challenge for cardiologists is to get out that science and make an impact. To that end, I am part of a group of cardiologists from around the world that early in the pandemic began to meet — virtually, of course — regularly to communicate about what we were seeing regarding the impact of the pandemic in our respective regions, and about what research projects we might be able to undertake to prevent and treat COVID-19.

INSPIRATION-S: Statin therapy fails to prevent thrombosis, death in severe COVID-19

Helio | Cardiology Today, May 19, 2021

Atorvastatin therapy did not reduce risk for venous or arterial thrombosis or all-cause death among patients with COVID-19 admitted to the ICU compared with placebo, according to data from the INSPIRATION-S study. A smaller treatment effect and findings within specific subgroups warrant additional investigation, Behnood Bikdeli, MD, MS, a clinical fellow in the cardiovascular medicine division at Brigham and Women’s Hospital and Harvard Medical School, said during a presentation at the American College of Cardiology Scientific Session. INSPIRATION-S was a double-blind, randomized controlled trial assessing the use of 20 mg atorvastatin once daily vs. placebo in 605 patients with confirmed COVID-19 who were admitted to the ICU across 11 hospitals in Iran (mean age, 57 years; 44% women; 16% with diabetes). Enrollment began in July 2020. Participants were naive to statin therapy prior to randomization; those with severe liver dysfunction were excluded. More than 90% of patients were receiving corticosteroids while hospitalized. The primary outcome was a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation (ECMO) or death within 30 days. Researchers also assessed liver enzyme levels and incidence of clinically diagnosed myopathy as the main safety outcomes. Researchers found statin therapy was not associated with a significant reduction in the primary outcome (HR = 0.84 95% CI, 0.58-1.21; P = .35); however, numerically fewer events occurred in the statin group compared with the placebo group (95 vs. 108). Individual endpoint components of all-cause death (HR = 0.84; 95% CI, 0.58-1.22; P = .39) and adjudicated venous thromboembolism (HR = 0.71; 95% CI, 0.24-2.06; P = .53) failed to reach significance, though fewer events for each occurred in the statin group vs. placebo, according to the researchers.

Prior RAAS Inhibitor Use Reduces hs-cTnT Levels in SARS-CoV-2 Infection

Cardiology Advisor, May 13, 2021

Renin-angiotensin-aldosterone system (RAAS) inhibitor use prior to SARS-CoV-2 infection may lead to decreased high-sensitivity cardiac troponin T (hs-cTnT) values in patients with hypertension, according to research results presented at the American College of Cardiology (ACC) 2021 Annual Meeting, held virtually May 15-17, 2021. To clarify the relationship between RAAS inhibitors and cardiac troponin levels in people with COVID-19, researchers conducted a single-institution, retrospective cohort study of adult patients diagnosed via PCR with SARS-CoV-2 infection. The primary study objective was to determine if evidence exists to support the current hypothesis that adults with hypertension receive cardioprotective benefits from daily RAAS inhibitor use prior to acquiring COVID-19. The study cohort included 112 patients with hypertension and PCR-confirmed SARS-CoV-2 infection. Within this group, 57.1% were taking a RAAS inhibitor at the time of their diagnosis. At 0- and 2-hours evaluation, patients on RAAS inhibitor therapy had median hs-cTnT values of 16.0 ng/L and 16.5 ng/L (interquartile range [IQR], 12.0-36.5 ng/L and 12.0-33.5 ng/L), respectively, compared with median hs-cTnT values of 34.5 ng/L and 32.0 ng/L (IQR, 17.8-77.5 ng/L and 16.0-67.0 ng/L), respectively, in patients not on RAAS inhibitor therapy. “RAAS inhibitor use prior to acquisition of COVID-19 is associated with decreased hs-cTnT values on [emergency department] presentation,” the researchers concluded. “RAAS inhibitors may attenuate myocardial injury in patients with COVID-19 and their role in this setting warrants further study.”

Myocardial Injury in COVID-19 Patients: Association with Inflammation, Coagulopathy and In-Hospital Prognosis

Journal of Clinical Medicine, May 13, 2021

The exact mechanisms leading to myocardial injury in the coronavirus disease 2019 (COVID-19) are still unknown. In this retrospective observational study, we include all consecutive COVID-19 patients admitted to our center. They were divided into two groups according to the presence of myocardial injury. Clinical variables, Charlson Comorbidity Index (CCI), C-reactive protein (CRP), CAC (COVID-19-associated coagulopathy), defined according to the ISTH score, treatment and in-hospital events were collected. Between March and April 2020, 331 COVID-19 patients were enrolled, 72 of them (21.8%) with myocardial injury. Patients with myocardial injury showed a higher CCI score (median (interquartile range), 5 (4–7) vs. 2 (1–4), p = 0.001), higher CRP values (18.3 (9.6–25.9) mg/dL vs. 12.0 (5.4–19.4) mg/dL, p ˂ 0.001) and CAC score (1 (0–2) vs. 0 (0–1), p = 0.001), and had lower use of any anticoagulant (57 patients (82.6%) vs. 229 patients (90.9%), p = 0.078), than those without. In the adjusted logistic regression, CRP, myocardial injury, CCI and CAC score were positive independent predictors of mortality, whereas anticoagulants resulted as a protective factor. Myocardial injury in COVID-19 patients is associated with inflammation and coagulopathy, resulting in a worse in-hospital prognosis. Treatment with anticoagulant agents may help to improve in-hospital outcomes.

COVID-19 pandemic and coronary angiography for ST-elevation myocardial infarction, use of mechanical support and mechanical complications in Canada; a Canadian Association of Interventional Cardiology national survey

CJC Open, May 12, 2021

As a result of the COVID-19 pandemic first wave, reductions in STEMI invasive care ranging from 23% to 76% have been reported from various countries. Whether it had any impact on coronary angiography (CA) volume or on mechanical support device use for ST-elevation myocardial infarction (STEMI) and post-STEMI mechanical complications in Canada is unknown. We administered a Canada-wide survey to all Cardiac Catheterization Laboratory Directors seeking the volume of CA for STEMI performed during 01/03/2020-31/05/2020 (pandemic period) and from two control periods (01/03/2019-31/05/2019 and 01/03/2018-31/05/2018). The number of left ventricular support devices used, as well as the number of ventricular septal defects or papillary muscle rupture cases diagnosed, were also recorded. We also assessed if the number of COVID-19 cases recorded in each province was associated with STEMI CA volume. Forty-one out of 42 Canadian catheterization laboratories (98%) provided data. There was a modest but statistically significant 16% reduction (Incidence Rate Ratio or IRR 0.84; 95%CI 0.80-0.87) in CA for STEMI during the first wave of the pandemic compared to control periods. IRR was not associated with provincial COVID-19 caseload. We observed a 26% reduction (IRR 0.74; 95%CI 0.61-0.89) in the use of intra-aortic balloon pump in STEMI. Use of Impella® and mechanical complications from STEMI were exceedingly rare. We observed a modest 16% decrease in CA for STEMI during the pandemic first wave in Canada, lower than reported in other countries.

ACC 2021 to highlight ‘silver lining lessons’, future challenges attributable to COVID-19

Helio | Cardiology Today, May 10, 2021

The 2021 American College of Cardiology Scientific Session will be held virtually from May 15 through 17 and will feature 25 late-breaking clinical trials, 17 featured clinical research presentations and numerous abstract presentations. “While this meeting is being delivered virtually, you will see that there have been benefits in the time to plan and also the lessons that ACC has learned in virtual education over the past year,” Pamela B. Morris, MD, FACC, FAHA, FASPC, FNLA, director of preventive cardiology, co-director of women’s heart care at the Medical University of South Carolina and chair of the 2021 ACC Scientific Session, said during a press conference. “This has come together to create a robust educational and scientific agenda. This meeting will feature everything you’ve come to expect from our annual scientific sessions and more.” This year, the meeting will be delivered through a new virtual education program with the goal of improving real-time discussion between learners and faculty. Subsequently, all streamed sessions and meeting content will be made available on demand, including more than 200 talks in addition to the “Heart to Heart Conversation” podcast. This year’s scientific session will also feature a COVID-19 intensive that will be co-chaired by David Rizik, MD, interventional cardiologist at HonorHealth in Scottsdale, Arizona, and Doreen DeFaria Yeh, MD, director of the Massachusetts General Hospital cardiovascular disease fellowship program.

Social Determinants of Adherence to COVID-19 Risk Mitigation Measures Among Adults with Cardiovascular Disease

Circulation, May 6, 2021

Social determinants of health (SDOH) may limit the practice of COVID-19 risk mitigation guidelines with health implications for individuals with underlying cardiovascular disease (CVD). Population-based evidence of the association between SDOH and practicing such mitigation strategies in adults with CVD is lacking. We used the National Opinion Research Center’s COVID-19 Household Impact Survey conducted between April and June 2020 to evaluate sociodemographic disparities in adherence to COVID-19 risk mitigation measures in a sample of respondents with underlying CVD representing 18 geographic areas of the United States (US). CVD status was ascertained by self-reported history of receiving heart disease, heart attack, or stroke diagnosis. We built de novo, a cumulative index of SDOH burden using education, insurance, economic stability, 30-day food security, urbanicity, neighborhood quality, and integration. We described the practice of measures under the broad strategies of personal protection (mask, hand hygiene, physical distancing), social distancing (avoiding crowds, restaurants, social activities, and high-risk contact), and work flexibility (work-from-home, canceling/postponing work). We reported prevalence ratios (PR) and 95% confidence intervals (CIs) for the association between SDOH burden (quartiles of cumulative indices) and practicing these measures adjusting for age, sex, race/ethnicity, comorbidity, and interview wave. 2036/25269 (7.0%) adults, representing 8.69 million in 18 geographic areas of the US, reported underlying CVD. Compared to the least SDOH burden, fewer individuals with the greatest SDOH burden practiced all personal protection (75.6% vs 89.0%) and social distancing measures (41.9% vs 58.9%) and had any flexible work schedule (26.2% vs 41.4%). These associations remained statistically significant after full adjustment: personal protection, (PR = 0.83; 95% CI [0.73-0.96]; P = 0.009); social distancing (PR = 0.69; 95% CI [0.51-0.94]; P = 0.018); and work flexibility (PR = 0.53; 95% CI [0.36-0.79]; P = 0.002).

ACC Offers Statement on Use of CBME for Training of Fellows During COVID-19

Pulmonary Advisor, May 5, 2021

In light of the recent pandemic, the American College of Cardiology (ACC) offered a statement drafted by the ACC Competency Management Committee and published in the Journal of the American College of Cardiology regarding specialized guidance for the administration of competency-based medical education (CBME) for cardiology fellows undergoing training during the continuing COVID-19 crisis. Whereas conventional CBME training relies heavily on numerical quotas for procedures performed and/or hours logged, COVID-19 has disrupted all aspects of health care, including this standard of operations, potentially putting some fellows in jeopardy of failing to meet these requirements. For this reason, the ACC recommends that the CBME principles outlined in the Core Cardiovascular and Advanced Training Statements be implemented and assessed with flexibility during this uniquely challenging time, offering several specific considerations regarding how to do so effectively. Program directors are advised that numerical or time-based requirements are approximate estimates based on “typical” trainees and that some time- and case-based requirements can be satisfied concurrently. Final responsibility for reviewing and evaluating trainees’ progress lies with the director, who can and must use their discretion to certify competency, regardless of whether all quotas have been met.

QTc Interval Prolonged in Some Patients Hospitalized With COVID-19

Pulmonology Advisor, May 5, 2021

COVID-19 infection is associated with significant mean QTc prolongation at days 2 and 5 of hospitalization, according to a study published online April 23 in JAMA Network Open. Geoffrey A. Rubin, M.D., from the Vagelos College of Physicians and Surgeons at Columbia University in New York City, and colleagues conducted a cohort study involving 3,050 patients aged 18 years and older who underwent severe acute respiratory syndrome coronavirus 2 testing and had electrocardiograms (ECGs) from March 1 through May 1, 2020. Overall, 965 patients had more than two ECGs and were included in the study; 76.0 and 24.0 percent were with and without COVID-19, respectively. The researchers found that by two-day and five-day multivariable models, COVID-19 infection was associated with significant mean QTc prolongation from baseline. Compared with COVID-19-negative status, COVID-19 infection was independently associated with a modeled mean 27.32 millisecond increase in QTc at five days. Compared with patients without COVID-19, more patients with COVID-19 not receiving hydroxychloroquine and azithromycin had QTc of 500 milliseconds or greater (25.0 versus 10.8 percent). In a multivariable analysis, QTc prolongation was seen in association with age 80 years and older versus younger than 50 years, severe chronic kidney disease versus no chronic kidney disease, elevated high-sensitivity troponin levels, and elevated lactate dehydrogenase levels.

Severe valvular disease, COVID-19 mortality ‘approaching’ 50% at 30 days

Helio | Cardiology Today, May 4, 2021

Thirty-day mortality among patients with severe valvular heart disease and COVID-19 topped more than 40%, according to data presented at the virtual Society for Cardiovascular Angiography and Interventions Scientific Sessions. Performing an invasive surgical or transcatheter procedure for valvular disease management in appropriate patients, even during the infection, was associated with lower prevalence of 30-day all-cause mortality, a speaker reported. “Patients with COVID-19 and severe valvular heart disease have poor clinical outcomes with mortality approaching 50% within 30 days of hospital admission,” Danny Dvir, MD, director of interventional cardiology at the Shaare Zedek Medical Centre at Hebrew University in Jerusalem, said during the presentation. “It seemed that valve repair or replacement in appropriate patients should still be considered in those at risk for infection, possibly during the infection. Although the present study suggests that this approach might be lifesaving, further studies are warranted to confirm the results.” For this multicenter trial, researchers included 136 patients (mean age, 80 years; 52% men) hospitalized with concomitant COVID-19 infection and severe valvular heart disease from an international valve disease registry.

At height of pandemic, patients presenting with acute MI dropped drastically

Helio | Cardiology Today, May 1, 2021

The number of patients presenting with acute MI significantly declined during the peak of the COVID-19 pandemic, according a presentation at the virtual Society for Cardiovascular Angiography and Interventions Scientific Sessions. According to the researchers, there was a 70% decline in the number of patients presenting with acute MI between April 2020 compared with April 2019, and patients who received care developed more severe symptoms due to delays in patients seeking emergency services. “We observed a dramatic decrease in patients presenting with acute myocardial infarction during the COVID-19 pandemic. Of the patients that did seek medical care for MI during the pandemic, we observed a trend toward delay between symptom onset and hospital presentation, compared to during the previous year. This may have contributed to increased overall MI in these patients. Our findings indicate a need for improved public health messaging to ensure timely and appropriate cardiovascular care,” Nina Talmor, MD, internal medicine resident at NYU Langone Health, told Healio. Researchers conducted a single-center, retrospective, observational study that compared patients with MI who underwent urgent invasive coronary angiography at NYU Langone Health in April 2020, during the peak of the pandemic, with those presenting in April 2019. According to the researchers, 13 patients with acute MI underwent invasive angiography in 2020, compared with 59 in 2019, a reduction of 78%. Due to limitations of testing in the early stages of the pandemic, few patients underwent COVID-19 testing before angiography, but two of 13 patients tested positive.

Mortality high, PCI common in patients with concomitant STEMI, COVID-19: NACMI Registry

Helio | Cardiology Today, April 29, 2021

In-hospital mortality remains high and primary PCI is common in patients with STEMI and COVID-19, according to new data from the North American COVID-19 Myocardial Infarction Registry. “One in three [patients with STEMI and COVID-19] does not make it out of the hospital,” Payam Dehghani, MD, FRCPC, FACC, FSCAI, co-director of Prairie Vascular Research Inc. and associate professor at the University of Saskatchewan, said during a press conference at the virtual Society for Cardiovascular Angiography and Interventions Scientific Sessions. Moreover, he said, “primary PCI is common, it’s feasible and it’s associated with reduced mortality. That’s in keeping with our current guidelines.” Dehghani reported results from nearly 1,000 patients with a positive diagnosis of COVID-19 or individuals with suspected COVID-19 who presented with STEMI to various sites in the U.S. and Canada and were enrolled in the North American COVID-19 Myocardial Infarction (NACMI) Registry. NACMI is an ongoing, prospective, observational registry that was created under the guidance of SCAI, the American College of Cardiology and the Canadian Association of Interventional Cardiology. The aim of the registry is to compare demographics, clinical findings, outcomes and management strategies of patients with COVID-19 and STEMI compared with a matched historical control of STEMI activation patients from the Midwest STEMI Consortium, and to develop data-driven treatment plans, guidelines and diagnostic acumen for this unique patient population.

The Clinical Challenge of ST-Segment Elevation Myocardial Infarction and COVID-19

Journal of the American College of Cardiology, April 27, 2021

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the cause of coronavirus disease 2019 (COVID-19), has major cardiovascular implications including myocardial injury, myocarditis, stress-induced cardiomyopathy, and arterial and venous thrombotic complications presenting as acute coronary syndromes (ACS) and venous thromboembolism (VTE). The combination of COVID-19 and ACS is particularly challenging for diagnosis and management strategies. Significant overlap in presenting symptoms, such as respiratory signs (dyspnea, hypoxia, cough), pulmonary infiltrates (mostly ground glass opacities), and chest pain may lead to missed or delayed diagnosis of significant cardiovascular scenarios and complications. Furthermore, elevated cardiac biomarkers, such as high-sensitivity cardiac troponin, N-terminal pro–B-type natriuretic peptide, and d-dimer may be elevated in both ACS and COVID-19 patients, making it even more difficult to distinguish between the clinical syndromes at the time of presentation to the hospital. In addition, hospital and health care system reorganization status in reaction to COVID-19 has jeopardized access to emergency treatment, including reperfusion therapy, by limiting or reducing coronary procedures and/or routine diagnostic cardiac evaluations. ST-segment elevation myocardial infarction (STEMI) and COVID-19 have exceptional considerations. In line with current guidelines, patients with suspected STEMI should be managed with primary percutaneous coronary intervention (PPCI) without delay while the safety of health care providers is ensured. In this case, PPCI should be performed routinely even if the patient is presumed to have COVID-19, because PPCI should not be postponed. Confirmation of SARS-CoV-2 infection should not delay urgent decision management concerning reperfusion strategy.

Impact of COVID-19 Pandemic on Presentation and Outcome of Consecutive Patients Admitted to Hospital Due to ST-Elevation Myocardial Infarction

American Journal of Cardiology, April 26, 2021

Impact of COVID-19 pandemic and pandemic-related social restrictions on clinical course of patients treated for acute ST-elevation myocardial infarction (STEMI) is unclear. In the present study presentation and outcome of patients with STEMI in 2020 were compared to the years before in a German registry that includes all patients hospitalized for acute STEMI in a region with approximately 1 million inhabitants. In the year 2020 726 patients with STEMI were registered compared to 10.226 patients in the years 2006-2019 (730 ± 57 patients per year). No significant differences were observed between the groups regarding age, sex and medical history of patients. However, in the year 2020 a significantly higher rate of patients admitted with cardiogenic shock (21.9% vs. 14.2%, p<0.01) and out-of-hospital cardiac arrest (OHCA) (14.3% vs. 11.1%, p<0.01) was observed. The rate of patients with subacute myocardial infarction (14.3% vs. 11.6%, p<0.05) was elevated in 2020. Hospital mortality increased by 52% from the years 2006-2019 (8.4%) to the year 2020 (12.8%, p<0.01). Only 4 patients (0.6%) with STEMI in the year 2020 had SARS-CoV-2 infection, none of those died in-hospital. In conclusion, in the year 2020 a highly significant increase of STEMI-patients admitted to hospital with advanced infarction and poor prognosis was observed. As the structure of the emergency network to treat patients with STEMI was unchanged during the study period, the most obvious reason for these changes was COVID-19 pandemic-related lockdown and the fear of many people to contact medical staff during the pandemic.

Can Heart Failure Show Up in COVID Patients Out of the Blue?

MedPage Today, April 26, 2021

It was rare but possible for COVID-19 patients without cardiovascular disease (CVD) or cardiovascular risk factors to develop new heart failure (HF) during their illness, according to a center in New York. A retrospective analysis of 6,439 hospitalized COVID-19 patients found that 0.6% had new HF and 6.6% had a history of HF, reported Anuradha Lala, MD, of Icahn School of Medicine at Mount Sinai in New York City, and colleagues. As shown in their research letter online in the Journal of the American College of Cardiology, out of the 37 people who experienced new HF, 13 had presented with shock (four cardiogenic, six septic, three mixed) and five with acute coronary syndrome. Just eight had neither CVD nor any related risk factors, whereas 14 had a history of CVD and another 15 at least one risk factor. The eight individuals developing new HF despite a lack of CVD tended to be younger and have a lower body mass index and fewer comorbidities compared with other new HF patients. These eight had similar lengths of stay in the hospital as peers with existing CVD or cardiovascular risk factors. However, these patients were more likely to require intensive care admission and intubation, and had a lower risk of in-hospital mortality, Lala’s group reported.

Certain younger patients with COVID-19, no risk factors or CVD may be at risk for new HF

Helio | Cardiology Today, April 26, 2021

While not great in number, there exists a distinct subgroup of younger patients with COVID-19 but no risk factors or prior CVD who are at elevated risk for new HF, according to a research letter. “This is one of the largest studies to date to specifically capture instances of new heart failure diagnosis among patients hospitalized with COVID-19. While rare, the finding of new heart failure was more common among patients with preexisting cardiovascular risk factors or disease. But, there were select individuals who developed new heart failure without risk factors or disease. We need to learn more about how SARS-CoV-2 [the virus that causes COVID-19] may directly affect the cardiovascular system and precipitate new heart failure — as to whether it is an indirect effect of critical illness or direct viral invasion,” Anuradha Lala, MD, director of heart failure research at the Icahn School of Medicine at Mount Sinai, said in a press release. “Importantly, though symptoms of heart failure — namely shortness of breath — can mimic symptoms associated with COVID-19, being alerted to the findings of this study may prompt clinicians to monitor for signs of congestion more consistent with heart failure than COVID-19 alone.” Of 6,439 patients with a positive COVID-19 test, 0.6% had new HF and 6.6% had a history of HF. Of those with new HF, 13 presented with shock and five presented with ACS. The researchers found 22% of patients with new HF had no CV risk factors or CVD; 38% had a history of CVD; and 40% had at least one risk factor.

Coronary angioplasty and COVID-19: are heparin requirements and thrombotic complications increasing?

American Heart Journal | Acute Cardiovascular Care, April 26, 2021

Covid-19 infection is associated with coagulopathy and possible heparin resistance, raising concerns that routine heparin during percutaneous coronary intervention (PCI) is failing to achieve adequate anticoagulation. We examined heparin requirements and efficacy in patients treated by PCI before and after the first reported UK case of Covid-19 (January 31, 2020). We retrospectively compared heparin dose, Activated Clotting Time (ACT) and coronary flow (TIMI grade) for PCI procedures at a London cardiac centre in the 3 months before the UK pandemic and the three months afterwards. Testing for COVID was not routinely performed. Pre-specified analyses in patients with STEMI, NSTEMI and Stable angina were undertaken. Of 1227 PCI procedures performed over the period of observation, 690 were pre-pandemic and 537 were afterwards. Overall median heparin dose per case was 11000 units versus 11500 units (p = 0.137) and maximum ACTs were 291s versus 305s, respectively (p = 0.135). Pre-PCI TIMI 3 flow was lower during the pandemic than before (60% v 65%, p = 0.005) but Post-PCI flow was similar (96% versus 96%, p = 0.839). There were no statistically significant differences in heparin dose or achieved ACT among patients with STEMI, NSTEMI or Stable presentations.

Prevalence and clinical significance of relative bradycardia at hospital admission in patients with Coronavirus Disease 2019 (COVID-19)

Clinical Microbiology and Infection, April 24, 2021

The clinical relevance of relative bradycardia in patients with Coronavirus Disease 2019 (COVID-19) has been poorly investigated. We evaluated the prevalence and clinical significance of relative bradycardia at hospital admission in patients with COVID-19 in a retrospective single-center study including all adult patients with confirmed COVID-19. Relative bradycardia was observed in 41.6% of patients presenting with COVID-19 and fever. Patients with relative bradycardia were older and with higher body temperature than patients without relative bradycardia. No statistical differences were observed between the two groups as for Intensive Care Unit admission and in-hospital mortality. Relative bradycardia is a common feature of COVID-19. The presence of relative bradycardia at admission was not associated with worse outcomes.


Cardiovascular Pathology, April 23, 2021

The year 2020 will go down in history as an annus horribilis due to the rampant pandemic of the novel human coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus. While COVID-19 begins as a respiratory illness, severe COVID-19 is a systemic disease with multifaceted manifestations of involvement of the cardiovascular system. Clinical evidence of cardiovascular involvement portents an adverse, and often fatal, outcome. Cardiovascular pathologists, individually and through their organizations, the Society for Cardiovascular Pathology (SCVP) and the Association for European Cardiovascular Pathology (AECVP), have been committed to proactively studying and providing credible information about the pathological basis for the diverse manifestations of cardiovascular system involvement in COVID-19. Cardiovascular pathologists have advocated for autopsy-based investigation, participated in a multi-institutional autopsy interest group, published initial reports describing the pathological features of multi-organ involvement in COVID-19, and lead investigative efforts to determine the multifaceted clinical manifestations of involvement of the cardiovascular system in COVID-19. Fittingly, the SCVP Symposium in 2021 was focused on COVID-19. The SCVP 2021 Symposium was organized by the SCVP program committee led by Dr. Dylan Miller and was held virtually on Saturday March 13 as part of the SCVP Companion Meeting accompanying the United States and Canadian Academy of Pathology (USCAP) Annual Meeting. The title was, “A Novel Coronavirus Meets the Cardiovascular System: What We Know and How We Know It.” An important feature of the Symposium was the multidisciplinary approach to addressing the issues related to the topic. Read more on the speakers and titles of their presentations.

Commentary: The silver lining of CABG in the COVID-19 era

JTCVS Open, April 22, 2021

There has been a substantial decline in patients presenting for emergent and routine cardiovascular care in the United States after the onset of the corona-virus disease 2019 (COVID-19) pandemic. We sought to assess the risk of adverse clinical outcomes among patients undergoing coronary artery bypass graft (CABG) surgery during the 2020 COVID-19 pandemic period and compare the risks with those undergoing CABG before the pandemic in the year 2019. A retrospective cross-sectional analysis of the TriNetX Research Network database was performed. Patients undergoing CABG between January 20, 2019, and September 15, 2019, contributed to the 2019 cohort, and those undergoing CABG between January 20, 2020, and September 15, 2020, contributed to the 2020 cohort. Propensity-score matching was performed, and the odds of mortality, acute kidney injury, stroke, acute respiratory distress syndrome, and mechanical ventilation occurring by 30 days were evaluated. The number of patients undergoing CABG in 2020 declined by 35.5% from 5534 patients in 2019 to 3569 patients in 2020. After propensity-score matching, 3569 patient pairs were identified in the 2019 and the 2020 cohorts. Compared with those undergoing CABG in 2019, the odds of mortality by 30 days were 0.96 (95%confidence interval [CI], 0.69-1.33; P = .80) in those undergoing CABG in 2020. The odds for stroke (odds ratio [OR], 1.201; 95%CI, 0.96-1.39), acute kidney injury (OR, 0.76; 95%CI, 0.59-1.08), acute respiratory distress syndrome (OR, 1.01; 95%CI, 0.60-2.42), and mechanical ventilation (OR, 1.11; 95%CI, 0.94-1.30) were similar between the 2 cohorts.

COVID-19 and hypertension: Is there a role for dsRNA and activation of Toll-like receptor 3?

Vascular Pharmacology, April 22, 2021

The virus responsible for the coronavirus disease of 2019 (COVID-19) is the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Evidences suggest that COVID-19 could trigger cardiovascular complications in apparently healthy patients. Coronaviruses are enveloped positive-strand RNA viruses acting as a pathogen-associated molecular pattern (PAMP)/ danger-associated molecular patterns (DAMP). Interestingly, Toll-like receptor (TLR) 3 recognize both PAMPs DAMPs and is activated by viral double-stranded RNA (dsRNA) leading to activation of TIR receptor domain-containing adaptor inducing IFN-β (TRIF) dependent pathway. New evidence has shown a link between virus dsRNA and increased BP. Hence, we hypothesize that COVID-19 infection may be over activating the TLR3 through dsRNA, evoking further damage to the patients, leading to vascular inflammation and increased blood pressure, favoring the development of several cardiovascular complications, including hypertension.

Wide QRS complex and left ventricular lateral repolarization abnormality: The importance of ECG markers on outcome prediction in patients with COVID-19

American Journal of the Medical Sciences, April 21, 2021

[Editorial] There is a clear reported increased morbidity and mortality with coronavirus disease 2019 (COVID-19) with the presence of cardiac injury. Non-ischemic events and ischemic myocardial involvement are the two main pathophysiological mechanisms described for acute cardiac injury in COVID-19 patients. This pandemic is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Up to November 5, 2020, this disease resulted in considerable morbidity and mortality worldwide with 47,596,852 laboratory-confirmed cases and 1,216,357 deaths. Most of the studies that reported myocardial involvement were based on elevated serum cardiac biomarkers, while others on cardiac magnetic resonance imaging. It was reported recently that there is also evidence of direct viral damage of the myocardium causing acute myocarditis detected by histological studies. This was manifested as myocardial edema and acute myocardial injury with the presence of SARS-CoV-2 on electron microscopy. Electrocardiogram (ECG) abnormalities commonly seen in cardiac injury are ST elevation and PR depression. Other ECG abnormalities that can be observed in acute cardiac injury include new-onset bundle branch block, QT prolongation, pseudoinfarct pattern, premature ventricular complexes, bradyarrhythmias and ventricular tachycardia (VT). In this issue of the American Journal of The Medical Sciences, Sonsoz MR, et al. demonstrated that two simple ECG parameters can be associated with markers of myocardial injury and clinical outcomes in hospitalized patients with COVID-19. The authors succeeded in finding that the presence of QRS duration longer than 120 ms and left ventricular (LV) lateral ST-T segment abnormalities were associated with worse clinical outcome and higher levels of myocardial injury biomarkers.

Cardiology in the COVID-19 era: Performing TAVR in unprecedented times

Helio | Cardiology Today, April 20, 2021

The early days of the COVID-19 pandemic challenged interventional cardiologists in unexpected ways, including the disruption of all aspects of care and the halting of most transcatheter aortic valve replacements. As cases rose in the spring of 2020, statewide mandates forced many hospitals to stop performing elective procedures. TAVR, which is primarily performed on an elective basis, was among them. Consequently, for several months, cath labs and operating rooms stood silent, except for urgent or emergent cases. In an interview with Healio, Jordan G. Safirstein, MD, FACC, FSCAI, director of transradial intervention at Morristown Medical Center in New Jersey, discussed his personal experiences with COVID-19; how the disease affected care of patients with aortic stenosis and the decision to perform TAVR; what has changed within the past year; and a slow return to some degree of normalcy with the resumption of elective TAVR procedures.

Adverse outcomes elevated in concomitant COVID-19, STEMI

Helio | Cardiology, April 19, 2021

Patients with STEMI and COVID-19 were less likely to undergo primary PCI and were more likely to experience adverse outcomes compared with those who presented with STEMI before the pandemic, researchers reported. Also, according to new data from the North American COVID-19 STEMI Registry, underrepresented groups more often tested positive for COVID-19 when presenting with STEMI. For the present analysis, researchers divided patients into those with STEMI and confirmed COVID-19 (n = 230), those with STEMI and suspected COVID-19 infection (n = 495) and age- and sex-matched patients with STEMI treated from 2015 to 2019, who served as controls (n = 460). The primary outcome was a composite endpoint that comprised in-hospital death, stroke, recurrent MI or repeat unplanned revascularization. Researchers observed that patients who tested positive for COVID-19 were mostly men (71%) and from an underrepresented group (23% Hispanic; 24% Black; 6% Asian). White patients represented 39% of those who tested positive. Among the cohort who tested positive for COVID-19, 18% had cardiogenic shock and 11% had cardiac arrest.

Prevalence and prognostic associations of cardiac abnormalities among hospitalized patients with COVID-19: a systematic review and meta-analysis

Scientific Reports, April 19, 2021

Although most patients recover from COVID-19, it has been linked to cardiac, pulmonary, and neurologic complications. Despite not having formal criteria for its diagnosis, COVID-19 associated cardiomyopathy has been observed in several studies through biomarkers and imaging. This study aims to estimate the proportion of COVID-19 patients with cardiac abnormalities and to determine the association between the cardiac abnormalities in COVID-19 patients and disease severity and mortality. Observational studies were obtained from electronic databases (PubMed, Embase, Cochrane Library, CNKI) and preprint servers (medRxiv, bioRxiv, ChinaXiv). Studies that have data on prevalence were included in the calculation of the pooled prevalence, while studies with comparison group were included in the calculation of the odds ratio. If multiple tests were done in the same study yielding different prevalence values, the largest one was used as the measure of prevalence of that particular study. A total of 400 records were retrieved from database search, with 24 articles included in the final analysis. Pooled prevalence of cardiac abnormalities in 20 studies was calculated to be 0.31 [95% Confidence Intervals (CI) of (0.23; 0.41)], with statistically significant heterogeneity (percentage of variation or I-squared statistic I2 = 97%, p < 0.01). Pooled analysis of 19 studies showed an overall odds ratio (OR) of 6.87 [95%-CI (3.92; 12.05)] for cardiac abnormalities associated with disease severity and mortality, with statistically significant heterogeneity (I2 = 85%, between-study variance or tau-squared statistic τ2 = 1.1485, p < 0.01). Due to the high uncertainty in the pooled prevalence of cardiac abnormalities and the unquantifiable magnitude of risk (although an increased risk is certain) for severity or mortality among COVID-19 patients, much more long-term prognostic studies are needed to check for the long-term complications of COVID-19 and formalize definitive criteria of “COVID-19 associated cardiomyopathy”.

High-Sensitivity Cardiac Troponin T for the Detection of Myocardial Injury and Risk Stratification in COVID-19

Clinical Chemistry, April 16, 2021

We conducted a multicenter, retrospective, observational, US-based study of COVID-19 patients undergoing hs-cTnT. Outcomes included short-term mortality (in-hospital and 30-days post-discharge) and a composite of major adverse events including respiratory failure requiring mechanical ventilation, cardiac arrest, and shock within the index presentation and/or mortality during the index hospitalization or within 30-days post-discharge. Among 367 COVID-19 patients undergoing hs-cTnT, myocardial injury was identified in 46%. They had a higher risk for mortality (20% vs. 12%, P<0.0001; unadjusted HR 4.44, 95% CI 2.13-9.25, P<0.001) and major adverse events (35% vs. 11%, P<0.0001; unadjusted OR 4.29, 95% CI 2.50-7.40, P<0.0001). Myocardial injury was associated with major adverse events (adjusted OR 3.84, 95% CI 2.00-7.36, P<0.0001) but not mortality. Baseline (adjusted OR 1.003, 95% CI 1.00-1.007, P=0.047) and maximum (adjusted OR 1.005, 95% CI 1.001-1.009, P=0.0012) hs-cTnT were independent predictors of major adverse events. Most (95%) increases were due to myocardial injury, with 5% (n = 8) classified as type 1 or 2 myocardial infarction. A single hs-cTnT <6 ng/L identified 26% of patients without mortality, with a 94.9% (95% CI 87.5-98.6) negative predictive value and 93.1% sensitivity (95% CI 83.3-98.1) for major adverse events in those presenting to the ED. Myocardial injury is frequent and prognostic in COVID-19. While most hs-cTnT increases are modest and due to myocardial injury, they have important prognostic implications. A single hs-cTnT <6 ng/L at presentation may facilitate the identification of patients with a favorable prognosis.

FDA rescinds EUA for bamlanivimab monotherapy as COVID-19 treatment

Infectious Disease News, April 16, 2021

The FDA has rescinded the emergency use authorization for bamlanivimab monotherapy for the treatment of mild-to-moderate COVID-19 in adults and certain children. The emergency use authorization (EAU) has been revoked because of the sustained increase in COVID-19 viral variants that are resistant to bamlanivimab (Eli Lilly) alone, resulting in treatment failure, according to an FDA-issued press release. Last year, the FDA issued an EUA to Eli Lilly for the emergency use of bamlanivimab, a monoclonal antibody, alone. Eli Lilly has now requested the FDA to revoke the EUA because they want to focus on the combination of bamlanivimab and etesevimab. Alternative monoclonal antibody therapies remain available under EUA for this same indication. These include the combination of casirivimab (REGN10933, Regeneron Pharmaceuticals) and imdevimab (REGN10987, Regeneron Pharmaceuticals), or REGEN-COV, and bamlanivimab combined with etesevimab, according to the FDA.

How The COVID-19 Pandemic Has Affected Cardiology Fellow Training

American Journal of Cardiology, April 15, 2021

With the advent of the COVID-19 pandemic in the United States, resources have been reallocated and elective cases have been deferred to minimize the spread of the disease, altering the workflow of cardiac catheterization laboratories across the country. This has in turn affected the training experience of cardiology fellows, including diminished procedure numbers and a narrow breadth of cases as they approach the end of their training before joining independent practice. It has also taken a toll on the emotional well-being of fellows as they see their colleagues, loved ones, patients or even themselves struggling with COVID-19, with some succumbing to it. The aim of this opinion piece is to focus attention on the impact of the COVID-19 pandemic on fellows and their training, challenges faced as they transition to practicing in the real world in the near future and share the lessons learned thus far. We believe that this is an important contribution and would be of interest not only to cardiology fellows-in-training and cardiologists but also trainees in other procedural specialties.

Stroke occurs infrequently in large cohort study of patients hospitalized with COVID-19

American Academy of Neurology, April 15, 2021

Acute stroke occurred rarely in a cohort of nearly 2,700 “critically ill” patients with COVID-19, according to findings from an international registry that also demonstrated greater mortality with hemorrhagic, but not ischemic, stroke. Study results showed that 59 of the 2,699 patients with COVID-19 (2.2%) had an acute stroke during their ICU admission. The researchers presented their findings at the American Academy of Neurology annual meeting, which is being held virtually. The researchers registered 2,699 patients from more than 370 sites in 52 countries. The study comprised mostly men (65%) and the median age of patients was 53 years. Of these patients, 59 (2.2%) experienced an acute stroke during their ICU stay, including 19 patients who had an ischemic stroke (32%) and 27 patients who had a hemorrhagic stroke (46%). The type of stroke was unspecified in 13 patients (22%), according to the study results. The researchers observed high mortality in patients who had a hemorrhagic stroke (72%), but stroke was the primary cause of death in only 15% of patients. Multiorgan failure represented the leading cause of death, according to the study results.

Out-of-hospital cardiac arrests rose when local COVID-19 prevalence high

Cardiology Today, April 14, 2021

Most cities experienced significant increases in out-of-hospital cardiac arrest that paralleled spikes in local COVID-19 prevalence, researchers reported. “The highly stressful clinical challenge of out-of-hospital cardiac arrest occurs frequently and somewhat predictable with about 30,000 cases routinely presenting each month in North America and a similar proportionate number in European nations,” Kevin E. McVaney, MD, specialist in the department of emergency medicine at the University of Colorado School of Medicine and the Denver Health and Hospital Authority, and colleagues wrote in EClinicalMedicine. “However, as SARS-CoV-2 infections began to surge in the first epicenters such as Milan, London, New York and Detroit, their emergency medical services (EMS) agencies were already reporting alarming increases in out-of-hospital cardiac arrest, even prior to implementation of shelter-at-home directives and the tallying of COVID-19-related deaths.” In April 2020, there was a 1.5-fold increase in out-of-hospital cardiac arrests among 13 U.S. cities, and three COVID-19 epicenters — New York City, Detroit and Washington, D.C. — more than doubled their usual numbers for out-of-hospital cardiac arrest events; there was a 2.5-fold increase in New York City. Researchers observed unchanged or diminished numbers of out-of-hospital cardiac arrest events in cities with lesser COVID-19 impact. During April 2020, on average, there was a 59% increase in out-of-hospital cardiac arrest cases per city (P = .03). London, Milan, New York City, Detroit, St. Louis and New Orleans had the highest out-of-hospital cardiac arrest increases but returned to or approached the pre-COVID numbers after mitigation of the spread of COVID-19 in June 2020. However, cities that were minimally affected by COVID-19 during April 2020 experienced marked out-of-hospital cardiac arrest increases when they had local surges of COVID-19 infections.

The Jessa Hospital experience for cardiac rehabilitation

European Heart Journal, April 14, 2021

Everyone around the world is experiencing challenging times in dealing with the COVID-19 pandemic. It has impacted personal life as much as it has influenced the way we work. Healthcare systems and healthcare professionals are being tested to the limit and the effects will affect us even long after the acute crisis is passed. It is on the other hand impressive to see how fast healthcare organizations such as hospitals are able to reorganize and develop new ways of communicating and reaching patients through tele-medicine. Just a few months ago, COVID-19 restrictions were announced in Belgium. Suddenly every non-urgent medical contact needed to be postponed and extra caution was advised for many high-risk patients. This led to the discontinuation of ambulatory cardiac rehabilitation (CR) programmes. In this article, the experience of one of the European Association of Preventive Cardiology (EAPC) accredited CR centres (Heart Centre Hasselt, Jessa Hospital) is described. We hope it can inspire other centres in Europe to adopt new methods in order to reach our CR patients by using digital tools.

Stroke Imaging Utilization According to Age and Severity during the COVID-19 Pandemic

Radiology, April 13, 2021

Stroke imaging utilization decreased early in the pandemic, particularly for less severe strokes, but later recovered; there was no meaningful change in the age of imaged patients during the pandemic. There was a profound decrease in acute ischemic stroke (AIS) evaluations across the United States during the early Covid-19 pandemic. This decrease was attributed to stay-at-home measures that were lifted for the later “reopening” period. Here, we report trends in nationwide stroke imaging utilization, patient demographics, and imaging characteristics in the early pandemic and reopening periods. CTP data prospectively acquired at over 800 U.S. hospitals between January 1, 2019 and October 31, 2020 and processed with RAPID (iSchemaView, Inc., Menlo Park, CA) were entered into a de-identified, de-duplicated database. Counts of daily unique patients were generated from this database using imaging timestamps. Counts were subdivided by age, gender, and CTP findings and normalized by the number of active, RAPID-connected hospitals. Cases with missing or mislabeled data were retained. Patients ≤50 years were classified as young. CTP was classified as positive if hypoperfusion volume or estimated ischemic core volume was non-zero, and as substantial penumbra if it met the DEFUSE 3 target mismatch profile. Counts were grouped into epochs. The pre-pandemic epoch was January 5, 2020 to February 29, 2020, as counts from this period were similar to an earlier baseline. The early-pandemic epoch was March 26, 2020 to April 8, 2020, corresponding to nadir of the two-week moving average of daily counts. The reopening epoch was June 9, 2020 to October 26, 2020, the earliest period with no active statewide stay-at-home orders. Epochs were defined in 7-day multiples to exclude weekend effects. The per-site daily volume of CTP, positive CTP, and CTP with substantial penumbra in the early-pandemic period was 37.0% (34.7%, 39.3%), 29.7% (26.1%, 33.1%), and 26.3% (20.7%, 31.5%) lower, respectively, than the pre-pandemic baseline. Following this nadir, imaging volume recovered over 10 weeks. The per-site daily volume of CTP, positive CTP, and CTP with substantial penumbra during the reopening period was 5.1% (2.9%, 7.3%), 7.8% (5.5%, 10.0%), and 5.3% (1.4%, 8.9%) lower, respectively, than the pre-pandemic baseline.

Effect SARS-COV-2 on Cases of Transcatheter Aortic Valve Implantation

American Journal of Cardiology, April 13, 2021

 The effect of SARS-COV-2 diagnosis on cases of aortic stenosis that requires a transcatheter aortic valve implantation (TAVI) is poorly understood, and the long-term effects are not well reported. The researchers aimed to determine whether there exists a difference in all-cause mortality between patients with a SARS-COV-2 diagnosis that received a TAVI compared to those that did not contract SARS-COV-2. The researchers queried the TriNetX database, a COVID-19 research network of 61 health care organizations. They analyzed the data using the ICD 10 codes used for TAVI procedures from January 20th, 2020 to January 30th, 2021, and identified 3,075 patients aged 18–90 between the two groups: 224 SARS-COV-2 TAVI and 2,851 non-SARS-COV-2 TAVI patients. Descriptive statistics were used to measure association, and the Kaplan-Meier survival curve was used to assess the endpoints of mortality. A propensity score matching of 1:1 was performed with the covariates (i.e., age, male, female, hypertension, coronary artery disease, heart failure, diabetes, smoking history, chronic obstructive pulmonary disease, and body mass index < 30) to reduce possible differences, which resulted in a matched cohort (n = 224/224) over a 365-day time frame. Adjusted hazard ratios of mortality were compared by SAR-COV-2 diagnosis using the Cox proportional hazards model. The researchers identified 3,075 patients aged 18–90 with comparable ages between the two groups (77.1± 9.26 vs. 76.9 ± 8.94; P = 0.65). Compared to the non-SARS-COV-2 TAVI group, the SARS-COV-2 TAVI group had higher baseline comorbidities, including hypertension (95.9% vs. 76.1%; P < 0.01), coronary artery disease (88.8% vs. 66.8%; P < 0.01), heart failure (86.1% vs. 47.0%; P < 0.01), diabetes (65.1% vs. 35.4%; P < 0.01), smoking history (50.4% vs. 29.4%; P < 0.01), chronic obstructive pulmonary disease (38.3% vs. 16.8%; P < 0.01), and body mass index < 30 (66.5% vs. 40.7%; P < 0.01). A log rank test illustrated that the SARS-COV-2 TAVI group had a lower survival probability at end of time window compared to the non-SARS-COV-2 TAVI group (70.7% vs. 92.9%; P < 0.01). A hazards ratio further verified the results (9.8, P < 0.02).

Cytosorb treatment in severe COVID-19 cardiac and pulmonary disease

European Heart Journal-Case Reports, April 12, 2021

A 75-year-old man was admitted for COVID-19-related respiratory failure (p/F ratio 205 on Day 1). He was treated with intravenous dexamethasone (6 mg per day), enoxaparin (4000 international units once daily), and non-invasive ventilation. Levels of cardiac damage and inflammatory biomarkers, including high-sensitivity troponin T (25 pg/mL, normal values 0–14 pg/mL), N-terminal pro-brain natriuretic peptide (2546 ng/L, normal values 0–125 ng/L), D-dimer (633 ng/mL, normal values 0–500 ng/mL), and interleukin-6 (6768 ng/L, normal values 0–7 ng/L), were significantly elevated. On Days 2 and 3 from admission, the patient received two cycles of tocilizumab therapy (two intravenous bolus of 400 mg over 2 days) but during the following 72 h his clinical conditions deteriorated due to severe respiratory failure with severe hypoxaemia (p/F ratio 95), hypotension, and hypoperfusion. He was intubated and transferred to COVID-19 intensive care. Contrast-enhanced chest computed tomography (CT) showed bilateral ground-glass lesions, subpleural consolidations, pleural effusions, and subsegmental pulmonary embolism. Echocardiography showed normal left ventricular function but signs of acute cor pulmonale with reduced tricuspid annular systolic excursion plane, fractional area change, and right ventricular (RV) longitudinal strain with increased systolic pulmonary artery pressure. Despite treatment with high-dose vasoactive drugs, unfractionated heparins and antibiotics, he developed refractory shock with anuria. Due to the presence of persisting anuria with hyperkaliaemia (6.0 mmol/L), we started continuous renal replacement therapy (CRRT) and immunoadsorption with Cytosorb™ (Cytosorbents Corporation, NJ, USA) system. After 72 h, we observed a significant haemodynamic improvement together with an important decline of inflammatory and cardiac damage markers levels and, due to the presence of spontaneous diuresis with negative fluid balance, we stopped CRRT and immunoadsorption therapy. Control chest CT showed significant reduction of consolidations, pleural effusions and ground-glass lesions, while echocardiography documented significant improvement of RV function. The patient was extubated 3 days later and on Day 14 (p/F ratio 390) transferred to a respiratory rehabilitation centre with stable haemodynamics and no need for CRRT. After 6 months, the patient has completely recovered, with normal RV function.


Cardiovascular Research, April 11, 2021

The coronavirus disease 2019 (COVID-19) pandemic has been as unprecedented as unexpected, affecting more than 105 million people worldwide as of February 8th, 2020 and causing more than 2.3 million deaths according the World Health Organization. Not only affecting the lungs and provoking acute respiratory distress, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is able to infect multiple cell types including cardiac and vascular cells. Hence, a significant proportion of infected patients develop cardiac events such as arrhythmias and heart failure. Patients with cardiovascular comorbidities are at highest risk of cardiac death. To face the pandemic and limit its burden, health authorities have launched several fast track calls for research projects aiming to develop rapid strategies to combat the disease, as well as longer-term projects to prepare for the future. Biomarkers have the possibility to aid in clinical decision-making and tailoring healthcare in order to improve patient quality of life. The biomarker potential of circulating RNAs has been recognized in several disease conditions, including cardiovascular disease. RNA biomarkers may be useful in the current COVID-19 situation. The discovery, validation and marketing of novel biomarkers, including RNA biomarkers, require multi-centre studies by large and interdisciplinary collaborative networks, involving both the academia and the industry. Here, members of the EU-CardioRNA COST Action CA17129 summarize the current knowledge about the strain that COVID-19 places on the cardiovascular system and discuss how RNA biomarkers can aid to limit this burden. They present the benefits and challenges of the discovery of novel RNA biomarkers, the need for networking efforts and the added value of artificial intelligence to achieve reliable advances.

COVID-19 confers elevated VTE risk in veterans

Cardiology Today, April 6, 2021

Among veterans hospitalized at Veterans Affairs facilities, patients with COVID-19 are at elevated risk for venous thromboembolism, according to a study published in the American Heart Journal. “This study of patients at U.S. VA hospitals demonstrates that patients hospitalized with COVID-19, despite thromboprophylaxis, are at increased risk for VTE during admission and following discharge,” the researchers wrote. The elevated risk is “potentially resulting from propagation of a consumptive coagulopathy due to activation of inflammatory pathways or via endotheliitis,” J. Antonio Gutierrez, MD, MHS, assistant professor of medicine at Duke University School of Medicine, and colleagues wrote.
The researchers analyzed 4,461 veterans who tested positive for COVID-19 and 76,929 with negative test results (median age, 68 years; 93% men) who were hospitalized at VA centers from May 1 to Aug. 1, 2020. Researchers found that among patients with COVID-19, 9.2% had VTE compared with 6.8% of those without COVID-19 (P < .0001). After propensity score matching, patients with a positive COVID-19 test remained at elevated risk for VTE compared with those without one (HR = 1.28; 95% CI, 1.1-1.48; P = .001).

Temporal Relation Between Second Dose BNT162b2 mRNA Covid-19 Vaccine and Cardiac involvement in a Patient with Previous SARS-COV-2 Infection

IJC Heart & Vasculature, April 5, 20221

Coronavirus disease (COVID)-19 caused by severe acute respiratory syndrome coronarvirus (SARS-COV)-2 infection has been demonstrated to be associated with cardiac injury. Cases of acute myocarditis have been reported, even in patients with COVID-19 in the absence of significant lung involvement, suggesting a viral triggered immune-mediated injury. The modified RNA vaccines, the BNT162b2 and mRNA-1273, that encode the prefusion SARS-COV-2 spike glycoprotein, have shown to confer 94-95% protection against COVID-19 with a safe profile. Although these vaccines can counteract the COVID-19 pandemic, there is apprehension for patients who experienced previous SARS-COV-2 infection, as these subjects have not been tested in the trials. Systemic reactogenicity, leading to systemic adverse events often occurred after dose 2 and within 2 days after vaccination. The present report describes a case of cardiac involvement in a patient with previous SARS-COV-2 infection within days of the second dose of BNT162b2 mRNA vaccine.

Current Testing Strategies for SARS-CoV-2 in the United States

Clinical Chemistry, April 5, 2021

Since the discovery and recognition of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the official declaration of the coronavirus disease-2019 (COVID-19) pandemic at the beginning of 2020, various different test methodologies have been developed at record speeds and made available for the diagnosis, screening, surveillance, and management of SARS-CoV-2 infection and COVID-19 illness. The rapid scientific developments in the quest to learn and define the mechanisms of SARS-CoV-2 transmission, illness, and recovery, in combination with the public health challenges of a rapidly spreading virus, have forced the healthcare community to adapt continuously to the unfolding pandemic. To help answer some of the questions about how testing is being used and how the in vitro diagnostic industry can help meet diagnostic testing needs, a panel of experts was convened with the objective of gaining critical insights regarding different testing strategies for SARS-CoV-2 in a variety of healthcare, community, congregate, and public health settings. We have invited back a select group of experts who participated in the Scientific Advisory Board to share their perspectives and to provide an update on the current state of testing strategies for SARS-CoV-2 from their respective points of view.

Hyperinflammation as underlying mechanism predisposing patients with cardiovascular diseases for severe COVID-19

European Heart Journal, April 2, 2021

It was already realized early in the COVID-19 pandemic that patients with cardiovascular disease, such as arterial hypertension, have a higher risk for an adverse course of COVID-19, raising the question of the underlying mechanisms. Furthermore, when it was described that the viral spike (S) glycoprotein mediates viral entry via binding to the angiotensin-converting enzyme 2 (ACE2), the question was raised whether therapies acting on the renin-angiotensin system, such as ACE inhibitors (ACEI) or angiotensin receptor blockers (ARBs), could affect the risk of infection or the clinical course of COVID-19. In a recent study, both aspects have been approached by using in-depth single-cell sequencing data of airway samples.

Adults with congenital heart disease may be at elevated risk for complicated COVID-19

Helio | Cardiology Today, April 1, 2021

Patients with adult congenital heart disease who have general risk factors such as age, obesity and multiple comorbidities had elevated risk for complicated COVID-19, according to researchers. Cyanotic lesions, such as unrepaired cyanotic defects or Eisenmenger syndrome, were among the congenital cardiac defects that put patients at particularly high risk, the researchers wrote. “So far, COVID-19 risk stratification in patients with adult congenital heart disease was based on expert opinion. Our cohort study provides observational evidence regarding COVID-19 risk factors in patients with adult congenital heart disease and improves tailoring of recommendations for preventive measures in individual patients,” Markus Schwerzmann, MD, clinician scientist at the Center for Congenital Heart Disease, Inselspital University Hospital in Bern, Switzerland, and colleagues wrote. The researchers analyzed a cohort of 105 patients (mean age, 38 years; 58% women), of whom 13 had a complicated disease course and five died. According to the researchers, 74% of patients had a confirmed diagnosis of COVID-19 determined by testing vs. 26% who had a diagnosis based on clinical grounds.

Determining which hospitalized COVID-19 patients require an urgent echocardiogram

Journal of the American Society of Echocardiography, April 1, 2021

Patients hospitalized with COVID-19 infection often have abnormal transthoracic echocardiogram (TTE) findings. However, while not all TTE abnormalities result in changes in clinical management, performing TTEs in recently infected patients increases disease transmission risks. It remains unknown whether common biomarker tests, such as troponin and B-type natriuretic peptide (BNP), can help distinguish in which COVID-19 patients a TTE may be safely delayed until infection risks subside. Using electronic health records data and chart review, we retrospectively studied all patients hospitalized with COVID-19 infection at our multi-site healthcare system from 2/27/2020-1/15/2021 who underwent a TTE within 14 days of their first positive COVID-19 test and had a BNP and troponin measured before or within 7 days of TTE. The primary outcome was presence of ≥1 urgent echocardiographic finding defined as left ventricular ejection fraction ≤35%, wall motion score index ≥1.5, ≥moderate right ventricular dysfunction, ≥moderate pericardial effusion, intracardiac thrombus, pulmonary artery systolic pressure >50mmHg, or ≥moderate-severe valvular disease. We conducted stepwise logistic regression to determine biomarkers and comorbidities associated with the outcome. We evaluated the performance of a rule for classifying TTEs using troponin and BNP. We included 434 hospitalized and 151 ICU COVID-19 patients. Urgent TTE findings were present in 105 (24.2%) patients. Troponin and BNP were abnormal in 311 (71.7%). Heart failure (OR (95%CI) 5.41 (2.61-11.68)), troponin >0.04ng/mL (4.40 (2.05-10.05)), BNP >100pg/mL (5.85 (2.35-16.09)) remained significant predictors of urgent TTE findings after stepwise selection. 95.1% of all patients and 91.3% of ICU patients with normal troponin and BNP had no urgent TTE findings.

Aortic thrombosis in a patient with COVID-19-associated hyperinflammatory syndrome

International Journal of Infectious Diseases, April 1, 2021

A 77-year-old man was admitted for severe PCR-confirmed COVID-19. The patient presented with severe hypoxemia and biological findings suggestive of hyperinflammatory syndrome: severe lymphopenia in combination with signs of hypercytokinemia (elevated C-reactive protein), coagulopathy (elevated D-dimer levels) and hepatic injury (elevated lactate dehydrogenase). A CT-angiography of the thorax showed ground glass opacities in the 5 lobes, but no signs of pulmonary embolism. The patient was treated with dexamethasone, prophylactic dose of low molecular weight heparin (LMWH), high flow oxygen therapy and a single infusion of tocilizumab within a clinical trial. After six days of hospitalization D-dimer levels were remarkably rising to a level of 9210 ng/ml. A CT-angiography was repeated because pulmonary embolism was suspected. The images showed a partial thrombosis of the descending aorta. The patient was treated with therapeutic anti-coagulation and made a full recovery. Thrombo-embolic events are frequently described in Covid-19 patients and are the consequence of hyperinflammatory response and endothelial dysfunction. A potential role of antiphospholipid syndrome secondary to Sars-cov-2 infection has been proposed. D-dimer level increase has been shown to be associated with thrombo-embolic events, including arterial thrombosis.

Intraventricular Conundrum in a SARS-CoV-2–Positive Patient With Elevated Biomarkers of Myocardial Injury

Journal of the American College of Cardiology: Case Reports, March 31, 2021

We present a case of acute myocarditis with left ventricular dysfunction and intracavitary thrombosis in a 55-year-old man with severe acute respiratory syndrome coronavirus 2 infection (coronavirus disease 2019) who was admitted with bilateral atypical pneumonia. The patient was treated with anticoagulation and optimal heart failure therapy and had an improvement of left ventricular function and thrombus resolution.

Coronary Artery Bypass Graft Surgery Outcomes in the United States: Impact of COVID-19 Pandemic

Journal of Thoracic and Cardiovascular Surgery (JTCVS) Open, March 30, 2021

There has been a substantial decline in patients presenting for emergent and routine cardiovascular care in the United States after the onset of the coronavirus disease-2019 (COVID-19) pandemic. We sought to assess the risk of adverse clinical outcomes among patients undergoing coronary artery bypass graft (CABG) surgery during the 2020 COVID-19 pandemic period and compare the risks to those undergoing CABG prior to the pandemic in the year 2019. A retrospective cross-sectional analysis of the TriNetX Research Network database was performed. Patients undergoing CABG between January 20, 2019, and September 15, 2019, contributed to the 2019 cohort, and those undergoing CABG between January 20, 2020, and September 15, 2020, contributed to the 2020 cohort. Propensity-score matching was performed, and the odds of mortality, acute kidney injury (AKI), stroke, acute respiratory distress syndrome (ARDS), and mechanical ventilation occurring by 30-days were evaluated. The number of patients undergoing CABG in 2020 declined by 35.5% from 5,534 patients in 2019 to 3,569 patients in 2020. After propensity-score matching, 3,569 patient pairs were identified in the 2019 and the 2020 cohorts. Compared with those undergoing CABG in 2019, the odds of mortality by 30-days were 0.96 (95%CI:0.69-1.33;p=0.80) in those undergoing CABG in 2020. The odds for stroke (OR:1.21 [95%CI:0.96-1.39]), AKI (OR: 0.76 [95%CI:0.59-1.08]), ARDS (OR:1.01 [95%CI:0.60-2.42]) and mechanical ventilation (OR: 1.11 [95% CI: 0.94-1.30]) were similar between the two cohorts.

How Information About Race-based Health Disparities Affects Policy Preferences: Evidence from a Survey Experiment About the COVID-19 Pandemic in the United States

Social Science & Medicine, March 29, 2021

In this article, we report on the results of an experimental study to estimate the effects of delivering information about racial disparities in COVID-19-related death rates. On the one hand, we find that such information led to increased perception of risk among those Black respondents who lacked prior knowledge; and to increased support for a more concerted public health response among those White respondents who expressed favorable views towards Blacks at baseline. On the other hand, for Whites with colder views towards Blacks, the informational treatment had the opposite effect: it led to decreased risk perception and to lower levels of support for an aggressive response. Our findings highlight that well-intentioned public health campaigns spotlighting disparities might have adverse side effects and those ought to be considered as part of a broader strategy. The study contributes to a larger scholarly literature on the challenges of making and implementing social policy in racially-divided societies.

Impact of COVID-19 pandemic and infection on in hospital survival for patients presenting with acute coronary syndromes: A multicenter registry

International Journal of Cardiology, March 29, 2021

The impact of Covid-19 on the survival of patients presenting with acute coronary syndrome (ACS) remains to be defined. Consecutive patients presenting with ACS at 18 Centers in Northern-Italy during the Covid-19 outbreak were included. In-hospital all-cause death was the primary outcome. In-hospital cardiovascular death along with mechanical and electrical complications were the secondary ones. A case period (February 20, 2020-May 3, 2020) was compared vs. same-year (January 1–February 19, 2020) and previous-year control periods (February 20–May 3, 2019). ACS patients with Covid-19 were further compared with those without. Among 779 ACS patients admitted during the case period, 67 (8.6%) tested positive for Covid-19. In-hospital all-cause mortality was significantly higher during the case period compared to the control periods (6.4% vs. 3.5% vs. 4.4% respectively; p 0.026), but similar after excluding patients with COVID-19 (4.5% vs. 3.5% vs. 4.4%; p < 0.73). Cardiovascular mortality was similar between the study groups. After multivariable adjustment, admission for ACS during the COVID-19 outbreak had no impact on in-hospital mortality. In the case period, patients with concomitant ACS and Covid-19 experienced significantly higher in-hospital mortality (25% vs. 5%, p < 0.001) compared to patients without. Moreover, higher rates of cardiovascular death, cardiogenic shock and sustained ventricular tachycardia were found in Covid-19 patients.

Is the heart rate variability monitoring using the analgesia nociception index a predictor of illness severity and mortality in critically ill patients with COVID-19? A pilot study

PLOS ONE, March 24, 2021

The analysis of heart rate variability (HRV) has proven to be an important tool for the management of autonomous nerve system in both surgical and critically ill patients. We conducted this study to show the different spectral frequency and time domain parameters of HRV as a prospective predictor for critically ill patients, and in particular, for COVID-19 patients who are on mechanical ventilation. The hypothesis is that most severely ill COVID-19 patients have a depletion of the sympathetic nervous system and a predominance of parasympathetic activity reflecting the remaining compensatory anti-inflammatory response. A single-center, prospective, observational pilot study, which included COVID-19 patients, admitted to the Surgical Intensive Care Unit was conducted. The normalized high-frequency component (HFnu), i.e. ANIm, and the standard deviation of RR intervals (SDNN), i.e. Energy, were recorded using the analgesia nociception index monitor (ANI). To estimate the severity and mortality we used the SOFA score and the date of discharge or date of death.

Cardiac surgery outcome during the COVID-19 pandemic: a retrospective review of the early experience in nine UK centres

Journal of Cardiothoracic Surgery, March 22, 2021

Early studies conclude patients with Covid-19 have a high risk of death, but no studies specifically explore cardiac surgery outcome. We investigate UK cardiac surgery outcomes during the early phase of the Covid-19 pandemic. This retrospective observational study included all adult patients undergoing cardiac surgery between 1st March and 30th April 2020 in nine UK centres. Data was obtained and linked locally from the National Institute for Cardiovascular Outcomes Research Adult Cardiac Surgery database, the Intensive Care National Audit and Research Centre database and local electronic systems. The anonymised datasets were analysed by the lead centre. Statistical analysis included descriptive statistics, propensity score matching (PSM), conditional logistic regression and hierarchical quantile regression. Of 755 included individuals, 53 (7.0%) had Covid-19. Comparing those with and without Covid-19, those with Covid-19 had increased mortality (24.5% v 3.5%, p < 0.0001) and longer post-operative stay (11 days v 6 days, p = 0.001), both of which remained significant after PSM. Patients with a pre-operative Covid-19 diagnosis recovered in a similar way to non-Covid-19 patients. However, those with a post-operative Covid-19 diagnosis remained in hospital for an additional 5 days (12 days v 7 days, p = 0.024) and had a considerably higher mortality rate compared to those with a pre-operative diagnosis (37.1% v 0.0%, p = 0.005).

COVID Strokes: Rates, Types, Disparities

MedPage Today, March 20, 2021

Large studies reported at American Stroke Association virtual International Stroke Conference (ISC) homed in on more accurate estimates of the stroke implications of COVID-19. Ischemic stroke incidence among COVID-19 patients in the American Heart Association (AHA) COVID-19 Registry was 0.75% overall, reported Saate Shakil, MD, of the University of Washington in Seattle. That rate was lower than the 0.9% to 2% reported in other studies of stroke in COVID-19 patients, she noted during an ISC late-breaking trial session. The retrospective study included consecutive patients admitted with acute ischemic stroke and COVID-19 from March 1 to May 1, 2020, at 12 stroke centers from four countries, although three of the centers were excluded from the stroke incidence calculation as they only accepted LVO transfer patients. Large vessel occlusion was also more prominent in a separate analysis of the “Get With The Guidelines-Stroke” database, accounting for 30.4% of acute ischemic strokes in COVID-19 patients versus 23.6% among non-COVID stroke patients. The analysis of 41,971 acute ischemic stroke patients (1,143 with COVID-19) hospitalized between Feb. 4 and June 29, 2020, at 458 participating hospitals was reported by Gregg Fonarow, MD, of the University of California Los Angeles, and colleagues at ISC and online in Stroke.

Effect of Intermediate-Dose vs Standard-Dose Prophylactic Anticoagulation on Thrombotic Events, Extracorporeal Membrane Oxygenation Treatment, or Mortality Among Patients With COVID-19 Admitted to the Intensive Care Unit—The INSPIRATION Randomized Clinical Trial

Journal of the American Medical Association, March 18, 2021

Thrombotic events are commonly reported in critically ill patients with COVID-19. Limited data exist to guide the intensity of antithrombotic prophylaxis. The objective was to evaluate the effects of intermediate-dose vs standard-dose prophylactic anticoagulation among patients with COVID-19 admitted to the intensive care unit (ICU). This was a multicenter randomized trial with a 2 × 2 factorial design performed in 10 academic centers in Iran, comparing intermediate-dose vs standard-dose prophylactic anticoagulation (first hypothesis) and statin therapy vs matching placebo among adult patients admitted to the ICU with COVID-19. Patients were recruited between July 29, 2020, and November 19, 2020. The final follow-up date for the 30-day primary outcome was December 19, 2020. Intermediate-dose (enoxaparin, 1 mg/kg daily) (n = 276) vs standard prophylactic anticoagulation (enoxaparin, 40 mg daily) (n = 286), with modification according to body weight and creatinine clearance. The assigned treatments were planned to be continued until completion of 30-day follow-up. The primary efficacy outcome was a composite of venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days, assessed in randomized patients who met the eligibility criteria and received at least 1 dose of the assigned treatment.

The association of COVID-19 occurrence and severity with the use of angiotensin converting enzyme inhibitors or angiotensin-II receptor blockers in patients with hypertension

PLOS ONE, March 18, 2021

A number of studies have reported the association between the use of angiotensin-converting enzyme inhibitor (ACEI) and angiotensin-II receptor blocker (ARB) medications and the occurrence or severity of coronavirus disease 2019 (COVID-19). Published results are inconclusive, possibly due to differences in participant comorbidities and sociodemographic backgrounds. Since ACEI and ARB are frequently used anti-hypertension medications, we aim to determine whether the use of ACEI and ARB is associated with the occurrence and severity of COVID-19 in a large study of US Veterans with hypertension. Data were collected from the Department of Veterans Affairs (VA) National Corporate Data Warehouse (VA-COVID-19 Shared Data Resource) between February 28, 2020 and August 18, 2020. Using data from 228,722 Veterans with a history of hypertension who received COVID-19 testing at the VA, we investigated whether the use of ACEI or ARB over the two years prior to the index date was associated with increased odds of (1) a positive COVID-19 test, and (2) a severe outcome (hospitalization, mortality, and use of intensive care unit (ICU) and/or mechanical ventilation) among COVID-19-positive patients. We used logistic regression with and without propensity score weighting (PSW) to estimate the odds ratio (OR) and 95% confidence interval (95% CI) for the association between ACEI/ARB use and a positive COVID-19 test result. The association between medication use and COVID-19 outcome severity was examined using multinomial logistic regression comparing participants who were not hospitalized to participants who were hospitalized, were admitted to the ICU, used a mechanical ventilator, or died. All models were adjusted for relevant covariates, including demographics (age, sex, race, ethnicity), selected comorbidities, and the Charlson Comorbidity Index (CCI).

The Association between Cardiovascular Disease Admission Rates and the Coronavirus Disease 2019 Lockdown and Reopening of a Nation: a Danish Nationwide Cohort Study

European Heart Journal Quality of Care & Clinical Outcomes, March 17, 2021

The objective of the study was to investigate the admission rates of cardiovascular diseases, overall and according to subgroups, and subsequent mortality rates during the Covid-19 societal lockdown (March 12, 2020) and reopening phase (April 15, 2020) in Denmark. Using Danish nationwide registries, we identified patients with a first-time acute cardiovascular admission in two periods: 1) January 2-October 16, 2019 and 2) January 2-October 15, 2020. Weekly incidence rates of a first-time cardiovascular admission, overall and according to subtypes, in the two periods were calculated. The incidence rate of first-time cardiovascular admissions overall was significantly lower during the first weeks of lockdown in 2020 compared with a similar period in 2019 but increased after the gradual reopening of the Danish society. A similar trend was observed for all subgroups of cardiovascular diseases. The mortality rate among patients admitted after March 12 was not significantly different in 2020 compared with 2019 (mortality rate ratio 0.98 [95% CI, 0.91-1.06]). In Denmark, we observed a substantial decrease in the rate of acute cardiovascular admissions, overall and according to subtypes, during the first weeks of lockdown. However, after the gradual reopening of the Danish society, the admission rates for acute cardiovascular diseases increased and returned to rates similar to those observed in 2019. The mortality rate in patients admitted with cardiovascular diseases during lockdown was similar to that of patients during the same period in 2019.

Admission Rates and Care Pathways in Patients with Atrial Fibrillation during the COVID-19 Pandemic – Insights from the German-wide Helios Hospital Network

European Heart Journal Quality of Care & Clinical Outcomes, March 16, 2021

Several reports indicate lower rates of emergency admissions in the cardiovascular sector and reduced admissions of patients with chronic diseases during the COVID-19 pandemic. The aim of this study was therefore to evaluate numbers of admissions in incident and prevalent atrial fibrillation and flutter (AF) and to analyze care pathways in comparison to 2019. A retrospective analysis of claims data of 74 German Helios hospitals was performed to identify consecutive patients hospitalized with a main discharge diagnosis of AF. A study period including the start of the German national protection phase (13th March 2020 to 16th July 2020) was compared to a previous year control cohort (15th March 2019 to 18th July 2019), with further sub-division into early and late phase. Incidence rate ratios (IRR) were calculated. Numbers of admission per day (A/day) for incident and prevalent AF and care pathways including readmissions, numbers of transesophageal echocardiogram (TEE), electrical cardioversion (CV) and catheter ablation (CA) were analyzed. During the COVID-19 pandemic, there was a significant decrease of total AF admissions both in the early (44.4 vs. 77.5 A/day, IRR 0.57 [95% CI 0.54–0.61], p < 0.01) and late phase (59.1 vs. 63.5 A/day, IRR 0.93 [95% CI 0.90–0.96], p < 0.01), length of stay was significantly shorter (3.3 ± 3.1 nights vs. 3.5 ± 3.6 nights, p < 0.01), admissions were more frequently in high volume centers (77.0% vs. 75.4%, p = 0.02) and frequency of readmissions was reduced (21.7% vs. 23.6%, p < 0.01) compared to the previous year. Incident AF admission rates were significantly lower both in the early (21.9 admission per day vs. 41.1 A/day, IRR 0.53 [95% CI 0.48 − 0.58]) and late phase (35.5 vs. 39.3 A/day, IRR 0.90 [95% CI 0.86 − 0.95]), whereas prevalent admissions were only lower in the early phase (22.5 vs 36.4 A/day IRR 0.62 [95% CI 0.56 − 0.68]), but not in the late phase (23.6 vs. 24.2 A/day IRR 0.97 [95% CI 0.92 − 1.03]).

Renin-angiotensin system inhibitors and susceptibility to COVID-19 in patients with hypertension: a propensity score-matched cohort study in primary care

BMC Infectious Diseases, March 15, 2021

Renin-angiotensin system (RAS) inhibitors have been postulated to influence susceptibility to Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). This study investigated whether there is an association between their prescription and the incidence of COVID-19 and all-cause mortality. We conducted a propensity-score matched cohort study comparing the incidence of COVID-19 among patients with hypertension prescribed angiotensin-converting enzyme I (ACE) inhibitors or angiotensin II type-1 receptor blockers (ARBs) to those treated with calcium channel blockers (CCBs) in a large UK-based primary care database (The Health Improvement Network). We estimated crude incidence rates for confirmed/suspected COVID-19 in each drug exposure group. We used Cox proportional hazards models to produce adjusted hazard ratios for COVID-19. We assessed all-cause mortality as a secondary outcome. The incidence rate of COVID-19 among users of ACE inhibitors and CCBs was 9.3 per 1000 person-years (83 of 18,895 users [0.44%]) and 9.5 per 1000 person-years (85 of 18,895 [0.45%]), respectively. The adjusted hazard ratio was 0.92 (95% CI 0.68 to 1.26). The incidence rate among users of ARBs was 15.8 per 1000 person-years (79 out of 10,623 users [0.74%]). The adjusted hazard ratio was 1.38 (95% CI 0.98 to 1.95). There were no significant associations between use of RAS inhibitors and all-cause mortality.

Op-Ed: COVID Shot While on a Blood Thinner?

MedPage Today, March 14, 2021

As COVID-19 vaccination continues to roll out to older and medically eligible people across the country, many questions arise for those taking blood thinners. The most important point is that COVID-19 vaccine is fine for pretty much all individuals, no matter whether they have a thrombophilia, a prior deep vein thrombosis (DVT) or pulmonary embolism (PE), or are on a blood thinner. Reasons not to get the vaccine have to do with allergies but not with the fact that a patient has had a clot or is on an anticoagulant. While COVID-19 infection is associated with an increased risk of DVT and PE, particularly in the very sick and hospitalized patient, there is no reason to believe that the vaccine would increase the risk for blood clots. Recent concerns with thrombotic side effects after vaccination with the AstraZeneca shot in Europe appear to be chance events, no causally related to the vaccine. Most patients do not need to interrupt their anticoagulant before getting the vaccine. The COVID-19 vaccine is given as a shot into the deltoid muscle, just like the flu shot. The needle diameter used for injections is very fine, typically 22-25 gauge. It has been shown that intramuscular flu shots in patients on full-dose warfarin (Coumadin, Jantoven) do not increase the risk for bleeding at the site of the injection.

What we (don’t) know about myocardial injury after COVID-19

European Heart Journal, March 13, 2021

[Editorial] The frequency of cardiac injury among hospitalized patients with acute coronavirus disease 2019 (COVID-19) is estimated at 13–41% as defined by elevated troponin levels. Evidence of cardiac involvement in hospitalized COVID-19 patients is significant because cardiac injury is associated with higher mortality. Multiple mechanisms can lead to cardiac damage, including demand ischaemia, systemic hypoxia, intravascular thrombosis and endotheliitis, and myocarditis. Myocardial inflammation can result from both a systemic inflammatory response and, less commonly, direct viral injury. Because of a low rate of histological inflammation associated with the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the tissue on autopsy or endomyocardial biopsy, some have questioned whether COVID-19-related myocarditis exists. Cardiovascular injury from COVID-19 in children and adolescents is much less common than rates seen in cohorts of older patients and includes a multisystem inflammatory syndrome (termed MIS-C) with higher rates of myocarditis and arterial aneurysms. Following recovery from the acute COVID-19 illness, shortness of breath and fatigue may persist. In a recent study, 64% of patients 2–3 months after COVID-19 reported dyspnoea and fatigue, an incidence much higher than after other viral diseases. The reasons for ‘long COVID’ are not well understood, but are associated with signs of ongoing inflammation as well as tissue abnormalities of the lungs, heart, and kidneys as identified by magnetic resonance imaging (MRI).

Postural Tachycardia an Emerging Concern During COVID-19 Recovery

MedPage Today, March 10, 2021

The possibility of COVID-19 long-haulers experiencing symptoms suggestive of postural orthostatic tachycardia syndrome (POTS) was strengthened by a small case series from Sweden. Three young patients who were suspected of having COVID-19 in the spring of 2020 were diagnosed with POTS more than 3 months later on the grounds of orthostatic tachycardia and chronic symptoms of orthostatic intolerance after exclusion of competing etiologies, reported a group led by Madeleine Johansson, MD, PhD, of Lund University and Skåne University Hospital in Malmö, Sweden, in a paper published online in JACC: Case Reports. Much remains unknown about the specific mechanisms responsible for the POTS-like symptoms in post-COVID-19 patients or how long these symptoms will last, but chronic symptoms are expected in a subset of patients based on this initial clinical experience,” Johansson’s team said. “This article from Sweden documents what many autonomic clinics are starting to see, which is an increase in referrals for patients with POTS late post-COVID…The full impact of long COVID and long COVID POTS is not yet known. With over 117 million patients who have suffered from COVID-19, we may be seeing many similar patients,” said Satish Raj, MD, of University of Calgary in Alberta, who was not involved with the study. It is important for clinicians to recognize that POTS can present as a manifestation of post-acute sequelae of SARS-CoV-2 infection, given that there are many treatment options for POTS and a delay in diagnosis leads to further physical deconditioning and poor quality of life, commented Pam Taub, MD, of UC San Diego Health System in La Jolla, California.

Machine learning models to identify low adherence to influenza vaccination among Korean adults with cardiovascular disease

BMC Cardiovascular Disorders, March 9, 2021

Annual influenza vaccination is an important public health measure to prevent influenza infections and is strongly recommended for cardiovascular disease (CVD) patients, especially in the current coronavirus disease 2019 (COVID-19) pandemic. The aim of this study is to develop a machine learning model to identify Korean adult CVD patients with low adherence to influenza vaccination. Adults with CVD (n = 815) from a nationally representative dataset of the Fifth Korea National Health and Nutrition Examination Survey (KNHANES V) were analyzed. Among these adults, 500 (61.4%) had answered “yes” to whether they had received seasonal influenza vaccinations in the past 12 months. The classification process was performed using the logistic regression (LR), random forest (RF), support vector machine (SVM), and extreme gradient boosting (XGB) machine learning techniques. Because the Ministry of Health and Welfare in Korea offers free influenza immunization for the elderly, separate models were developed for the < 65 and ≥ 65 age groups. The accuracy of machine learning models using 16 variables as predictors of low influenza vaccination adherence was compared; for the ≥ 65 age group, XGB (84.7%) and RF (84.7%) have the best accuracies, followed by LR (82.7%) and SVM (77.6%). For the < 65 age group, SVM has the best accuracy (68.4%), followed by RF (64.9%), LR (63.2%), and XGB (61.4%).

Quick Tips and Considerations for COVID-19 Vaccination in Heart Failure and Transplant Patients

American College of Cardiology, March 5, 2021

It has been nearly a year since the World Health Organization declared SARS-CoV-2/COVID-19 as a global pandemic on March 11, 2020. While a large number of SARS-CoV-2 infections result in mild symptoms, the overall death toll is staggering with nearly 2.9 million deaths worldwide and over 500,000 deaths in the United States alone as of February 27th, 2021. Underlying co-morbidities such as diabetes, hypertension, and cardiac or pulmonary disease, significantly increase the risk of death due to COVID-19. In fact, an early systematic review and meta-analysis found a case fatality rate (CFR) of 12-14% for patients with two to five co-morbidities, nearly double the baseline CFR of 7%. Patients with heart failure and those who have undergone heart transplantation may be at increased risk of mortality from COVID-19 due to co-morbidities and immunosuppression. As vaccines for COVID-19 have recently become available, many providers are receiving questions regarding vaccine recommendations for this population. The International Society for Heart and Lung Transplantation (ISHLT) and the American Society for Transplantation (AST) have both released guidance regarding COVID-19 vaccination in patients with chronic heart or lung failure and those who have undergone thoracic transplantation.

Prognostic value of cardiac biomarkers in COVID-19 infection

Scientific Reports, March 2, 2021

Multiple Biomarkers have recently been shown to be elevated in COVID-19, a respiratory infection with multi-organ dysfunction; however, information regarding the prognostic value of cardiac biomarkers as it relates to disease severity and cardiac injury are inconsistent. The goal of this meta-analysis was to summarize the evidence regarding the prognostic relevance of cardiac biomarkers from data available in published reports. PubMed, Embase and Web of Science were searched from inception through April 2020 for studies comparing median values of cardiac biomarkers in critically ill versus non-critically ill COVID-19 patients, or patients who died versus those who survived. The weighted mean differences (WMD) and 95% confidence interval (CI) between the groups were calculated for each study and combined using a random effects meta-analysis model. The odds ratio (OR) for mortality based on cardiac injury was combined from studies reporting it. Troponin levels were significantly higher in COVID-19 patients who died or were critically ill versus those who were alive or not critically ill (WMD 0.57, 95% CI 0.43–0.70, p < 0.001). Additionally, BNP levels were also significantly higher in patients who died or were critically ill (WMD 0.45, 95% CI − 0.21–0.69, p < 0.001). Cardiac injury was independently associated with significantly increased odds of mortality (OR 6.641, 95% CI 1.26–35.1, p = 0.03). A significant difference in levels of D-dimer was seen in those who died or were critically ill. CK levels were only significantly higher in those who died versus those who were alive (WMD 0.79, 95% CI 0.25–1.33, p = 0.004). Cardiac biomarkers add prognostic value to the determination of the severity of COVID-19 and can predict mortality.

Severe acute respiratory syndrome coronavirus 2-induced acute aortic occlusion: a case report

Journal of Medical Case Reports, March 2, 2021

Severe acute respiratory syndrome coronavirus 2 infection can lead to a constellation of viral and immune symptoms called coronavirus disease 2019. Emerging literature increasingly supports the premise that severe acute respiratory syndrome coronavirus 2 promotes a prothrombotic milieu. However, to date there have been no reports of acute aortic occlusion, itself a rare phenomenon. We report a case of fatal acute aortic occlusion in a patient with coronavirus disease 2019. A 59-year-old Caucasian male with past medical history of peripheral vascular disease presented to the emergency department for evaluation of shortness of breath, fevers, and dry cough. His symptoms started 5–7 days prior to the emergency department visit, and he received antibiotics in the outpatient setting without any effect. He was found to be febrile, tachypneic, and hypoxemic. He was placed on supplemental oxygen via a non-rebreather mask. Chest X-ray showed multifocal opacifications. Intravenous antibiotics for possible pneumonia were initiated. Hydroxychloroquine was initiated to cover possible coronavirus disease 2019 pneumonia. During the hospitalization, the patient became progressively hypoxemic, for which he was placed on bilevel positive airway pressure. D-dimer, ferritin, lactate dehydrogenase, and C-reactive protein were all elevated. Severe acute respiratory syndrome coronavirus 2 reverse transcription polymerase chain reaction was positive. On day 3, the patient was upgraded to the intensive care unit. Soon after he was intubated, he developed a mottled appearance of skin, which extended from his bilateral feet up to the level of the subumbilical plane. Bedside ultrasound revealed an absence of flow from the mid-aorta to both common iliac arteries. The patient was evaluated emergently by vascular surgery. After a discussion with the family, it was decided to proceed with comfort-directed care, and the patient died later that day. We believe that healthcare providers should be aware of both venous and arterial thrombotic complications associated with coronavirus disease 2019, including possible fatal outcome.

Use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers associated with lower risk of COVID-19 in household contacts

PLOS ONE, March 2, 2021

Use of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) has been hypothesized to affect COVID-19 risk. Our objective was to examine the association between use of ACEI/ARB and household transmission of COVID-19. We conducted a modified cohort study of household contacts of patients who tested positive for COVID-19 between March 4 and May 17, 2020 in a large Northeast US health system. Household members were identified by geocoding and full address matching with exclusion of addresses with >10 matched residents or known congregate living functions. Medication use, clinical conditions and sociodemographic characteristics were obtained from electronic medical record (EMR) data on cohort entry. Cohort members were followed for at least one month after exposure to determine who tested positive for SARS-CoV-2. Mixed effects logistic regression and propensity score analyses were used to assess adjusted associations between medication use and testing positive. 1,499 of the 9,101 household contacts were taking an ACEI or an ARB. Probability of COVID-19 diagnosis during the study period was slightly higher among ACEI/ARB users in unadjusted analyses. However, ACEI/ARB users were older and more likely to have clinical comorbidities so that use of ACEI/ARB was associated with a decreased risk of being diagnosed with COVID-19 in mixed effect models (OR 0.60, 95% CI 0.44–0.81) or propensity score analyses (predicted probability 18.6% in ACEI/ARB users vs. 24.5% in non-users, p = 0.03). These associations were similar within age and comorbidity subgroups, including patients with documented hypertension, diabetes or cardiovascular disease, as well as when including other medications in the models. In this observational study of household transmission, use of ACEIs or ARBs was associated with a decreased risk of being diagnosed with COVID-19.

Evaluation of myocardial injury patterns and ST changes among critical and non-critical patients with coronavirus-19 disease

Scientific Reports, March 1, 2021

Novel coronavirus disease (COVID-19) has led to a major public health crisis globally. Currently, myocardial damage is speculated to be associated with COVID-19, which can be seen as one of the main causes of death of patients with COVID-19. We therefore, aim to investigate the effects of COVID-19 disease on myocardial injury in hospitalized patients who have been tested positive for COVID-19 pneumonia in this study. A prospective study was conducted among 201 patients with COVID-19 in the Pakistan Military Hospital from April 1 to August 31, 2020, including non-critical cases and critical cases. COVID-19 patients were stratified as critical and non-critical according to the signs and symptoms severity; with those requiring intensive care and invasive mechanical ventilation as critical, and those did not requiring invasive mechanical ventilation as non-critical. A total of 201 COVID-19 patients with critical and non-critical categories presented with myocardial injury. All patients with myocardial injury had an elevation in CKMB and Troponin-I levels. Of these patients, 43.7% presented with new electrocardiography (ECG) changes, and ST depression was typically observed in 36.3% patients. In addition, 18.7% patients presented with abnormal echocardiography findings, with right ventricular dilatation and dysfunction commonly seen among critical group patients. Results analyzed by a logistic regression model showing COVID-19 direct contribution to myocardial injury in these patients. COVID-19 disease directly leads to cardiovascular damage among critical and non-critical patients. Myocardial injury is associated not only with abnormal ECG changes but also with myocardial dysfunction on echocardiography and more commonly observed among critical patients.

Myocardial injury in hospitalized patients with COVID-19 infection—Risk factors and outcomes

PLOS ONE, February 26, 2021

Myocardial injury in hospitalized patients is associated with poor prognosis. This study aimed to evaluate risk factors for myocardial injury in hospitalized patients with coronavirus disease 2019 (COVID-19) and its prognostic value. We retrieved all consecutive patients who were hospitalized in internal medicine departments in a tertiary medical center from February 9th, 2020 to August 28th with a diagnosis of COVID-19. A total of 559 adult patients were hospitalized in the Sheba Medical Center with a diagnosis of COVID-19, 320 (57.24%) of whom were tested for troponin levels within 24-hours of admission, and 91 (28.44%) had elevated levels. Predictors for elevated troponin levels were age (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01–1.06), female sex (OR, 3.03; 95% CI 1.54–6.25), low systolic blood pressure (OR, 5.91; 95% CI 2.42–14.44) and increased creatinine level (OR, 2.88; 95% CI 1.44–5.73). The risk for death (hazard ratio [HR] 4.32, 95% CI 2.08–8.99) and a composite outcome of invasive ventilation support and death (HR 1.96, 95% CI 1.15–3.37) was significantly higher among patients who had elevated troponin levels. In conclusion, in hospitalized patients with COVID-19, elevated troponin levels are associated with poor prognosis. Hence, troponin levels may be used as an additional tool for risk stratification and a decision guide in patients hospitalized with COVID-19.

Cardiac involvement in COVID-19 patients: mid-term follow up by cardiovascular magnetic resonance

Journal of Cardiac Magnetic Resonance, February 25, 2021

Coronavirus disease 2019 (COVID-19) induces myocardial injury, either direct myocarditis or indirect injury due to systemic inflammatory response. Myocardial involvement has been proved to be one of the primary manifestations of COVID-19 infection, according to laboratory test, autopsy, and cardiovascular magnetic resonance (CMR). However, the middle-term outcome of cardiac involvement after the patients were discharged from the hospital is yet unknown. The present study aimed to evaluate mid-term cardiac sequelae in recovered COVID-19 patients by CMR. A total of 47 recovered COVID-19 patients were prospectively recruited and underwent CMR examination. The CMR protocol consisted of black blood fat-suppressed T2 weighted imaging, T2 star mapping, left ventricle (LV) cine imaging, pre- and post-contrast T1 mapping, and late gadolinium enhancement (LGE). LGE were assessed in mixed both recovered COVID-19 patients and healthy controls. The LV and right ventricle (RV) function and LV mass were assessed and compared with healthy controls. A total of 44 recovered COVID-19 patients and 31 healthy controls were studied. LGE was found in 13 (30%) of COVID-19 patients. All LGE lesions were located in the mid myocardium and/or sub-epicardium with a scattered distribution. Further analysis showed that LGE-positive patients had significantly decreased LV peak global circumferential strain (GCS), RV peak GCS, RV peak global longitudinal strain (GLS) as compared to non-LGE patients (p < 0.05), while no difference was found between the non-LGE patients and healthy controls. Myocardium injury existed in 30% of COVID-19 patients.

Association of coagulation dysfunction with cardiac injury among hospitalized patients with COVID-19

Scientific Reports, February 24, 2021

Cardiac injury is a common complication of the coronavirus disease 2019 (COVID-19), and is associated with adverse clinical outcomes. In this study, we aimed to reveal the association of cardiac injury with coagulation dysfunction. We enrolled 181 consecutive patients who were hospitalized with COVID-19, and studied the clinical characteristics and outcome of these patients. Cardiac biomarkers high-sensitivity troponin I (hs-cTnI), myohemoglobin and creatine kinase-myocardial band (CK-MB) were assessed in all patients. The clinical outcomes were defined as hospital discharge or death. The median age of the study cohort was 55 (IQR, 46–65) years, and 102 (56.4%) were males. Forty-two of the 181 patients (23.2%) had cardiac injury. Old age, high leukocyte count, and high levels of aspartate transaminase (AST), D-dimer and serum ferritin were significantly associated with cardiac injury. Multivariate regression analysis revealed old age and elevated D-dimer levels as being strong risk predictors of in-hospital mortality. Interleukin 6 (IL6) levels were comparable in patients with or without cardiac injury. Serial observations of coagulation parameters demonstrated highly synchronous alterations of D-dimer along with progression to cardiac injury. Cardiac injury is a common complication of COVID-19 and is an independent risk factor for in-hospital mortality. Old age, high leukocyte count, and high levels of AST, D-dimer and serum ferritin are significantly associated with cardiac injury, whereas IL6 are not. Therefore, the pathogenesis of cardiac injury in COVID-19 may be primarily due to coagulation dysfunction along with microvascular injury.

All-cause mortality and location of death in patients with established cardiovascular disease before, during, and after the COVID-19 lockdown: a Danish Nationwide Cohort Study

European Heart Journal, February 24, 2021

On 13 March 2020, the Danish authorities imposed extensive nationwide lockdown measures to prevent the spread of the coronavirus disease 2019 (COVID-19) and reallocated limited healthcare resources. We investigated mortality rates, overall and according to location, in patients with established cardiovascular disease before, during, and after these lockdown measures. Using Danish nationwide registries, we identified a dynamic cohort comprising all Danish citizens with cardiovascular disease (i.e. a history of ischaemic heart disease, ischaemic stroke, heart failure, atrial fibrillation, or peripheral artery disease) alive on 2 January 2019 and 2020. The cohort was followed from 2 January 2019/2020 until death or 16/15 October 2019/2020. The cohort comprised 340 392 and 347 136 patients with cardiovascular disease in 2019 and 2020, respectively. The overall, in-hospital, and out-of-hospital mortality rate in 2020 before lockdown was significantly lower compared with the same period in 2019 [adjusted incidence rate ratio (IRR) 0.91, 95% confidence interval (CI) CI 0.87–0.95; IRR 0.95, 95% CI 0.89–1.02; and IRR 0.87, 95% CI 0.83–0.93, respectively]. The overall mortality rate during and after lockdown was not significantly different compared with the same period in 2019 (IRR 0.99, 95% CI 0.97–1.02). However, the in-hospital mortality rate was lower and out-of-hospital mortality rate higher during and after lockdown compared with the same period in 2019 (in-hospital, IRR 0.92, 95% CI 0.88–0.96; out-of-hospital, IRR 1.04, 95% CI1.01–1.08). These trends were consistent irrespective of sex and age.

The collateral cardiovascular damage of COVID-19: only history will reveal the depth of the iceberg

European Heart Journal, February 24, 2021

[Editorial] The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented global public health emergency that has dramatically changed all aspects of our lives. To date, the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected almost 100 million people and directly caused >2 million deaths. To prevent the spread of the virus and relieve pressure on healthcare services, governments enforced lockdown measures. At the same time, healthcare systems rapidly repurposed by redeploying resources and staff to tackle this unique challenge. These strategies limited the impact of the first wave of COVID-19 but disrupted usual care pathways for non-COVID-19 conditions. The prevalence of cardiovascular diseases has consistently increased over time as effective interventions have prolonged survival. Despite this, they are still the leading cause of morbidity and mortality worldwide, mandating ongoing efforts to provide prompt diagnosis, complex interventions, structured follow-up, and uninterrupted care.2 The advent of the COVID-19 pandemic has abruptly discontinued this continuum of care for all cardiovascular conditions, with potentially devastating consequences.

Association of coagulation dysfunction with cardiac injury among hospitalized patients with COVID-19

Scientific Reports, February 24, 2021

Cardiac injury is a common complication of the coronavirus disease 2019 (COVID-19), and is associated with adverse clinical outcomes. In this study, we aimed to reveal the association of cardiac injury with coagulation dysfunction. We enrolled 181 consecutive patients who were hospitalized with COVID-19, and studied the clinical characteristics and outcome of these patients. Cardiac biomarkers high-sensitivity troponin I (hs-cTnI), myohemoglobin and creatine kinase-myocardial band (CK-MB) were assessed in all patients. The clinical outcomes were defined as hospital discharge or death. The median age of the study cohort was 55 (IQR, 46–65) years, and 102 (56.4%) were males. Forty-two of the 181 patients (23.2%) had cardiac injury. Old age, high leukocyte count, and high levels of aspartate transaminase (AST), D-dimer and serum ferritin were significantly associated with cardiac injury. Multivariate regression analysis revealed old age and elevated D-dimer levels as being strong risk predictors of in-hospital mortality. Interleukin 6 (IL6) levels were comparable in patients with or without cardiac injury. Serial observations of coagulation parameters demonstrated highly synchronous alterations of D-dimer along with progression to cardiac injury. Cardiac injury is a common complication of COVID-19 and is an independent risk factor for in-hospital mortality. Old age, high leukocyte count, and high levels of AST, D-dimer and serum ferritin are significantly associated with cardiac injury, whereas IL6 are not. Therefore, the pathogenesis of cardiac injury in COVID-19 may be primarily due to coagulation dysfunction along with microvascular injury.

In- and out-of-hospital mortality for myocardial infarction during the first wave of the COVID-19 pandemic in Emilia-Romagna, Italy: A population-based observational study

The Lancet – Regional Health Europe, February 24, 2021

The COVID-19 pandemic has put several healthcare systems under severe pressure. The present analysis investigates how the first wave of the COVID-19 pandemic affected the myocardial infarction (MI) network of Emilia-Romagna (Italy). Based on Emilia-Romagna mortality registry and administrative data from all the hospitals from January 2017 to June 2020, we analysed: i) temporal trend in MI hospital admissions; ii) characteristics, management, and 30-day mortality of MI patients; iii) out-of-hospital mortality for cardiac cause. Admissions for MI declined on February 22, 2020 (IRR -19.5%, 95%CI from -8.4% to -29.3%, p = 0.001), and further on March 5, 2020 (IRR -21.6%, 95%CI from -9.0% to -32.5%, p = 0.001). The return to pre-COVID-19 MI-related admission levels was observed from May 13, 2020 (IRR 34.3%, 95%CI 20.0%-50.2%, p<0.001). As compared to those before the pandemic, MI patients admitted during and after the first wave were younger and with fewer risk factors. The 30-day mortality remained in line with that expected based on previous years (ratio observed/expected was 0.96, 95%CI 0.84–1.08). MI patients positive for SARS-CoV-2 were few (1.5%) but showed poor prognosis (around 5-fold increase in 30-day mortality). In 2020, the number of out-of-hospital cardiac deaths was significantly higher (ratio observed/expected 1.17, 95%CI 1.08–1.27). The peak was reached in April.

COVID-19 and changes in activity and treatment of ST elevation MI from a UK cardiac centre

IJC Heart & Vasculature, February 23, 2021

The international healthcare response to COVID-19 has been driven by epidemiological data related to case numbers and case fatality rate. Second order effects have been less well studied. This study aimed to characterise the changes in emergency activity of a high-volume cardiac catheterisation centre and to cautiously model any excess indirect morbidity and mortality. Retrospective cohort study of patients admitted with acute coronary syndrome fulfilling criteria for the heart attack centre (HAC) pathway at St. Bartholomew’s hospital, UK. Electronic data were collected for the study period March 16th – May 16th 2020 inclusive and stored on a dedicated research server. Standard governance procedures were observed in line with the British Cardiovascular Intervention Society audit. There was a 28% fall in the number of primary percutaneous coronary interventions (PCIs) for ST elevation myocardial infarction (STEMI) during the study period (111 vs. 154) and 36% fewer activations of the HAC pathway (312 vs. 485), compared to the same time period averaged across three preceding years. In the context of ‘missing STEMIs’, the excess harm attributable to COVID-19 could result in an absolute increase of 1.3% in mortality, 1.9% in nonfatal MI and 4.5% in recurrent ischemia.

Impact of Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers in Hypertensive Patients with COVID-19 (COVIDECA Study)

American College of Cardiology, February 20, 2021

Effect of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) among hypertensive patients with coronavirus disease 2019 (COVID-19) is debated. The aim of the COVIDECA study was to assess the outcome of ACEI and ARB among hypertensive patients presenting with COVID-19. We reviewed from the Assistance Publique-Hôpitaux de Paris healthcare record database all patients presenting with confirmed COVID-19 by RT-PCR. We compared hypertensive patients with ACEI or ARB and hypertensive patients without ACEI and ARB. Among 13,521 patients presenting with confirmed COVID-19 by RT-PCR, 2,981 hypertensive patients (mean age: 78.4 ± 13.6 years, 1,464 men) were included. Outcome of hypertensive patients was similar whatever the use or non-use of ACEI or ARB: admission in ICU (13.4% in patients with ACEI or ARB versus 14.8% in patients without ACEI/ARB, p = 0.35), need of mechanical ventilation (5.5% in patients with ACEI or ARB vs 6.3% in patients without ACEI/ARB, p = 0.45), in-hospital mortality (27.5% in patients with ACEI or ARB vs 26.7% in patients without ACEI/ARB, p = 0.70). In conclusion, the use of ACEI and ARB remains safe and can be maintained in hypertensive patients presenting with COVID-19.

Frequency of Atrial Arrhythmia in Hospitalized Patients with COVID-19

American Journal of Cardiology, February 20, 2021

There is growing evidence that COVID-19 can cause cardiovascular complications. However, there are limited data on the characteristics and importance of atrial arrhythmia (AA) in patients hospitalized with COVID-19. Data from 1029 patients diagnosed with of COVID-19 and admitted to Columbia University Medical Center between March 1st and April 15th 2020 were analyzed. The diagnosis of AA was confirmed by 12-lead electrocardiographic recordings, 24-hour telemetry recordings and implantable device interrogations. Patients’ history, biomarkers and hospital course were reviewed. Outcomes of death, intubation and discharge were assessed. Of 1029 patients, 82 (8%) were diagnosed with AA. Out of the 82 patients with AA. Of the AA patients, new-onset AA was seen in 46 (56%) patients, recurrent paroxysmal and chronic persistent were diagnosed in 16 (20%) and 20 (24%) individuals, respectively. Sixty-five percent of the patients diagnosed with AA (n=53) died. Patients diagnosed with AA had significantly higher mortality compared to those without AA (65% vs. 21%; p < 0.001). Predictors of mortality were older age (Odds Ratio (OR) =1.12, [95% Confidence Interval (CI), 1.04 to 1.22]); male gender (OR=6.4 [95% CI, 1.3 to 32]); azithromycin use (OR=13.4 [95% CI, 2.14 to 84]); and higher D-dimer levels (OR=2.8 [95% CI, 1.1 to7.3]). In conclusion, patients diagnosed with AA had 3.1 times significant increase in mortality rate versus patients without diagnosis of AA in COVID-19 patients. Older age, male gender, azithromycin use and higher baseline D-dimer levels were predictors of mortality.

Excess deaths in people with cardiovascular diseases during the COVID-19 pandemic

European Journal of Preventive Cardiology, February 20, 2021

Cardiovascular diseases (CVDs) increase mortality risk from coronavirus infection (COVID-19). There are also concerns that the pandemic has affected supply and demand of acute cardiovascular care. We estimated excess mortality in specific CVDs, both ‘direct’, through infection, and ‘indirect’, through changes in healthcare. We used (i) national mortality data for England and Wales to investigate trends in non-COVID-19 and CVD excess deaths; (ii) routine data from hospitals in England (n = 2), Italy (n = 1), and China (n = 5) to assess indirect pandemic effects on referral, diagnosis, and treatment services for CVD; and (iii) population-based electronic health records from 3 862 012 individuals in England to investigate pre- and post-COVID-19 mortality for people with incident and prevalent CVD. We incorporated pre-COVID-19 risk (by age, sex, and comorbidities), estimated population COVID-19 prevalence, and estimated relative risk (RR) of mortality in those with CVD and COVID-19 compared with CVD and non-infected (RR: 1.2, 1.5, 2.0, and 3.0). Mortality data suggest indirect effects on CVD will be delayed rather than contemporaneous (peak RR 1.14). CVD service activity decreased by 60–100% compared with pre-pandemic levels in eight hospitals across China, Italy, and England. In China, activity remained below pre-COVID-19 levels for 2–3 months even after easing lockdown and is still reduced in Italy and England. For total CVD (incident and prevalent), at 10% COVID-19 prevalence, we estimated direct impact of 31 205 and 62 410 excess deaths in England (RR 1.5 and 2.0, respectively), and indirect effect of 49 932 to 99 865 deaths.

Delayed-onset myocarditis following COVID-19

The Lancet – Respiratory Medicine, February 19, 2021

A multisystem inflammatory syndrome occurring several weeks after SARS-CoV-2 infection and that can include severe acute heart failure has been reported in children (MIS-C). In adults with acute severe heart failure, we have identified a similar syndrome (MIS-A) and describe presenting characteristics, diagnostic features, and early outcomes. Our data also complement reports of MIS-A. The recognition that three patients presenting with fulminant myocarditis also had clinical features of COVID-19, but were negative for SARS-CoV-2 on RT-PCR, was made during recruitment for a study of patients with cardiac injury associated with SARS-CoV-2. To identify implications for patient care, we audited digital records to identify similar presentations to Barts Health National Health Service (NHS) Trust, London, UK, and Guy’s and St Thomas’ NHS Trust, London, between March 1, and Sept 30, 2020. All participants had stored serum for antibody testing, and included nine patients (cases 1–9) with acute cardiac decompensation, negative RT-PCR for SARS-CoV-2, markedly increased serum troponin, and substantially raised inflammatory markers. We also studied three controls (cases 10–12) with acute heart failure and SARS-CoV-2 antibodies, but without all the other features. Patients were mostly male (seven [78%] of nine), of Black African ancestry (seven [78%] of nine), and the mean age was 36 years (IQR 23–53). Both female patients (cases 6 and 8) presented during or shortly after pregnancy, one of whom had gestational diabetes. One male patient had a significant comorbidity (case 4, hypertension secondary to primary hyperaldosteronism). The primary purpose of this Correspondence is to highlight a novel clinical presentation of a multisystem disorder that can have life-threatening features, yet might respond adroitly to therapy.

Key factors leading to fatal outcomes in COVID-19 patients with cardiac injury

Scientific Reports, February 18, 2021
Cardiac injury among patients with COVID-19 has been reported and is associated with a high risk of mortality, but cardiac injury may not be the leading factor related to death. The factors related to poor prognosis among COVID-19 patients with myocardial injury are still unclear. This study aimed to explore the potential key factors leading to in-hospital death among COVID-19 patients with cardiac injury. This retrospective single-center study was conducted at Renmin Hospital of Wuhan University, from January 20, 2020 to April 10, 2020, in Wuhan, China. All inpatients with confirmed COVID-19 (≥ 18 years old) and cardiac injury who had died or were discharged by April 10, 2020 were included. Demographic data and clinical and laboratory findings were collected and compared between survivors and nonsurvivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with mortality in COVID-19 patients with cardiac injury. A total of 173 COVID-19 patients with cardiac injury were included in this study, 86 were discharged and 87 died in the hospital. Multivariable regression showed increased odds of in-hospital death were associated with advanced age (odds ratio 1.12, 95% CI 1.05–1.18, per year increase; p < 0.001), coagulopathy (2.54, 1.26–5.12; p = 0·009), acute respiratory distress syndrome (16.56, 6.66–41.2; p < 0.001), and elevated hypersensitive troponin I (4.54, 1.79–11.48; p = 0.001). A high risk of in-hospital death was observed among COVID-19 patients with cardiac injury in this study. The factors related to death include advanced age, coagulopathy, acute respiratory distress syndrome and elevated levels of hypersensitive troponin I.

Ventricular septal defect complicating delayed presentation of acute myocardial infarction during COVID-19 lockdown: a case repor

European Heart Journal – Case Reports, February 16, 2021

Post-myocardial infarction ventricular septal defects (VSDs) have become rare in the reperfusion era but remain associated with very high morbidity and mortality. As patients defer prompt evaluation and management of acute coronary syndromes during the COVID-19 global pandemic, the incidence of these and other post-infarction mechanical complications is expected to increase. A 37-year-old gentleman with multiple coronary artery disease risk factors presented with intermittent chest discomfort and 1 week of heart failure symptoms. An echocardiogram demonstrated a large muscular VSD and coronary angiography confirmed the presence of an anterior wall infarction. He was subsequently referred for transcatheter VSD repair and showed rapid clinical improvement in his symptoms. Post-infarction VSDs remain associated with a high degree of morbidity and mortality. Surgical repair of acutely ruptured myocardium can be technically challenging, and transcatheter repair has emerged as a safe and effective alternative.

Remdesivir for COVID-19 Treatment: APA Practice Points

American College of Cardiology, February 16, 2021

This second version of a guidelines document by the Scientific Medical Policy Committee of the American College of Physicians (ACP) based on an updated systematic review provides evidence-based recommendations surrounding the use of remdesivir in the treatment of coronavirus disease 2019 (COVID-19). Read 10 key points to remember summarizing the data and guidelines.

Myocarditis in COVID-19 presenting with cardiogenic shock: a case series

European Heart Journal – Case Reports, February 16, 2021

SARS-CoV2, also known as COVID-19, is a specific strain of coronavirus that is responsible for an ongoing global pandemic. COVID-19 primarily targets the respiratory system via droplet transmission, causing symptoms similar to influenza, including fever, cough, and shortness of breath. It is now known to impact other organ systems, causing significant cardiovascular and gastrointestinal illness, among others. We describe two cases of COVID-19 induced myocarditis presenting with cardiogenic shock. These cases highlight the importance of understanding the lethal cardiac complications of COVID-19 infection, as well as its presentation, diagnosis, pathophysiology, and potential treatment options. These two cases involve patients without underlying cardiovascular disease risk factors who experienced prolonged symptoms of COVID-19 infection. Both patients presented with cardiogenic shock more than one week after symptom onset and diagnosis. These cases demonstrate the late presentation of myocarditis and cardiogenic shock, treated with corticosteroids and inotropes, with subsequent recovery of cardiac function.

Spotlight on Cardiovascular Scoring Systems in Covid-19: Severity Correlations in Real-world Setting

Current Problems in Cardiology, February 15, 2021

The current understanding of the interplay between cardiovascular (CV) risk and Covid-19 is grossly inadequate. CV risk-prediction models are used to identify and treat high risk populations and to communicate risk effectively. These tools are unexplored in Covid-19. The main objective is to evaluate the association between CV scoring systems and chest X ray (CXR) examination (in terms of severity of lung involvement) in 50 Italian Covid-19 patients. Only the Framingham Risk Score (FRS) was applicable to all patients. The Atherosclerotic Cardiovascular Disease Score (ASCVD) was applicable to half. 62% of patients were classified as high risk according to FRS and 41% according to ASCVD. Patients who died had all a higher FRS compared to survivors. They were all hypertensive. FRS≥30 patients had a 9.7 higher probability of dying compared to patients with a lower FRS. We found a strong correlation between CXR severity and FRS and ASCVD (p<0.001). High CV risk patients had consolidations more frequently. CXR severity was significantly associated with hypertension and diabetes. 71% of hypertensive patients’ CXR and 88% of diabetic patients’ CXR had consolidations. Patients with diabetes or hypertension had 8 times greater risk of having consolidations. High CV risk correlates with more severe CXR pattern and death. Diabetes and hypertension are associated with more severe CXR. FRS offers more predictive utility and fits best to our cohort. These findings may have implications for clinical practice and for the identification of high-risk groups to be targeted for the vaccine precedence.

One clot after another in COVID-19 patient: diagnostic utility of handheld echocardiogram

Oxford Medical Case Reports, February 15, 2021

A 63-year-old woman was admitted with severe respiratory distress requiring mechanical ventilation and shock requiring vasopressor support. She was found to have COVID-19 pneumonia. Focused cardiac ultrasound performed for evaluation of shock was significant for right ventricular dilation and dysfunction with signs of right ventricular pressure overload. Given worsening shock and hypoxemia systemic thrombolysis was administered for presumed massive pulmonary embolism with remarkable improvement of hemodynamics and respiratory failure. In next 24 h patient’s neurologic status deteriorated to the point of unresponsiveness. Emergent computed tomography showed multiple ischemic infarcts concerning for embolic etiology. Focused cardiac ultrasound with agitated saline showed large right to left shunt due to a patent foramen ovale. This was confirmed by transesophageal echocardiogram, 5 months later. This case highlights strengths of focused cardiac ultrasound in critical care setting and in patients with COVID-19 when access to other imaging modalities can be limited.

Clinical Features and Outcomes of Critically Ill Patients with Coronavirus Disease 2019 (COVID-19): A Multicenter Cohort Study

International Journal of Infectious Diseases, February 15, 2021

Coronavirus disease-19 (COVID-19) manifested by a broad spectrum of symptoms, ranging from asymptomatic manifestations to severe illness and death. The purpose of the study was to extensively describe the clinical features and outcomes in critically ill patients with COVID19 in Saudi Arabia. A multi-center, non-interventional, cohort study for all critically ill patients aged 18 years or older who are admitted to intensive care units (ICUs) between March 1st to August 31st, 2020 with an objectively confirmed diagnosis of COVID19. The diagnosis of COVID19 was confirmed by Reverse Transcriptase–Polymerase Chain Reaction (RT-PCR) on nasopharyngeal and/or throat swabs. Multivariate logistic regression and generalized linear regression were used. We considered a P value of < 0.05 statistically significant. A total of 560 patients met the inclusion criteria. An extensive list of clinical features were associated with higher 30-days ICU mortality rate such as requiring mechanical ventilation (MV) or developing acute kidney injury within 24 hours of ICU admission, higher body temperature, white blood cells, blood glucose level, serum creatinine, fibrinogen, procalcitonin, creatine phosphokinase, aspartate aminotransferase and Total iron-binding capacity. The most common complication during ICU stay was respiratory failure that required MV (71.4%), followed by acute kidney injury (AKI) and thrombosis with a proportion of 46.8% and 11.4% respectively. Among patients with COVID19 who were admitted to the ICU, several variables were associated with increasing the risk of ICU mortality at 30 days.

COVID-19 patients with hypertension are at potential risk of worsened organ injury

Scientific Reports, February 12, 2021

In less than 6 months, COVID-19 spread rapidly around the world and became a global health concern. Hypertension is the most common chronic disease in COVID-19 patients, but its impact on these patients has not been well described. In this retrospective study, 82 patients diagnosed with COVID-19 were enrolled, and epidemiological, demographic, clinical, laboratory, radiological and therapy-related data were analyzed and compared between COVID-19 patients with (29 cases) or without (53 cases) hypertension. The median age of the included patients was 60.5 years, and the cohort included 49 women (59.8%) and 33 (40.2%) men. Hypertension (31 [28.2%]) was the most common chronic illness, followed by diabetes (16 [19.5%]) and cardiovascular disease (15 [18.3%]). The most common symptoms were fatigue (55 [67.1%]), dry cough (46 [56.1%]) and fever ≥ 37.3 °C (46 [56.1%]). The median time from illness onset to positive RT-PCR test was 13.0 days (range 3–25 days). There were 6 deaths (20.7%) in the hypertension group and 5 deaths (9.4%) in the nonhypertension group, and more hypertensive patients with COVID-19 (8 [27.6%]) than nonhypertensive patients (2 [3.8%]) (P = 0.002) had at least one comorbid disease. Compared with nonhypertensive patients, hypertensive patients exhibited higher neutrophil counts, serum amyloid A, C-reactive protein, and NT-proBNP and lower lymphocyte counts and eGFR. Dynamic observations indicated more severe disease and poorer outcomes after hospital admission in the hypertension group. COVID-19 patients with hypertension have increased risks of severe inflammatory reactions, serious internal organ injury, and disease progression and deterioration.

COVID-19 and cardiovascular diseases

Journal of Molecular Cell Biology, February 12, 2021

The coronavirus disease 2019 (COVID-19) remains a global public health emergency. Despite being caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), besides the lung, this infectious disease also has severe implications in the cardiovascular system. In this review, we summarize diverse clinical complications of the heart and vascular system, as well as the relevant high mortality, in COVID-19 patients. Systemic inflammation and angiotensin-converting enzyme 2-involved signaling networking in SARS-CoV-2 infection and the cardiovascular system may contribute to the manifestations of cardiovascular diseases. Therefore, integration of clinical observations and experimental findings can promote our understanding of the underlying mechanisms, which would aid in identifying and treating cardiovascular injury in patients with COVID-19 appropriately.

ACC Statement Urges COVID-19 Vaccine Prioritization For Highest Risk CVD Patients

American College of Cardiology, February 12, 2021

COVID-19 vaccine prioritization should prioritize those with advanced cardiovascular disease over well-managed cardiovascular disease, according to an ACC health policy statement published Feb. 12 in the Journal of the American College of Cardiology. All cardiovascular disease patients face a higher risk of COVID-19 complications and should receive the vaccine quickly, but recommendations in the paper serve to guide clinicians in prioritizing their most vulnerable patients within the larger cardiovascular disease group, while considering disparities in COVID-19 outcomes among different racial/ethnic groups and socioeconomic levels.

Anticoagulation therapy in non-valvular atrial fibrillation in the COVID-19 era: is it time to reconsider our therapeutic strategy?

European Journal of Preventive Cardiology, February 10, 2021

Non-vitamin K antagonist oral anticoagulants (NOACs) are considered the first-line therapy to prevent stroke in non-valvular atrial fibrillation (AF) and are recommended by the recent ESC guidelines in preference to vitamin K antagonists (VKAs). Non-vitamin K antagonist oral anticoagulants offer many advantages compared to VKAs, which include fixed dosing (up to two times a day), fewer dietary and drug interactions, predictable anticoagulation effect (rapid onset and offset) precluding the need for periprocedural bridging anticoagulation, and no need for regular monitoring of anticoagulant effect. Non-vitamin K antagonist oral anticoagulants have been proven to be at least non-inferior to VKAs in large clinical trials in the prevention of stroke, while they are associated with a significant reduction in intracranial haemorrhage. On the other hand, VKAs require frequent monitoring of their anticoagulant effect and have many food and drug interactions. Moreover, the use of VKAs is limited by the narrow therapeutic interval, and consequently, the necessity for frequent international normalized ratio (INR) monitoring and dose adjustments (INR 2–3 is recommended in most cases with non-valvular AF). …in the era of COVID-19, anticoagulation therapy in non-valvular AF with NOACs seems to be the safest approach. Non-vitamin K antagonist oral anticoagulants are contraindicated in AF patients with a prosthetic mechanical valve or moderate-to-severe mitral stenosis, and long-term anticoagulation therapy with VKAs is indicated. In these patients with ‘valvular AF’, the ‘at-home’ INR test method, and consulting the results by phone may be an alternative solution to minimize healthcare centre visits.

Statin Therapy and the Risk of COVID-19: A Cohort Study of the National Health Insurance Service in South Korea

Journal of Personalized Medicine, February 10, 2021

We aimed to investigate whether statin therapy is associated with the incidence of coronavirus disease 2019 (COVID-19) among the South Korean population. In addition, we examined whether statin therapy affects hospital mortality among COVID-19 patients. The National Health Insurance Service (NHIS)-COVID-19 database in South Korea was used for data extraction for this population-based cohort study. A total of 122,040 adult individuals, with 22,633 (18.5%) in the statin therapy group and 101,697 (91.5%) in the control group, were included in the analysis. Among them, 7780 (6.4%) individuals were diagnosed with COVID-19 and hospital mortality occurred in 251 (3.2%) COVID-19 cases. After propensity score matching, logistic regression analysis showed that the odds of developing COVID-19 were 35% lower in the statin therapy group than in the control group (odds ratio: 0.65, 95% confidence interval: 0.60 to 0.71; p < 0.001). Regarding hospital mortality among COVID-19 patients, the multivariable model indicated that there were no differences between the statin therapy and control groups (odds ratio: 0.74, 95% confidence interval: 0.52 to 1.05; p = 0.094). Statin therapy may have potential benefits for the prevention of COVID-19 in South Korea. However, we found that statin therapy does not affect the hospital mortality of patients who are diagnosed with COVID-19.

Prediction of thromboembolic events and mortality by the CHADS2 and the CHA2DS2-VASc in COVID-19

EP Europace, February 10, 2021

Age, sex, and cardiovascular disease have been linked to thromboembolic complications and poorer outcomes in COVID-19. We hypothesize that CHADS2 and CHA2DS2-VASc scores may predict thromboembolic events and mortality in COVID-19. COVID-19 hospitalized patients with confirmed SARS-CoV-2 infection from 1 March to 20 April 2020 who completed at least 1-month follow-up or died were studied. CHADS2 and CHA2DS2-VASc scores were calculated. Given the worse prognosis of male patients in COVID-19, a modified CHA2DS2-VASc score (CHA2DS2-VASc-M) in which 1 point was given to male instead of female was also calculated. The associations of these scores with laboratory results, thromboembolic events, and death were analysed. A total of 3042 patients (mean age 62.3 ± 20.3 years, 54.9% male) were studied and 115 (3.8%) and 626 (20.6%) presented a definite thromboembolic event or died, respectively, during the study period [median follow 59 (50–66) days]. Higher score values were associated with more marked abnormalities of inflammatory and cardiac biomarkers. Mortality was significantly higher with increasing scores for CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-M (P < 0.001 for trend). The CHA2DS2-VASc-M showed the best predictive value for mortality [area under the receiver operating characteristic curve (AUC) 0.820, P < 0.001 for comparisons]. All scores had poor predictive value for thromboembolic events (AUC 0.497, 0.490, and 0.541, respectively). The CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-M scores are significantly associated with all-cause mortality but not with thromboembolism in COVID-19 patients. They are simple scoring systems in everyday use that may facilitate initial ‘quick’ prognostic stratification in COVID-19.

Contemporary use of cardiac imaging for COVID-19 patients: a three center experience defining a potential role for cardiac MRI

International Journal of Cardiovascular Imaging, February 9, 2021

The pandemic of coronavirus disease 2019 (COVID-19) secondary to the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has bestowed an unprecedented challenge upon us, resulting in an international public health emergency. COVID-19 has already resulted in > 1,600,000 deaths worldwide and the fear of a global economic collapse. SARS-CoV-2 is notorious for causing acute respiratory distress syndrome, however emerging literature suggests various dreaded cardiac manifestations associated with high mortality. The mechanism of myocardial damage in COVID-19 is unclear but thought to be multifactorial and mainly driven by the host’s immune response (cytokine storm), hypoxemia and direct myocardial injury by the virus. Cardiac manifestations from COVID-19 include but are not limited to, acute myocardial injury, cardiac arrhythmias, congestive heart failure and acute coronary syndrome. Cardiac imaging is paramount to appropriately diagnose and manage the cardiac manifestations of COVID-19. Herein, we present cardiac imaging findings of COVID-19 patients with biomarker and imaging confirmed myocarditis to provide insight regarding the variable manifestations of COVID-19 myocarditis via Cardiac MRI (CMR) coupled with CMR-edema education along with recommendations on how to incorporate advanced CMR into the clinicians’ COVID-19 armamentarium.

Cardiac care of Non-COVID-19 patients during the SARS-CoV-2 pandemic: The pivotal role of CCTA

European Heart Journal – Cardiovascular Imaging, February 8, 2021

To describe the role of coronary CT angiography (CCTA) as the sole available non-invasive diagnostic test for symptomatic patients with suspected CAD in a hub center for cardiovascular emergencies in the presence of limited access to hospital facilities during the COVID-19 pandemic. From March 9th to April 30th, during the peak of the COVID-19 pandemic, a consecutive cohort of symptomatic patients with high clinical suspicion of CAD and clinical indication to CCTA were enrolled in a hub hospital in Milan, Italy. When obstructive coronary artery disease was detected (>70% diameter stenosis in a proximal coronary segment or >90% stenosis in any coronary segment) patients were referred to invasive coronary angiography (ICA). Clinical follow-up was assessed in patients in whom ICA was considered deferrable. Overall, 58 consecutive patients were included. Ten (17.2%) symptomatic patients underwent ICA according to CCTA findings, while in 48 (82.8%) patients ICA was deferred. No clinical events were recorded after a mean follow-up of 49.7 ± 16.8 days. In nine out of ten patients referred to ICA, severe coronary artery disease was confirmed and treated accordingly. Changes in medical therapy were significantly more prevalent in patients with vs. those without CAD at CCTA. We report a potential pivotal role for CCTA in the triage of non-COVID-19 patients with suspected CAD during the SARS-CoV-2 pandemic. CCTA may be helpful for identifying patients who necessitate ICA, ensuring adequate resource utilization during the pandemic.

Effects of COVID-19 on in-hospital cardiac arrest: incidence, causes, and outcome – a retrospective cohort study
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, February 8, 2021

SARS-CoV-2, an emerging virus, has caused a global pandemic. COVID-19 caused by SARS-CoV-2, has led to high hospitalization rates worldwide. Little is known about the occurrence of in-hospital cardiac arrest (IHCA) and high mortality rates have been proposed. The aim of this study was to investigate the incidence, characteristics and outcome of IHCA during the pandemic in comparison to an earlier period. This was a retrospective analysis of data prospectively recorded during 3-month-periods 2019 and 2020 at the University Medical Centre Hamburg-Eppendorf (Germany). All consecutive adult patients with IHCA were included. Clinical parameters, neurological outcomes and organ failure/support were assessed. During the study period hospital admissions declined from 18,262 (2019) to 13,994 (2020) (− 23%). The IHCA incidence increased from 4.6 (2019: 84 IHCA cases) to 6.6 (2020: 93 IHCA cases)/1000 hospital admissions. Median stay before IHCA was 4 (1–9) days. Demographic characteristics were comparable in both periods. IHCA location shifted towards the ICU (56% vs 37%, p < 0.01); shockable rhythm (VT/VF) (18% vs 29%, p = 0.05) and defibrillation were more frequent in the pandemic period (20% vs 35%, p < 0.05). Resuscitation times, rates of ROSC and post-CA characteristics were comparable in both periods. The severity of illness (SAPS II/SOFA), frequency of mechanical ventilation and frequency of vasopressor therapy after IHCA were higher during the 2020 period. Overall, 43 patients (12 with & 31 without COVID-19), presented with respiratory failure at the time of IHCA. The Horowitz index and resuscitation time were significantly lower in patients with COVID-19 (each p < 0.01). Favourable outcomes were observed in 42 and 10% of patients with and without COVID-19-related respiratory failure, respectively, Hospital admissions declined during the pandemic, but a higher incidence of IHCA was observed. IHCA in patients with COVID-19 was a common finding.

Gastroenteritis and cardiogenic shock in a healthcare worker: a case report of COVID-19 myocarditis confirmed with serology

European Heart Journal – Case Reports, February 8, 2021

Coronavirus disease 2019 (COVID-19) myocarditis is emerging as a component of the hyperactive inflammatory response secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Isolated gastrointestinal symptoms are uncommon presenting features in adults with COVID-19 myocarditis. The availability of antibody testing is a valuable addition to the confirmation of COVID-19, when repeated reverse transcriptase–polymerase chain reaction of nasopharyngeal swabs are negative. A young healthcare worker presented with dizziness and pre-syncope, 4 weeks after his original symptoms that included fever, lethargy, and diarrhoea. Despite 2 weeks of isolation, followed by a quiescent spell, his symptoms had returned. Shortly after, he presented in cardiogenic shock (left ventricular ejection fraction 25%), that required vasopressor support, at the height of the COVID-19 pandemic. Cardiac magnetic resonance imaging suggested florid myocarditis. Three nasopharyngeal swabs (Days 1, 3, and 5) were negative for SARS-CoV-2, but subsequent serology (Day 13) confirmed the presence of SARS-CoV-2 IgG. Treatment with intravenous immunoglobulin and glucocorticoids led to full recovery. Our case study highlights the significance of the use of the available serological assays for diagnosis of patients presenting late with SARS-CoV-2. Importantly, it supports further research in the use of immunomodulatory drugs for the hyperinflammatory microenvironment induced by COVID-19.

Cardiac function during COVID-19 intensive care unit hospitalisation – deformation analysis and outcomes

European Heart Journal – Cardiovascular Imaging, February 8, 2021

Although the cardiac burden of COVID-19 has been demonstrated, follow-up imaging studies are scarce. The aim was to use speckle-tracking deformation imaging (STE) to prospectively assess cardiac function during intensive care unit (ICU) hospitalisation, comparing ventricular and atrial function of COVID-10 patients that died and those that were discharged. In a single-centre, COVID-19 patients (n = 41) (71% male, aged 65 ± 11 years) were prospectively followed with echocardiography as part of ICU treatment. The left and right ventricles (LV, RV, respectively) were studied with STE in the 4-chamber cardiac view. The endpoint was defined as death or ICU discharge. Average values of the strain parameters from the first and final scans in the ICU, respectively, were calculated for the two outcome groups. Endpoint was not reached in 15% (n = 6) at the time of analysis. The remaining patients (n = 32) were 69% male, aged 66 (interquartile range (IQR) 60-72) years, and with an ICU mortality 26% (n = 9). The median spent in ICU was 24 (IQR 15-43) days. On average, echocardiography was performed three times during ICU hospitalisation, amounting to 103 examinations. Worsening of LV strain and lack of improvement of RV strain is linked to higher mortality in the ICU. The assessment of cardiac function might contain prognostic information in COVID-19 patients that are admitted to the ICU.

Prognostic utility of quantitative offline 2D-echocardiography in hospitalized patients with COVID-19

European Heart Journal – Cardiovascular Imaging, February 5, 2021

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was declared as a pandemic by the World Health Organization (WHO) on 11 March 2020. Clinical presentation ranges from asymptomatic to acute respiratory distress syndrome (ARDS) that can lead to death. Patients with concomitant cardiac diseases have an extremely poor prognosis, and SARS-CoV-2 may cause direct acute and chronic damage to the cardiovascular system. Echocardiography may provide useful information, especially in critical care patients, because it can be performed quickly at the bedside. To date, there is no means to predict the impact of the virus on patient outcome probably because the pathophysiology of COVID-19 remains unexplained. Our objective was to assess the prognostic utility of quantitative 2D-echocardiography, including strain, in patients with COVID-19 disease. COVID-19 patients admitted to the San Paolo University Hospital of Milan, that underwent a clinically indicated echocardiographic exam were included in the study. Quantitative measurements were obtained by an operator blinded to the clinical data. Among the 49 patients, non-survivors (33%) had worse respiratory parameters, index of multiorgan failure and worse markers of lung involvement. Right Ventricular (RV) dysfunction was a common finding and a powerful independent predictor of mortality. At the ROC curve analyses, RV free-wall longitudinal strain (LS) showed an AUC 0.77 ± 0.08 in predicting death, p = 0.008, and global RV LS (RV-GLS) showed an AUC 0.79 ± 0.04, p = 0.004. This association remained significant after correction for age (OR= 1.16, 95%CI 1.01-1.34, p = 0.029 for RV free-wall LS and OR = 1.20, 95%CI 1.01-1.42, p = 0.033 for RV-GLS), for oxygen partial pressure at arterial gas analysis/fraction of inspired oxygen (OR= 1.28, 95%CI 1.04-1.57, p = 0.021 for RV free wall-LS and OR = 1.30, 95%CI 1.04-1.62, p = 0.020 for RV-GLS) and for the severity of pulmonary involvement measured by a computed tomography lung score (OR = 1.27, 95%CI 1.02-1.19, p = 0.034 for RV free-wall LS, and OR = 1.30, 95%CI 1.04-1.63, p = 0.022 for RV-GLS).

COVID-19 as a Possible Cause of Myocarditis and Pericarditis

American College of Cardiology, February 5, 2021

Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) is an unmatched challenge for the healthcare community across the world. Respiratory involvement is the main clinical manifestation of COVID-19, ranging from mild flu-like illness to severe pneumonia, and potentially lethal acute respiratory distress syndrome. The initial mechanism for SARS-CoV-2 infection is viral binding to the membrane-bound form of angiotensin-converting enzyme 2 (ACE2) by a protein expressed in the viral coat, termed SPIKE (S protein) followed by its priming by the serine protease TMPRSS2 mediating virus uptake. ACE2 is a membrane-bound peptidase that is expressed in all tissues but is especially represented in lung, heart, vessels, kidney, brain, and gut. At present, limited data have been published on cases with COVID-19 who develop pericarditis and pericardial effusion. Most reported cases have been associated myocardial involvement with troponin elevation. …heart and vessels are potential targets for COVID-19, however at present, there are no findings which provide evidence of direct infection and replication of SARS-CoV-2 in heart cells. Additional pathologic studies and autopsy series will be very helpful to clarify the potentiality of SARS-CoV-2 to directly infect the myocardium/pericardium and cause myocarditis and pericarditis.

Estrogen receptors are linked to angiotensin-converting enzyme 2 (ACE2), ADAM metallopeptidase domain 17 (ADAM-17), and transmembrane protease serine 2 (TMPRSS2) expression in the human atrium: insights into COVID-19

Hypertension Research, February 3, 2021

Premenopausal women have a reduced incidence of cardiovascular disease (CVD) compared to postmenopausal women or age-matched men, suggesting a cardioprotective role for estrogen [1]. Although estrogen replacement maintains cardiac structure and function in ovariectomized rodent models, clinical trials of estrogen-based hormone therapy have yielded inconsistent results with regard to improving heart function in older women. Overall, it is critical to further elucidate the functional roles of estrogen, especially its individual receptors, in the heart to develop more effective and specific hormone therapy for postmenopausal women. Estrogen interacts with the renin-angiotensin system (RAS), one of the most critical pathways in CVD, by inhibiting or downregulating renin, angiotensin-converting enzyme (ACE), and angiotensin II (Ang II) type 1 receptor (AT1-R). However, the effects on cardiac ACE2 expression involve both increases and decreases depending on the species and experimental model studied. The identification of the ACE2 enzyme receptor, which acts with host transmembrane serine protease 2 TMPRSS2, as the primary means of cellular entry by the novel β-coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) justifies the importance of examining the potential contributory function of sex hormones in COVID-19 pathogenesis.

Eagle’s Eye View: COVID-19 Tip of the Week

American College of Cardiology, February 2, 2021

[Video, 1:04] Dr. Kim Eagle, MD, MACC, Editor of ACC.org, provides a weekly tip for clinicians on the front lines of the COVID-19 pandemic. How do health care workers hospitalized with COVID-19 fare when compared to the general population?

Relation of Cardiovascular Risk Factors to Mortality and Cardiovascular Events in Hospitalized Patients with Coronavirus Disease 2019 (From the Yale COVID-19 Cardiovascular Registry)

American Journal of Cardiology, February 1, 2021

Individuals with established cardiovascular disease or a high burden of cardiovascular risk factors may be particularly vulnerable to develop complications from coronavirus disease 2019 (COVID-19). We conducted a prospective cohort study at a tertiary care center to identify risk factors for in-hospital mortality and major adverse cardiovascular events (MACE; a composite of myocardial infarction, stroke, new acute decompensated heart failure, venous thromboembolism, ventricular or atrial arrhythmia, pericardial effusion, or aborted cardiac arrest) among consecutively hospitalized adults with COVID-19, using multivariable binary logistic regression analysis. The study population comprised 586 COVID-19 positive patients. Median age was 67 (IQR: 55-80) years, 47.4% were female, and 36.7% had cardiovascular disease. Considering risk factors, 60.2% had hypertension, 39.8% diabetes, and 38.6% hyperlipidemia. Eighty-two individuals (14.0%) died in-hospital, and 135 (23.0%) experienced MACE. In a model adjusted for demographic characteristics, clinical presentation, and laboratory findings, age (odds ratio [OR], 1.28 per 5 years; 95% confidence interval [CI], 1.13-1.45), prior ventricular arrhythmia (OR, 18.97; 95% CI, 3.68-97.88), use of P2Y12-inhibitors (OR, 7.91; 95% CI, 1.64-38.17), higher C-reactive protein (OR, 1.81: 95% CI, 1.18-2.78), lower albumin (OR, 0.64: 95% CI, 0.47-0.86), and higher troponin T (OR, 1.84; 95% CI, 1.39-2.46) were associated with mortality (p<0.05). After adjustment for demographics, presentation, and laboratory findings, predictors of MACE were higher respiratory rates, altered mental status, and laboratory abnormalities, including higher troponin T (p<0.05). In conclusion, poor prognostic markers among hospitalized patients with COVID-19 included older age, pre-existing cardiovascular disease, respiratory failure, altered mental status, and higher troponin T concentrations.

ACC Survey Finds Robust Interest in Video-Visitations, Telehealth Amidst COVID-19 Pandemic

American College of Cardiology, February 1, 2021

A robust interest in video-visitations and adoption of telehealth has developed in response to the COVID-19 pandemic, with valuable insight on how clinicians aim to utilize telehealth for patient care, according to survey results which will be presented as part of ACC’s Cardiovascular Summit Virtual, taking place Feb. 12 – 13. To understand the uptake and barriers to telehealth in everyday clinical practice, the ACC Health Care Innovation Section surveyed cardiologists regarding their perspectives of telehealth – specifically video-visitations – and common barriers for how telehealth is implemented. In total, 342 cardiovascular professionals (92% physicians) completed the survey from 303 different practice zip codes across 42 states. Fifty-five percent of respondent’s work setting was identified as a cardiovascular group or multi-specialty group, with 52%, 24% and 18% as part of a hospital, physician or university-owned practice, respectively. In addition, over half (54%) have been in practice for more than 15 years, a demographic not often identified to adopt digital tools. Results showed that nearly 90% of survey respondents were new telehealth users and have been using video-visitations for less than two months. In the context of integration, 69% of respondents stated that their institution required telehealth to be integrated within an electronic health record (EHR). Among those that stated this requirement, 67% stated that they would use telehealth even if not integrated.

Some of Last Year’s Deferred Cardiac Surgeries Likely Still in Backlog

MedPage Today, January 31, 2021

A nationwide database confirmed the sharp reduction of adult cardiac surgery volumes and unexpectedly high procedural mortality during the COVID pandemic, one group reported. Surgical cases had been fairly stable month to month until they dropped to 12,000 across the country during the month of April 2020, a 53% reduction (65% drop in elective cases and a 40% reduction in non-elective cases) from the 2019 monthly average that roughly coincided with the first wave of the pandemic. The Mid-Atlantic and New England regions, hit hardest by COVID during the first surge, showed the biggest drops of cardiac surgery volumes (71% and 63% reductions, respectively). The Mid-Atlantic in particular had a whopping 75% reduction in elective cases and a 59% decline in non-elective ones in April, reported Tom Nguyen, MD, of University of California San Francisco, at the Society of Thoracic Surgeons (STS) virtual meeting. These two regions also had spikes in operative mortality: their observed-to-expected (O/E) ratio for mortality rose by 75% from below 1.0 before the pandemic to nearly 1.2 in April. In particular, O/E mortality for isolated coronary artery bypass grafting (CABG) surgeries there jumped by 148%.

Temporal association of contamination obsession on the prehospital delay of STEMI during COVID-19 pandemic

American Journal of Emergency Medicine, January 31, 2021

One of the modifiable risk factors for ST elevation myocardial infarction is prehospital delay. The purpose of our study was to look at the effect of contamination contamination obsession on prehospital delay compared with other measurements during the Covid-19 pandemic. A total of 139 patients with acute STEMI admitted to our heart center from 20 March 2020 to 20 June 2020 were included in this study. If the time interval between the estimated onset of symptoms and admission to the emergency room was >120 min, it was considered as a prehospital delay. The Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), and Padua Inventory-Washington State University Revision (PI-WSUR) test were used to assess Contamination-Obsessive compulsive disorder (C-OCD). The same period STEMI count compared to the previous year decreased 25%. The duration of symptoms onset to hospital admission was longer in the first month compared to second and third months (180 (120–360), 120 (60–180), and 105 (60–180), respectively; P = 0.012). Multivariable logistic regression (model-2) was used to examine the association between 7 candidate predictors (age, gender, diabetes mellitus (DM), hypertension, smoking, pain-onset time, and coronary artery disease (CAD) history), PI-WSUR C-OCD, and admission month with prehospital delay. Among variables, PI-WSUR C-OCD and admission month were independently associated with prehospital delay (OR 5.36 (2.11–13.61) (P = 0.01); 0.26 (0.09–0.87) p < 0.001] respectively].

Clinical factors associated with massive pulmonary embolism and PE-related adverse clinical events

International Journal of Cardiology, January 31, 2021

Acute pulmonary embolism (PE) presentation varies from no symptoms and little hemodynamic consequence to massive PE with evidence of hemodynamic collapse with an estimated mortality of 20%. The annual incidence of PE has been increasing globally, and it has also been identified as an important clinical complication in SARS-COV2. Clinicians evaluating acute PE patients often have to identify risks for massive PE, a measure of hemodynamic instability and its consequence, massive PE related adverse clinical events (PEACE). We investigated the association of these risk factors with massive PE and PEACE in a consecutive PE cohort (n = 364). Massive PE was defined as an acute central clot (proximal to the lobar artery) in a patient with right heart strain and systolic blood pressure ≤ 90 mg. PEACE was defined as any massive PE who died or required one or more of the following: ACLS, assisted ventilation, vasopressor use, thrombolytic therapy, or invasive thrombectomy, within seven days of PE diagnosis. Univariate and multivariate analysis assessing associations between the risk factors (age, gender, comorbidities, PE provoking risks, and whether the PE was felt to be idiopathic) and massive PE or PEACE were performed. Significance was determined at p < 0.05. Thirteen percent (n = 48) of patients presented with massive PE, and 9% (n = 32) had PEACE. In the final multivariate model, recent invasive procedure (RR = 7.4, p = 0.007), recent hospitalization (RR = 7.3, p = 0.002), and idiopathic PE (RR = 6.5, p = 0.003) were associated with massive PE. Only idiopathic PE (RR = 5.7, p = 0.005) was significantly associated with PEACE. No comorbidities or other PE provoking risks were associated with massive PE or PEACE.

Using High Sensitivity Cardiac Troponin Values in Patients with SARS-CoV-2 Infection (COVID-19): The Padova Experience

Clinical Biochemistry, January 30, 2021

The spectrum of Coronavirus Disease 2019 (COVID-19) is broad and thus early appropriate risk stratification can be helpful. Our objectives were to define the frequency of myocardial injury using high-sensitivity cardiac troponin I (hs-cTnI) and to understand how to use its prognostic abilities. This retrospective study was performed with patients with COVID-19 presenting to an Emergency Department (ED) in Italy in 2020. Hs-cTnI was sampled based on clinical judgment. Myocardial injury was defined as values above the sex-specific 99th percentile upper reference limits (URLs). Most data is from the initial hospital value. Four hundred twenty-six unique patients were included. Hs-cTnI was measured in 313 (73.5%) patients; 85 (27.2%) had myocardial injury at baseline. Patients with myocardial injury had higher mortality during hospitalization (hazard ratio = 9 [95% confidence interval (CI) 4.55-17.79], p < 0.0001). Multivariable analysis including clinical and laboratory variables demonstrated an AUC of 0.942 with modest additional value of hs-cTnI. Myocardial injury was associated with mortality in patients with low APACHE II scores (<13) [OR (95% CI): 4.15 (1.40, 14.22), p = 0.014] but not in those with scores >13 [OR (95% CI): 0.48 (0.08, 2.65), p = 0.40]. Initial hs-cTnI < 5 ng/L identified 33% of patients that were at low risk with 97.8 % sensitivity (95% CI 88.7, 99.6) and 99.2% negative predictive value. Type 1 myocardial infarction (MI) and type 2 MI was infrequent.

Audio Interview: A Covid-19 Conversation with Anthony Fauci

New England Journal of Medicine, January 28, 2021

[Editorial, 43:42] The continuing spread of SARS-CoV-2 remains a Public Health Emergency of International Concern. What physicians need to know about transmission, diagnosis, and treatment of Covid-19 is the subject of ongoing updates from infectious disease experts at the Journal. In this audio interview conducted on January 27, 2021, the editors are joined by Dr. Anthony Fauci, U.S. Chief Medical Advisor, to discuss Covid-19 testing, therapeutics, and vaccines.

Widespread myocardial dysfunction in COVID-19 patients detected by myocardial strain imaging using 2-D speckle-tracking echocardiography

Acta Pharmacologica Sinica, January 28, 2021

COVID-19 is a multiorgan systemic inflammatory disease caused by SARS-CoV-2 virus. Patients with COVID-19 often exhibit cardiac dysfunction and myocardial injury, but imaging evidence is lacking. In the study we detected and evaluated the severity of myocardial dysfunction in COVID-19 patient population using two-dimensional speckle-tracking echocardiography (2-D STE). A total of 218 consecutive patients with confirmed diagnosis of COVID-19 who had no underlying cardiovascular diseases were enrolled and underwent transthoracic echocardiography. This study cohort included 52 (23.8%) critically ill and 166 noncritically ill patients. Global longitudinal strains (GLSs) and layer-specific longitudinal strains (LSLSs) were obtained using 2-D STE. Changes in GLS were correlated with the clinical parameters. We showed that GLS was reduced (<−21.0%) in about 83% of the patients. GLS reduction was more common in critically sick patients (98% vs. 78.3%, P < 0.001), and the mean GLS was significantly lower in the critically sick patients than those noncritical (−13.7% ± 3.4% vs. −17.4% ± 3.2%, P < 0.001). The alteration of GLS was more prominent in the subepicardium than in the subendocardium (P < 0.001). GLS was correlated to mean serum pulse oxygen saturation (SpO2, RR = 0.42, P < 0.0001), high-sensitive C-reactive protein (hsCRP, R = −0.20, P = 0.006) and inflammatory cytokines, particularly IL-6 (R = −0.21, P = 0.003). In conclusions, our results demonstrate that myocardial dysfunction is common in COVID-19 patients, particularly those who are critically sick. Changes in indices of myocardial strain were associated with indices of inflammatory markers and hypoxia, suggesting partly secondary nature of myocardial dysfunction.

Outcomes of COVID-19 Among Hospitalized Health Care Workers in North America

JAMA Network Open, January 28, 2021

Although health care workers (HCWs) are at higher risk of acquiring coronavirus disease 2019 (COVID-19), it is unclear whether they are at risk of poorer outcomes. The study objective was to evaluate the association between HCW status and outcomes among patients hospitalized with COVID-19. This retrospective, observational cohort study included consecutive adult patients hospitalized with a diagnosis of laboratory-confirmed COVID-19 across 36 North American centers. Data on patient baseline characteristics, comorbidities, presenting symptoms, treatments, and outcomes were collected, including HCW status. The primary outcome was a requirement for mechanical ventilation or death. Multivariable logistic regression was performed to yield adjusted odds ratios (AORs) and 95% CIs for the association between HCW status and COVID-19–related outcomes in a 3:1 propensity score–matched cohort, adjusting for residual confounding after matching. In total, 1790 patients were included, comprising 127 HCWs and 1663 non-HCWs. After 3:1 propensity score matching, 122 HCWs were matched to 366 non-HCWs. Women comprised 71 (58.2%) of matched HCWs and 214 (58.5%) of matched non-HCWs. Matched HCWs had a mean (SD) age of 52 (13) years, whereas matched non-HCWs had a mean (SD) age of 57 (17) years. In the matched cohort, the odds of the primary outcome, mechanical ventilation or death, were not significantly different for HCWs compared with non-HCWs (AOR, 0.60; 95% CI, 0.34-1.04). The HCWs were less likely to require admission to an intensive care unit (AOR, 0.56; 95% CI, 0.34-0.92) and were also less likely to require an admission of 7 days or longer (AOR, 0.53; 95% CI, 0.34-0.83). There were no differences between matched HCWs and non-HCWs in terms of mechanical ventilation (AOR, 0.66; 95% CI, 0.37-1.17), death (AOR, 0.47; 95% CI, 0.18-1.27), or vasopressor requirements (AOR, 0.68; 95% CI, 0.37-1.24).

Cardiovascular protective properties of oxytocin against COVID-19

Life Sciences, January 26, 2021

SARS-CoV-2 infection or COVID-19 has become a worldwide pandemic; however, effective treatment for COVID-19 remains to be established. Along with acute respiratory distress syndrome (ARDS), new and old cardiovascular injuries are important causes of significant morbidity and mortality in COVID-19. Exploring new approaches managing cardiovascular complications is essential in controlling the disease progression and preventing long-term complications. Oxytocin (OXT), an immune-regulating neuropeptide, has recently emerged as a strong candidate for treatment and prevention of COVID-19 pandemic. OXT carries special functions in immunologic defense, homeostasis and surveillance. It suppresses neutrophil infiltration and inflammatory cytokine release, activates T-lymphocytes, and antagonizes negative effects of angiotensin II and other key pathological events of COVID-19. Additionally, OXT can promote γ-interferon expression, which inhibits cathepsin L and raises superoxide dismutase expression, to reduce heparin and heparan sulphate fragmentation. Through these mechanisms, OXT can block viral invasion, suppress cytokine storm, reverse lymphocytopenia, and prevent progression to ARDS and multiple organ failures. Importantly, besides prevention of metabolic disorders associated with atherosclerosis and diabetes mellitus, OXT can protect the heart and vasculature through suppressing hypertension, brain-heart syndrome, and social stress, and promoting regeneration of injured cardiomyocytes. Unlike other therapeutic agents, exogenous OXT can be used safely without the side-effects seen in remdesivir and corticosteroid. Importantly, OXT can be mobilized endogenously to prevent pathogenesis of COVID-19. This article summarizes our current understandings of cardiovascular pathogenesis caused by COVID-19, explores the protective potentials of OXT against COVID-19-associated cardiovascular diseases, and discusses challenges in applying OXT in treatment and prevention of COVID-19.

Complete aortic thrombosis in SARS-CoV-2 infection

European Heart Journal, January 26, 2021

A 74-year-old man with a history of diabetes mellitus, coronary artery disease, and previous myocardial infarction presents to the emergency department with cardiogenic shock. Cardiopulmonary resuscitation and emergency care were performed. The patient’s consent for publication was obtained. His laboratory values were remarkable for leucocytosis of 25.2 cells/L (4.5–11.0), PT 17.2 s (12–14.5), INR 1.9 U (<1.0), PTT 30.9 s (23.9–36.6), and d-dimer >20 µg/mL (<0.5). C-reactive protein was significantly elevated at 226.3 mg/L (0–5), creatine phosphokinase was 178 UI/L (30–178), and lactate dehydrogenase 1405 UI/L (<205). Three-dimensional computed tomographic (CT) angiography revealed the complete thrombotic occlusion of the aorta, arising from the descending aorta and including all the visceral arteries, celiac trunk, superior mesenteric artery, and left and right renal arteries. Multifocal ground-glass opacities were visualized in the bilateral lungs. Diagnosis of SARS-CoV-2 was confirmed by reverse transcriptase–polymerase chain reaction analysis. The patient died immediately after the CT scan. COVID-19 infection due to the SARS-CoV-2 virus has shown to be associated with a hypercoaguable state. Excessive inflammation triggered by the cytokine storm, the massive macrophages, and platelet activation and endothelial dysfunction should be associated with the development of coagulopathy.

COVID-19 myopericarditis with cardiac tamponade in the absence of respiratory symptoms: a case report

Journal of Medical Case Reports, January 25, 2021

Previous reports have shown various cardiac complications to be associated with COVID-19 including: myocardial infarction, microembolic complications, myocardial injury, arrhythmia, heart failure, coronary vasospasm, non-ischemic cardiomyopathy, stress (Takotsubo) cardiomyopathy, pericarditis and myocarditis. These COVID-19 cardiac complications were associated with respiratory symptoms. However, our case illustrates that COVID-19 myopericarditis with cardiac tamponade can present without respiratory symptoms. A 58-year-old Caucasian British woman was admitted with fever, diarrhoea and vomiting. She developed cardiogenic shock and Transthoracic echocardiogram (TTE) found a pericardial effusion with evidence of cardiac tamponade. A nasopharyngeal swab showed a COVID-19 positive result, despite no respiratory symptoms on presentation. A pericardial drain was inserted and vasopressor support required on intensive treatment unit (ITU). The drain was removed as she improved, an antibiotic course was given and she was discharged on day 12. The case demonstrates that patients without respiratory symptoms could have COVID-19 and develop cardiac complications.

Angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs) may be safe for COVID-19 patients

BMC Infectious Diseases, January 25, 2021

The goal of the study was to investigate the effects of angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blockers (ARBs) administration to hypertension patients with the coronavirus disease 2019 (COVID-19) induced pneumonia. We recorded the recovery status of 67 inpatients with hypertension and COVID-19 induced pneumonia in the Raytheon Mountain Hospital in Wuhan during February 12, 2020 and March 30, 2020. Patients treated with ACEI or ARBs were categorized in group A (n = 22), while patients who were not administered either ACEI or ARBs were categorized into group B (n = 45). We did a comparative analysis of various parameters such as the pneumonia progression, length-of-stay in the hospital, and the level of alanine aminotransferase (ALT), serum creatinine (Cr), and creatine kinase (CK) between the day when these patients were admitted to the hospital and the day when the treatment ended. These 67 hypertension cases counted for 33.17% of the total COVID-19 patients. There was no significant difference in the usage of drug treatment of COVID-19 between groups A and B (p > 0.05). During the treatment, 1 case in group A and 3 cases in group B progressed from mild pneumonia into severe pneumonia. Eventually, all patients were cured and discharged after treatment, and no recurrence of COVID-2019 induced pneumonia occurred after the discharge. The length of stays was shorter in group A as compared with group B, but there was no significant difference (p > 0.05). There was also no significant difference in other general parameters between the patients of the groups A and B on the day of admission to the hospital (p > 0.05). The ALT, CK, and Cr levels did not significantly differ between groups A and B on the day of admission and the day of discharge (p > 0.05).

Statins in patients with COVID-19: a retrospective cohort study in Iranian COVID-19 patients

Translational Medicine Communications, January 25, 2021

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has profoundly affected the lives of millions of people. To date, there is no approved vaccine or specific drug to prevent or treat COVID-19, while the infection is globally spreading at an alarming rate. Because the development of effective vaccines or novel drugs could take several months (if not years), repurposing existing drugs is considered a more efficient strategy that could save lives now. Statins constitute a class of lipid-lowering drugs with proven safety profiles and various known beneficial pleiotropic effects. Our previous investigations showed that statins have antiviral effects and are involved in the process of wound healing in the lung. This triggered us to evaluate if statin use reduces mortality in COVID-19 patients. After initial recruitment of 459 patients with COVID-19 (Shiraz province, Iran) and careful consideration of the exclusion criteria, a total of 150 patients, of which 75 received statins, were included in our retrospective study. Cox proportional-hazards regression models were used to estimate the association between statin use and rate of death. After propensity score matching, we found that statin use appeared to be associated with a lower risk of morbidity [HR = 0.85, 95% CI = (0.02, 3.93), P = 0.762] and lower risk of death [(HR = 0.76; 95% CI = (0.16, 3.72), P = 0.735)]; however, these associations did not reach statistical significance. Furthermore, statin use reduced the chance of being subjected to mechanical ventilation [OR = 0.96, 95% CI = (0.61–2.99), P = 0.942] and patients on statins showed a more normal computed tomography (CT) scan result [OR = 0.41, 95% CI = (0.07–2.33), P = 0.312].

Meta-analysis of Atrial Fibrillation in Patients with COVID-19

American Journal of Cardiology, January 24, 2021

A number of published papers have investigated the relation between atrial fibrillation (AF) and clinical outcomes of patients with coronavirus disease 2019 (COVID-19). However, the conclusions drawn from previous studies are not consistent. For instance, some studies observed that AF was significantly associated with an increased risk of mortality among COVID-19 patients, while several other studies reported opposite results that there was no significant relation between AF and unfavorable outcomes of COVID-19 patients. Several confounding factors such as gender, age and pre-existing medical disorders (diabetes, hypertension, autoimmune diseases, chronic kidney disease and chronic obstructive pulmonary disease, etc.) have been reported to significantly influence the clinical outcomes of COVID-19 patients, suggesting that these factors might have significant impacts on the relation between AF and unfavorable outcomes of COVID-19 patients. In this meta-analysis, the pooled effect size was estimated on the basis of adjusted effect estimates reported in published papers. Nine hundred and sixteen potentially relevant studies were screened according to the inclusion and exclusion criteria. Finally, 23 studies with 108,745 COVID-19 patients were eligibly included in the present quantitative meta-analysis. Results of our meta-analysis indicated that AF was significantly associated with an increased risk of unfavorable outcomes among COVID-19 patients (pooled effect size = 1.14, 95% CI: 1.03-1.26, P = 0.01; I2 = 63.9%, random-effects analysis.

Rate control in atrial fibrillation using Landiolol is safe in critically ill Covid-19 patients

Critical Care, January 22, 2021

[Letter to Editor] Atrial fibrillation (AF) is frequent in shock patients admitted to the intensive care unit (ICU) and is associated with increased mortality. Several mechanisms are involved in the development of AF in the context of acute circulatory failure, including hypovolemia and β1-adrenergic stimulation in response to endogenous catecholamine production as well as norepinephrine infusion. Atrial fibrillation impairs left ventricular filling and consecutively stroke volume, and in fine potentially aggravates circulatory failure. Pharmacological options to control AF-related tachycardia are limited. Calcium channel blockers are not frequently used because of long-term negative inotropic effects. Amiodarone is the most used drug but its optimal dosage to fine tune heart rate remains an issue, as well as its potential lung toxicity, especially in case of acute respiratory disease. Landiolol is a beta-blocker with highly β1 selective activity, used either in AF patients either to control heart rate or to prevent supraventricular arrhythmia occurrence in the context of cardiac surgery. Landiolol has an ultrashort half-life of 4 min and weaker negative inotropic effect compared with other intravenous β-blockers [4]. A recent randomized controlled trial in patient with sepsis/septic shock developing tachyarrhythmia showed that Landiolol infusion efficiently reduced heart rate without any significant hemodynamic side effect. Here, we described in critically ill patients admitted to the ICU for SARS-CoV-2 infections presenting with AF, our experience of Landiolol use in terms of efficacy and safety.

Advanced echocardiographic phenotyping of critically ill patients with coronavirus-19 sepsis: a prospective cohort study

Journal of Intensive Care, January 20, 2021

Sepsis is characterized by various hemodynamic alterations which could happen concomitantly in the heart, pulmonary and systemic circulations. A comprehensive demonstration of their interactions in the clinical setting of COVID-19 sepsis is lacking. This study aimed at evaluating the feasibility, clinical implications, and physiological coherence of the various indices of hemodynamic function and acute myocardial injury (AMI) in COVID-19 sepsis. Hemodynamic and echocardiographic data of septic critically ill COVID-19 patients were prospectively recorded. A dozen hemodynamic indices exploring contractility and loading conditions were assessed. Several cardiac biomarkers were measured, and AMI was considered if serum concentration of high-sensitive troponin T (hs-TNT) was above the 99th percentile, upper reference. Sixty-seven patients were assessed (55 males), with a median age of 61 [50–70] years. Overall, the feasibility of echocardiographic parameters was very good, ranging from 93 to 100%. Hierarchical clustering method identified four coherent clusters involving cardiac preload, left ventricle (LV) contractility, LV afterload, and right ventricle (RV) function. LV contractility indices were not associated with preload indices, but some of them were positively correlated with RV function parameters and negatively correlated with a single LV afterload parameter. In most cases (n = 36, 54%), echocardiography results prompted therapeutic changes. Mortality was not influenced by the echocardiographic variables in multivariable analysis. Cardiac biomarkers’ concentrations were most often increased with high incidence of AMI reaching 72%. hs-TNT was associated with mortality and inversely correlated with most of LV and RV contractility indices.

Cardiovascular Deaths During the COVID-19 Pandemic in the United States

Journal of the American College of Cardiology, January 19, 2021

Although the direct toll of COVID-19 in the United States has been substantial, concerns have also arisen about the indirect effects of the pandemic. Hospitalizations for acute cardiovascular conditions have declined, raising concern that patients may be avoiding hospitals because of fear of contracting severe acute respiratory syndrome- coronavirus-2 (SARS-CoV-2). Other factors, including strain on health care systems, may also have had an indirect toll. This investigation aimed to evaluate whether population-level deaths due to cardiovascular causes increased during the COVID-19 pandemic. The authors conducted an observational cohort study using data from the National Center for Health Statistics to evaluate the rate of deaths due to cardiovascular causes after the onset of the pandemic in the United States, relative to the period immediately preceding the pandemic. Changes in deaths were compared with the same periods in the previous year. There were 397,042 cardiovascular deaths from January 1, 2020, to June 2, 2020. Deaths caused by ischemic heart disease increased nationally after the onset of the pandemic in 2020, compared with changes over the same period in 2019 (ratio of the relative change in deaths per 100,000 in 2020 vs. 2019: 1.11, 95% confidence interval: 1.04 to 1.18). An increase was also observed for deaths caused by hypertensive disease (1.17, 95% confidence interval: 1.09 to 1.26), but not for heart failure, cerebrovascular disease, or other diseases of the circulatory system. New York City experienced a large relative increase in deaths caused by ischemic heart disease (2.39, 95% confidence interval: 1.39 to 4.09) and hypertensive diseases (2.64, 95% confidence interval: 1.52 to 4.56) during the pandemic. More modest increases in deaths caused by these conditions occurred in the remainder of New York State, New Jersey, Michigan, and Illinois but not in Massachusetts or Louisiana. There was an increase in deaths caused by ischemic heart disease and hypertensive diseases in some regions of the United States during the initial phase of the COVID-19 pandemic. These findings suggest that the pandemic may have had an indirect toll on patients with cardiovascular disease.

International Impact of COVID-19 on the Diagnosis of Heart Disease

Journal of the American College of Cardiology, January 19, 2021

The coronavirus disease 2019 (COVID-19) pandemic has adversely affected diagnosis and treatment of noncommunicable diseases. Its effects on delivery of diagnostic care for cardiovascular disease, which remains the leading cause of death worldwide, have not been quantified. The study sought to assess COVID-19’s impact on global cardiovascular diagnostic procedural volumes and safety practices. The International Atomic Energy Agency conducted a worldwide survey assessing alterations in cardiovascular procedure volumes and safety practices resulting from COVID-19. Noninvasive and invasive cardiac testing volumes were obtained from participating sites. Availability of personal protective equipment and pandemic-related testing practice changes were ascertained. Surveys were submitted from 909 inpatient and outpatient centers performing cardiac diagnostic procedures, in 108 countries. Procedure volumes decreased 42% from March 2019 to March 2020, and 64% from March 2019 to April 2020. Transthoracic echocardiography decreased by 59%, transesophageal echocardiography 76%, and stress tests 78%, which varied between stress modalities. Coronary angiography (invasive or computed tomography) decreased 55% (p < 0.001 for each procedure). In multivariable regression, significantly greater reduction in procedures occurred for centers in countries with lower gross domestic product. Location in a low-income and lower–middle-income country was associated with an additional 22% reduction in cardiac procedures and less availability of personal protective equipment and telehealth. COVID-19 was associated with a significant and abrupt reduction in cardiovascular diagnostic testing across the globe, especially affecting the world’s economically challenged. Further study of cardiovascular outcomes and COVID-19–related changes in care delivery is warranted.

ACEi reduces hypertension-induced hyperinflammation in COVID-19

Nature Reviews Cardiology, January 18, 2021

Hypertension is associated with a pro-inflammatory state that worsens the prognosis of patients with coronavirus disease 2019 (COVID-19). According to a new study, antihypertensive blockade of the renin–angiotensin–aldosterone system (RAAS), particularly with the use of an angiotensin-converting enzyme inhibitor (ACEi), might improve outcomes in patients with hypertension and COVID-19. Irina Lehmann, Ulf Landmesser, Roland Eils and colleagues combined clinical data from 144 patients with COVID-19, single-cell sequencing data from 48 airway tissue samples and data from in vitro experiments. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) binds to ACE2 to gain entry into cells. Uncertainty had been raised whether RAAS blockade upregulates the expression of ACE2, causing ACEi-treated or angiotensin-receptor blocker (ARB)-treated patients to be more susceptible to SARS-CoV-2 infection. However, the researchers found no evidence that treatment with either an ACEi or an ARB increased the expression of ACE2 in patients with or without SARS-CoV-2 infection. “This result is in line with findings from observational studies that patients receiving antihypertensive treatment with an ACEi or ARB are not more susceptible to SARS-CoV-2 infection,” comments Lehmann. Moreover, the induction of ACE2 expression that occurs after SARS-CoV-2 infection was unaltered by either ACEi or ARB therapy. The investigators identified a hypertension-associated increase in immunological activity as being the prominent factor contributing to the worse prognosis of patients with high blood pressure and COVID-19.

Bioinformatics and system biology approach to identify the influences of COVID-19 on cardiovascular and hypertensive comorbidities

Briefings in Bioinformatics, January 18, 2021

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infected individuals that have hypertension or cardiovascular comorbidities have an elevated risk of serious coronavirus disease 2019 (COVID-19) disease and high rates of mortality but how COVID-1919 and cardiovascular diseases interact are unclear. We therefore sought to identify novel mechanisms of interaction by identifying genes with altered expression in SARS-CoV-22 infection that are relevant to the pathogenesis of cardiovascular disease and hypertension. Some recent research shows the SARS-CoV-22 uses the angiotensin converting enzyme-22 (ACE-22⁠) as a receptor to infect human susceptible cells. The ACE2 gene is expressed in many human tissues, including intestine, testis, kidneys, heart and lungs. ACE2 usually converts Angiotensin I in the renin–angiotensin-aldosterone system to Angiotensin II, which affects blood pressure levels. ACE inhibitors prescribed for cardiovascular disease and hypertension may increase the levels of ACE-22⁠, although there are claims that such medications actually reduce lung injury caused by COVID-1919⁠. We employed bioinformatics and systematic approaches to identify such genetic links, using messenger RNA data peripheral blood cells from COVID-1919 patients and compared them with blood samples from patients with either chronic heart failure disease or hypertensive diseases. We have also considered the immune response genes with elevated expression in COVID-1919 to those active in cardiovascular diseases and hypertension. Differentially expressed genes (DEGs) common to COVID-1919 and chronic heart failure, and common to COVID-1919 and hypertension, were identified; the involvement of these common genes in the signalling pathways and ontologies studied. COVID-1919 does not share a large number of differentially expressed genes with the conditions under consideration. However, those that were identified included genes playing roles in T cell functions, toll-like receptor pathways, cytokines, chemokines, cell stress, type 2 diabetes and gastric cancer. We also identified protein–protein interactions, gene regulatory networks and suggested drug and chemical compound interactions using the differentially expressed genes. The result of this study may help in identifying significant targets of treatment that can combat the ongoing pandemic due to SARS-CoV-22 infection.

Nearly 1 in 4 hospitalized patients with HF, COVID-19 die

Helio | Cardiology Today, January 15, 2021

Patients with HF and COVID-19 had high risk for complications, with nearly 1 in 4 dying during hospitalization, researchers reported. “Patients with heart failure have lower reserve, in general, than people without severe cardiovascular disease, and they are at increased risk from many respiratory infections, including influenza,” Scott D. Solomon, MD, professor of medicine at Harvard Medical School and senior physician at Brigham and Women’s Hospital, told Healio. “In addition, patients with cardiovascular disease, in general, appear to be at greater risk for COVID-19-related complications.” Researchers assessed the Premier Healthcare Database to identify patients with at least one HF hospitalization or two related outpatient visits from 2019 to March 2020 who were then hospitalized from April to September 2020. Predictors of in-hospital mortality were identified among patients with HF hospitalized with COVID-19. The researchers also compared this population and those hospitalized due to other factors. There were 132,312 patients with a history of HF hospitalized from April to September 2020, with 23,843 hospitalized with acute HF, 8,383 hospitalized with COVID-19 and 100,068 hospitalized for alternative causes.

Should all patients with hypertension be worried about developing severe coronavirus disease 2019 (COVID-19)?

Clinical Hypertension, January 15, 2021

Hypertension, the most common comorbidity among coronavirus disease 2019 (COVID-19) patients, is accompanied by worse clinical outcomes, but there is lack of evidence about prognostic factors among COVID-19 patients with hypertension. We have come up with some prognostic factors to predict the severity of COVID-19 among hypertensive patients. In addition, epidemiologic, clinical and laboratory differences among COVID-19 patients with and without underlying hypertension were evaluated. Medical profiles of 598 COVID-19 cases were analyzed. Patients were divided into two comparative groups according to their positive or negative history of hypertension. Then, epidemiologic, clinical, laboratory and radiological features and also clinical outcomes were compared. 176 (29.4%) patients had underlying hypertension. Diabetes was significantly higher in hypertensive group [72 (40.9%) vs 76 (18%)] (P-value: 0.001). Cardiovascular and renal disorders were significantly higher in hypertensive patients. (P-value: 0.001 and 0.013 respectively). In COVID-19 patients with hypertension, severe/critical types were significantly higher. [42(23.8%) vs. 41(9.7%)], (P-value: 0.012). In the logistic regression model, Body mass index > 25 (ORAdj: 1.8, 95% CI: 1.2 to 2.42; P-value: 0.027), age over 60 (ORAdj: 1.26, 95% CI: 1.08 to 1.42; P-value: 0.021), increased hospitalization period (ORAdj: 2.1, 95% CI: 1.24 to 2.97; P-value: 0.013), type 2 diabetes (ORAdj: 2.22, 95% CI: 1.15 to 3.31; P-value: 0.001) and chronic kidney disease (ORAdj: 1.83, 95% CI: 1.19 to 2.21; P-value: 0.013) were related with progression of COVID-19.

COVID-19 VTE Prevention: The Case for Intermediate and Outpatient Dosing

MedPage Today, January 15, 2021

Should patients hospitalized for COVID-19 routinely receive extra anticoagulation or go home with a course of antithrombotics? The first randomized controlled trial data are still emerging, leaving those questions to the realm of expert consensus statements with only observational and pre-COVID data from which to extrapolate. The key fulcrum on which the decision rests is how elevated venous thromboembolism (VTE) risk is versus how much bleeding occurs in COVID-19 patients, noted speakers at a Pulmonary Embolism Response Team Consortium webinar. A widely cited meta-analysis in CHEST yielded a 17% estimated incidence of VTE across 47 studies in hospitalized COVID-19 patients largely on standard thromboprophylaxis, which individually ranged from 0% to 85%. But you also can’t ignore the 7.8% rate of bleeds in that meta-analysis, noted Rachel Rosovsky, MD, MPH, of Massachusetts General Hospital and Harvard Medical School in Boston. Still, the major bleeding rate was a more modest 3.9%, so “using these escalated doses in ward patients is probably something we should be considering” to minimize thrombotic complications that might tip patients into needing ICU care, argued Lana Castellucci, MD, of the University of Ottawa, in her presentation on the webinar.

Evaluation for Myocarditis in Competitive Student Athletes Recovering From Coronavirus Disease 2019 With Cardiac Magnetic Resonance Imaging

JAMA Cardiology, January 14, 2021

The utility of cardiac magnetic resonance imaging (MRI) as a screening tool for myocarditis in competitive student athletes returning to training after recovering from coronavirus disease 2019 (COVID-19) infection is unknown. The objective was to describe the prevalence and severity of cardiac MRI findings of myocarditis in a population of competitive student athletes recovering from COVID-19. In this case series, an electronic health record search was performed at our institution (University of Wisconsin) to identify all competitive athletes (a consecutive sample) recovering from COVID-19, who underwent gadolinium-enhanced cardiac MRI between January 1, 2020, and November 29, 2020. The MRI findings were reviewed by 2 radiologists experienced in cardiac imaging, using the updated Lake Louise criteria. Serum markers of myocardial injury and inflammation (troponin-I, B-type natriuretic peptide, C-reactive protein, and erythrocyte sedimentation rate), an electrocardiogram, transthoracic echocardiography, and relevant clinical data were obtained. COVID-19 infection, confirmed using reverse transcription–polymerase chain reaction testing. Prevalence and severity of MRI findings were consistent with myocarditis among young competitive athletes recovering from COVID-19.

COVID’s Indirect Toll on the Heart

MedPage Today, January 12, 2021

COVID-19 has had an indirect toll on heart health around the world, as cardiovascular testing volumes plummeted and cardiovascular deaths rose in 2020, researchers found. CDC data revealed that in the first U.S. coronavirus epicenters like New York, the number of people who died from ischemic heart disease and hypertension increased dramatically after mid-March compared with historical controls from the year before. It remains unclear whether the excess deaths were related to people avoiding necessary medical care for fear of contracting SARS-CoV-2 or reflected other factors, such as undiagnosed COVID-19, according to study authors led by Rishi Wadhera, MD, MPP, MPhil, of Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, reporting in the Journal of the American College of Cardiology (JACC). However, the theory of avoidance of care would be consistent with the finding that cardiac testing centers in 108 countries were seeing sharp decreases in cardiac diagnostic procedures by the summer, as reported in the same issue of JACC by another group. “Clearly, the overwhelming priority should be emphasizing the importance of public health measures to prevent the spread of COVID-19. … Such a strategy may allow the economy, schools, and less urgent but important health services, including selective cardiac diagnostic tests, to be provided to a limited extent,” according to an accompanying editorial.

Elevated Extracellular Volume Fraction and Reduced Global Longitudinal Strains in Patients Recovered from COVID-19 without Clinical Cardiac Findings

Radiology, January 12, 2021

The purpose of this study was to evaluate cardiac involvement in participants recovered from COVID-19 without clinical evidence of cardiac involvement using cardiac MRI. In this prospective observational cohort study, 40 participants recovered from COVID-19 with moderate (n=24) or severe (n=16) pneumonia and no cardiovascular medical history, without cardiac symptoms, with normal ECG, normal serological cardiac enzyme levels, and discharged > 90 days between May and September 2020. Demographic characteristics, serum cardiac enzymes, and cardiac MRI were obtained. Cardiac function, native T1, ECV and Two-dimensional (2D) strain were quantitatively evaluated and compared with controls (n = 25).The Comparison among the 3 groups were performed using one-way analysis of variance (ANOVA) with Bonferroni corrected post-hoc comparisons(for normal distribution) or Kruskal-Wallis tests with post-hoc pairwise comparisons(for non-normal distribution). Forty participants (54±12 years; 24 men) enrolled with a mean time between admission and CMR of 158 ±18 days and discharge and CMR examination of 124 ±17 days. There was no LV and RV size or functional differences among participants recovered from COVID-19 and healthy controls. Only one (3%) participants had positive LGE located at the mid inferior wall. Global ECV values were elevated in both participants recovered from COVID-19 with moderate or severe pneumonia, compared to the healthy controls [median ECV (IQR)], [29.7% (28.0%-32.9%), versus 31.4% (29.3%-34.0%), versus 25.0% (23.7%-26.0%); both p<.001]. The 2D-global LV longitudinal stains (GLS) were reduced in both groups of participants [COVID-19 moderate group, -12.5% (-10.7%–15.5%), COVID-19 severe group, -12.5% (-8.7%–15.4%) compared to healthy control group -15.4% (-14.6%-17.6%), p=.002 and p=.001, respectively]. CMR myocardial tissue and strain imaging parameters suggest that a proportion of participants recovered from COVID-19 had subclinical myocardial abnormalities detectable months after recovery.

International Impact of COVID-19 on the Diagnosis of Heart Disease

Journal of the American College of Cardiology, January 11, 2021

The coronavirus disease 2019 (COVID-19) pandemic has adversely affected diagnosis and treatment of noncommunicable diseases. Its effects on delivery of diagnostic care for cardiovascular disease, which remains the leading cause of death worldwide, have not been quantified. The study sought to assess COVID-19’s impact on global cardiovascular diagnostic procedural volumes and safety practices. The International Atomic Energy Agency conducted a worldwide survey assessing alterations in cardiovascular procedure volumes and safety practices resulting from COVID-19. Noninvasive and invasive cardiac testing volumes were obtained from participating sites for March and April 2020 and compared with those from March 2019. Availability of personal protective equipment and pandemic-related testing practice changes were ascertained. Surveys were submitted from 909 inpatient and outpatient centers performing cardiac diagnostic procedures, in 108 countries. Procedure volumes decreased 42% from March 2019 to March 2020, and 64% from March 2019 to April 2020. Transthoracic echocardiography decreased by 59%, transesophageal echocardiography 76%, and stress tests 78%, which varied between stress modalities. Coronary angiography (invasive or computed tomography) decreased 55% (p < 0.001 for each procedure). In multivariable regression, significantly greater reduction in procedures occurred for centers in countries with lower gross domestic product. Location in a low-income and lower–middle-income country was associated with an additional 22% reduction in cardiac procedures and less availability of personal protective equipment and telehealth.

Cardiac implantable electronic devices replacements in patients followed by remote monitoring during COVID-19 lockdown

European Heart Journal – Digital Health, January 11, 2021

Following coronavirus disease (COVID-19) outbreak, the Italian government adopted strict rules of lockdown and social distancing. The aim of our study was to assess the admission rate for cardiac implantable electronic devices (CIEDs) replacement procedures in Campania, the 3rd-most-populous region of Italy, during COVID-19 lockdown. Data were sourced from 16 referral hospitals in Campania from 10 March to 4 May 2020 (lockdown period) and during the same period in 2019. We retrospectively evaluated consecutive patients hospitalized for CIEDs replacement procedures during the two observational periods. The number and type of CIEDs replacement procedures among patients followed by remote monitoring (RM), the admission rate, and the type of hospital admission between the two observational periods were compared. In total, 270 consecutive patients were hospitalized for CIEDs replacement procedures over the two observation periods. Overall CIEDs replacement procedures showed a reduction rate of 41.2% during COVID-19 lockdown. Patients were equally distributed for sex (P = 0.581), and both age [median 76 years (IQR: 68–83) vs. 79 years (IQR: 68–83); P = 0.497]. Cardiac implantable electronic devices replacement procedures in patients followed by RM significantly increased (IR: +211%; P < 0.001), mainly driven by the remarkable increase rate trend of both PM (IR: +475%; P < 0.001) and implantable cardiac defibrillator replacement procedures (IR: +67%, P = 0.01), during COVID-19 lockdown compared with 2019 timeframe.

Highlights of American Heart Association Scientific Sessions 2020: a virtual experience

Cardiovascular Research, January 10, 2021

The year 2020 has been unique and defiant due to pandemic of COVID-19. One of the new over-used terms this year is finding the ‘new normal’. Indeed, COVID-19 has transformed the scientific congress experience significantly. Social distancing and travel restrictions have enforced congress coordinators to make a tough decision between cancelling the events or re-formatting for online presentations. The American Heart Association (AHA) presented Scientific Sessions 2020 (13–17 November) as a 100% virtual experience, reached more people than ever, in real-time and asynchronously, with live chats that inspire scientific dialogues, providing an engaging online involvement. A wide variety of subjects were presented, ranging from new heart failure (HF) treatments to cardiovascular involvement in COVID-19 and a special focus in structural racism. Some of the exciting science included fresh takes on primary cardiovascular disease (CVD) prevention. In a new first-of-its-kind international outcomes trial, TIPS-3, involving more than 5000 patients with an intermediate CVD risk but no known CVD, treatment with a polypill formulation (simvastatin, atenolol, ramipiril, and hydrochlorothiazide), plus aspirin led to a lower incidence of cardiovascular events. In VITAL-Rhythm trial, involving more than 20 000 patients, treatment with vitamin D3, Omega-3 fatty acids, or a combination had no effect on the incidence of atrial fibrillation (AF), the most common cardiac arrhythmia and a major cause of morbidity and mortality, over a median treatment duration of 5.3 years. Likewise, in the AF field, SEARCH-AF study demonstrated that enhanced cardiac rhythm monitoring detected a higher incidence of post-operative AF after cardiac surgery, as compared to the usual care, in those who had no history of AF but had a high risk of stroke. Also, the VITAL-AF trial showed that point-of-care screening did not result in more new AF diagnoses in primary care, whereas mSToPS study found that continuous monitoring with a wearable electrocardiogram patch did lead to more AF detected and even better outcomes, emphasizing the importance of the use of mobile health technology in CVD prevention/management.

Cardiovascular risk factors and mortality in hospitalized patients with COVID-19: systematic review and meta-analysis of 45 studies and 18,300 patients

BMC Cardiovascular Disorders, January 7, 2021

A high prevalence of cardiovascular risk factors including age, male sex, hypertension, diabetes, and tobacco use, has been reported in patients with Coronavirus disease 2019 (COVID-19) who experienced adverse outcome. The aim of this study was to investigate the relationship between cardiovascular risk factors and in-hospital mortality in patients with COVID-19. MEDLINE, Cochrane, Web of Sciences, and SCOPUS were searched for retrospective or prospective observational studies reporting data on cardiovascular risk factors and in-hospital mortality in patients with COVID-19. Univariable and multivariable age-adjusted analyses were conducted to evaluate the association between cardiovascular risk factors and the occurrence of in-hospital death. The analysis included 45 studies enrolling 18,300 patients. The pooled estimate of in-hospital mortality was 12% (95% CI 9–15%). The univariable meta-regression analysis showed a significant association between age (coefficient: 1.06; 95% CI 1.04–1.09; p < 0.001), diabetes (coefficient: 1.04; 95% CI 1.02–1.07; p < 0.001) and hypertension (coefficient: 1.01; 95% CI 1.01–1.03; p = 0.013) with in-hospital death. Male sex and smoking did not significantly affect mortality. At multivariable age-adjusted meta-regression analysis, diabetes was significantly associated with in-hospital mortality (coefficient: 1.02; 95% CI 1.01–1.05; p = 0.043); conversely, hypertension was no longer significant after adjustment for age (coefficient: 1.00; 95% CI 0.99–1.01; p = 0.820). A significant association between age and in-hospital mortality was confirmed in all multivariable models.

SARS-CoV-2 leads to a small vessel endotheliitis in the heart

E Bio Medicine, January 7, 2021

SARS-CoV-2 infection (COVID-19 disease) can induce systemic vascular involvement contributing to morbidity and mortality. SARS-CoV-2 targets epithelial and endothelial cells through the ACE2 receptor. The anatomical involvement of the coronary tree is not explored yet. Cardiac autopsy tissue of the entire coronary tree (main coronary arteries, epicardial arterioles/venules, epicardial capillaries) and epicardial nerves were analyzed in COVID-19 patients (n = 6). All anatomical regions were immunohistochemically tested for ACE2, TMPRSS2, CD147, CD45, CD3, CD4, CD8, CD68 and IL-6. COVID-19 negative patients with cardiovascular disease (n = 3) and influenza A (n = 6) served as controls. COVID-19 positive patients showed strong ACE2 / TMPRSS2 expression in capillaries and less in arterioles/venules. The main coronary arteries were virtually devoid of ACE2 receptor and had only mild intimal inflammation. Epicardial capillaries had a prominent lympho-monocytic endotheliitis, which was less pronounced in arterioles/venules. The lymphocytic-monocytic infiltrate strongly expressed CD4, CD45, CD68. Peri/epicardial nerves had strong ACE2 expression and lympho-monocytic inflammation. COVID-19 negative patients showed minimal vascular ACE2 expression and lacked endotheliitis or inflammatory reaction. ACE2 / TMPRSS2 expression and lymphomonocytic inflammation in COVID-19 disease increases crescentically towards the small vessels suggesting that COVID-19-induced endotheliitis is a small vessel vasculitis not involving the main coronaries.

Early High-Titer Plasma Therapy to Prevent Severe Covid-19 in Older Adults

New England Journal of Medicine, January 6, 2021

Therapies to interrupt the progression of early coronavirus disease 2019 (Covid-19) remain elusive. Among them, convalescent plasma administered to hospitalized patients has been unsuccessful, perhaps because antibodies should be administered earlier in the course of illness. We conducted a randomized, double-blind, placebo-controlled trial of convalescent plasma with high IgG titers against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in older adult patients within 72 hours after the onset of mild Covid-19 symptoms. The primary end point was severe respiratory disease, defined as a respiratory rate of 30 breaths per minute or more, an oxygen saturation of less than 93% while the patient was breathing ambient air, or both. The trial was stopped early at 76% of its projected sample size because cases of Covid-19 in the trial region decreased considerably and steady enrollment of trial patients became virtually impossible. A total of 160 patients underwent randomization. In the intention-to-treat population, severe respiratory disease developed in 13 of 80 patients (16%) who received convalescent plasma and 25 of 80 patients (31%) who received placebo (relative risk, 0.52; 95% confidence interval [CI], 0.29 to 0.94; P=0.03), with a relative risk reduction of 48%. A modified intention-to-treat analysis that excluded 6 patients who had a primary end-point event before infusion of convalescent plasma or placebo showed a larger effect size (relative risk, 0.40; 95% CI, 0.20 to 0.81). No solicited adverse events were observed.

Age, sex, comorbidities impact outcomes after COVID-19 hospitalization

Helio | Cardiology Today, January 6, 2021

In a national private health care database, age, male sex and comorbidities increased risk for death in patients hospitalized with COVID-19, according to data presented at the virtual American Heart Association Scientific Sessions. The findings were mostly consistent with data from the AHA’s COVID-19 CVD registry, also presented at the meeting. The data set of patients with COVID-19 was created by Cerner Corp. and Amazon Web Services, Cardiology Today Next Gen Innovator Ann Marie Navar, MD, PhD, associate professor of internal medicine and of population and data sciences at University of Texas Southwestern Medical Center, said during a presentation. “We need to understand who is most at risk, particularly as we are deploying immunization strategies,” she said. “We also need to understand risk factors so that people can understand their own risk of disease and make appropriately informed choices. Among people who are hospitalized with COVID-19, it’s critical that we understand risk factors for worse outcomes, as we have to have important informed conversations with patients and their families about their prognosis.” The analysis included 19,584 patients with COVID-19 (median age, 52 years; 47% women; 29.4% Hispanic) who died or were discharged to home during the study period. Among the cohort, 31.1% had diabetes, 50.4% had hypertension, 14.3% had HF, 18% had CAD and 5.6% had end-stage renal disease, Navar said.

Case report of a COVID-19-associated myocardial infarction with no obstructive coronary arteries: the mystery of the phantom embolus or local endotheliitis

European Heart Journal – Case Reports, January 6, 2021

Since the first documented outbreak of a novel severe acute respiratory syndrome inducing Coronavirus in China at the end of 2019 the virus has spread to all continents, leading the WHO to declare a pandemic in March 2020. While this virus primarily targets the alveoli in the lungs, multiple authors have described an increased rate of thrombo-embolic events in affected patients. We present this case of a myocardial infarction with no obstructive coronary atherosclerosis in an otherwise healthy 48-year-old patient. A 48-year-old female, presenting with chest pain radiating to her left shoulder with no cardiovascular risk factors other than genetic predisposition, was screened for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and tested positive. Although computed tomography angiography excluded obstructive coronary heart disease, cardiac magnetic resonance imaging showed an acute myocardial infarction with no obstructive coronary arteries of the inferior wall. The patient was treated with dual anti-platelet therapy, an angiotensin-converting-enzyme inhibitor and a statin, and assigned to a cardiac rehabilitation program. We report a serious thrombo-embolic event during an oligosymptomatic SARS-CoV-2 infection in a healthy, young patient. While these two diseases may have occurred simultaneously, by chance, it is possible that the pro-thrombotic effects of the SARS-CoV-2 infection facilitated the infarction. This case further demonstrates the significant cardiovascular morbidity potentially caused by SARS-CoV-2.

Race, Age Implicated in Pandemic Cardiac Arrest Spike

MedPage Today, January 6, 2021

Detroit-area EMS workers saw disproportionately more Black people and nursing home residents in the surge of out-of-hospital cardiac arrests (OHCAs) roughly coinciding with the first wave of COVID-19, a study found. OHCA calls in the metropolitan Detroit area recorded in the Michigan EMS Information System jumped 60% in March 23 to May 31, 2020, compared with the same period in 2019 (1,854 vs 1,162 calls), according to Adrienne Nickles, MPH, of the Michigan Department of Health and Human Services in Lansing, and colleagues. The wave of OHCAs lagged just a few weeks behind the surge of confirmed COVID-19 cases and mirrored the shape of the epidemic curve, the authors reported online in JAMA Network Open. OHCAs increased across all demographic groups in 2020 compared with 2019 but made especially large jumps in:

  • Elderly individuals 85 years or older (18.4% vs 14.7% in 2019, P=0.01)
  • Black individuals (39.1% vs 30.4%, P<0.001)
  • Nursing home residents (22.0% vs 18.8%, P=0.03)

Patients with OHCA during the pandemic were less likely to be intubated or receive other advanced airway devices than peers the year before (21.4% vs 45.5%, P<0.001). “This study was limited to prehospital records; definitive causes of death are not known and it is not clear from these data whether the increase arose as a direct effect of COVID-19 infection or from indirect effects of the pandemic on utilization of EMS. Further investigation is needed to characterize the phenomena underlying these associations to design interventions to mitigate the impacts of the ongoing COVID-19 pandemic,” according to Nickles and colleagues.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the care of patients with acute and chronic aortic conditions

European Journal of Cardio-thoracic Surgery, January 4, 2021

The objective was to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on acute and elective thoracic and abdominal aortic procedures. Forty departments shared their data on acute and elective thoracic and abdominal aortic procedures between January and May 2020 and January and May 2019 in Europe, Asia and the USA. Admission rates as well as delay from onset of symptoms to referral were compared. No differences in the number of acute thoracic and abdominal aortic procedures were observed between 2020 and the reference period in 2019 [incidence rates ratio (IRR): 0.96, confidence interval (CI) 0.89–1.04; P = 0.39]. Also, no difference in the time interval from acute onset of symptoms to referral was recorded (<12 h 32% vs > 12 h 68% in 2020, < 12 h 34% vs > 12 h 66% in 2019 P = 0.29). Conversely, a decline of 35% in elective procedures was seen (IRR: 0.81, CI 0.76–0.87; P < 0.001) with substantial differences between countries and the most pronounced decline in Italy (−40%, P < 0.001). Interestingly, in Switzerland, an increase in the number of elective cases was observed (+35%, P = 0.02). In conclusion, there was no change in the number of acute thoracic and abdominal aortic cases and procedures during the initial wave of the COVID-19 pandemic, whereas the case load of elective operations and procedures decreased significantly.

Mediators of SARS-CoV-2 entry are preferentially enriched in cardiomyocytes

Hereditas, January 4, 2021

The coronavirus disease 2019 (COVID-19) has spread rapidly around the world. In addition to common respiratory symptoms such as cough and fever, some patients also have cardiac injury, however, the mechanism of cardiac injury is not clear. In this study, we analyzed the RNA expression atlases of angiotensin-converting enzyme 2(ACE2), cathepsin B (CTSB) and cathepsin L (CTSL) in the human embryonic heart at single-cell resolution. The results showed that ACE2 was preferentially enriched in cardiomyocytes. Interestingly, serine protease transmembrane serine protease 2 (TMPRSS2) had less expression in cardiomyocytes, but CTSB and CTSL, which belonged to cell protease, could be found to be enriched in cardiomyocytes. The results of enrichment analysis showed that differentially expressed genes (DEGs) in ACE2-positive cardiomyocytes were mainly enriched in the processes of cardiac muscle contraction, regulation of cardiac conduction, mitochondrial respiratory chain, ion channel binding, adrenergic signaling in cardiomyocytes and viral transcription. Our study suggests that both atrial and ventricular cardiomyocytes are potentially susceptible to severe acute respiratory syndrome coronavirus-2(SARS-CoV-2), and SARS-CoV-2 may enter ventricular cardiomyocytes using CTSB/CTSL for S protein priming.

Coronary calcium scoring assessed on native screening chest CT imaging as predictor for outcome in COVID-19: An analysis of a hospitalized German cohort

PLOS ONE, December 30, 2020

Since the outbreak of the COVID-19 pandemic, a number of risk factors for a poor outcome have been identified. Thereby, cardiovascular comorbidity has a major impact on mortality. We investigated whether coronary calcification as a marker for coronary artery disease (CAD) is appropriate for risk prediction in COVID-19. Hospitalized patients with COVID-19 (n = 109) were analyzed regarding clinical outcome after native computed tomography (CT) imaging for COVID-19 screening. CAC (coronary calcium score) and clinical outcome (need for intensive care treatment or death) data were calculated following a standardized protocol. We defined three endpoints: critical COVID-19 and transfer to ICU, fatal COVID-19 and death, composite endpoint critical and fatal COVID-19, a composite of ICU treatment and death. We evaluated the association of clinical outcome with the CAC. Patients were dichotomized by the median of CAC. Hazard ratios and odds ratios were calculated for the events death or ICU or a composite of death and ICU. We observed significantly more events for patients with CAC above the group’s median of 31 for critical outcome (HR: 1.97[1.09,3.57], p = 0.026), for fatal outcome (HR: 4.95[1.07,22.9], p = 0.041) and the composite endpoint (HR: 2.31[1.28,4.17], p = 0.0056. Also, odds ratio was significantly increased for critical outcome (OR: 3.01 [1.37, 6.61], p = 0.01) and for fatal outcome (OR: 5.3 [1.09, 25.8], p = 0.02).

Comparison of Characteristics and Outcomes of Patients With Acute Myocardial Infarction With Versus Without Coronarvirus-19

American Journal of Cardiology, December 29, 2020

The coronavirus disease 2019 (COVID-19) pandemic has greatly impacted the US healthcare system. Cardiac involvement in COVID-19 is common and manifested by troponin and natriuretic peptide elevation and tends to have a worse prognosis. We analyzed patients who presented to the MedStar Health system (11 hospitals in Washington, DC, and Maryland) with either an ST-elevation myocardial infarction or non-ST-elevation myocardial infarction early in the pandemic (March 1, 2020 to June 30, 2020) using the International Classification of Diseases, Tenth Revision. Patients’ clinical course and outcomes, including in-hospital mortality, were compared on the basis of the results of COVID-19 status (positive or negative). The cohort included 1533 patients admitted with an acute myocardial infarction (AMI), of whom 86 had confirmed severe acute respiratory syndrome coronavirus 2 infection, during the study period. COVID-19-positive patients were older and non-White and had more co-morbidities. Furthermore, inflammatory markers and N-terminal-proB-type-natriuretic peptide were higher in COVID-19-positive AMI patients. Only 20.0% (17) of COVID-19-positive patients underwent coronary angiography. In-hospital mortality was significantly higher in AMI patients with concomitant COVID-19-positive status (27.9%) than in patients without COVID-19 during the same period (3.7%; p < 0.001). Patients with AMI and COVID-19 tended to be older, with more co-morbidities, when compared to those with an AMI and without COVID-19. In conclusion, myocardial infarction with concomitant COVID-19 was associated with increased in-hospital mortality. Efforts should be focused on the early recognition, evaluation, and treatment of these patients.

COVID 19: in the eye of the cytokine storm

European Heart Journal, December 27, 2020

This study focused on four cytokines known to contribute to pathogenic inflammation in CRS of patients receiving CAR-T cells, with clinically available or experimental blocking drugs. The clinical picture of the cytokine storm in COVID-19 was different from that of the coordinated increase during traditional CRS, showing different patterns of cytokine expression, and potentially distinct clinical presentations based on the relative profile of each cytokine. Accordingly, serum levels of IL-6 and TNF-α were lower in COVID-19 compared to classical CRS. The plasma cytokine cluster of COVID-19 recalls the cytokine pattern associated with acute coronary syndromes (ACS). In ACS, IL-6 levels are correlated with prognosis, and IL-6 blockade by tocilizumab quenches the acute inflammatory response of ACS patients undergoing percutaneous coronary intervention. In COVID-19, the cytokine storm might evoke and/or potentiate existing or new cardiac functional abnormalities, as well as trigger ACS through a thrombo-inflammatory response. The present study convincingly demonstrated that early cytokine increases, in particular IL-6 and TNF-α, were reliable predictors of COVID-19 severity and mortality, independently of demographics, comorbidities, and clinical biomarkers of disease severity. Multiple cytokine profiling could be used to determine which individuals are likely to develop respiratory failure and end-organ damage, in order to prioritize treatment in those at highest risk. Moreover, the predictive value of these cytokines might help guide resource allocation, as well as the design of prospective interventional studies. Theoretically, patients with moderate disease severity and high IL-6 or TNF-α levels might benefit the most from cytokine blockade.

Endothelium Infection and Dysregulation by SARS-CoV-2: Evidence and Caveats in COVID-19

Viruses, December 26, 2020

The ongoing pandemic of coronavirus disease 2019 (COVID-19) caused by the acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) poses a persistent threat to global public health. Although primarily a respiratory illness, extrapulmonary manifestations of COVID-19 include gastrointestinal, cardiovascular, renal and neurological diseases. Recent studies suggest that dysfunction of the endothelium during COVID-19 may exacerbate these deleterious events by inciting inflammatory and microvascular thrombotic processes. Although controversial, there is evidence that SARS-CoV-2 may infect endothelial cells by binding to the angiotensin-converting enzyme 2 (ACE2) cellular receptor using the viral Spike protein. In this review, we explore current insights into the relationship between SARS-CoV-2 infection, endothelial dysfunction due to ACE2 downregulation, and deleterious pulmonary and extra-pulmonary immunothrombotic complications in severe COVID-19. We also discuss preclinical and clinical development of therapeutic agents targeting SARS-CoV-2-mediated endothelial dysfunction. Finally, we present evidence of SARS-CoV-2 replication in primary human lung and cardiac microvascular endothelial cells. Accordingly, in striving to understand the parameters that lead to severe disease in COVID-19 patients, it is important to consider how direct infection of endothelial cells by SARS-CoV-2 may contribute to this process.

Cardiovascular Comorbidities and Pharmacological Treatments of COVID-19 Patients Not Requiring Hospitalization

International Journal of Environmental Research and Public Health, December 25, 2020

The Coronavirus disease 2019 (COVID-19) outbreak is a whole Earth health emergency related to a highly pathogenic human coronavirus responsible for severe acute respiratory syndrome (SARS-CoV-2). Despite the fact that the majority of infected patients were managed in outpatient settings, little is known about the clinical characteristics of COVID-19 patients not requiring hospitalization. The aim of our study was to describe the clinical comorbidity and the pharmacological therapies of COVID-19 patients managed in outpatient settings. We performed an observational, retrospective analysis of laboratory-confirmed COVID-19 patients managed in outpatient setting. The clinical features and pharmacological therapies of COVID-19 patients not requiring hospitalization and managed in outpatient settings have been described. A total of 351 laboratory-confirmed COVID-19 patients (mean age 54 ± 17 years; 193 males) with outpatient management were evaluated. Hypertension was the most prevalent comorbidity (35%). The distribution of cardiovascular comorbidities showed no gender-related differences. A total of 201 patients (57.3%) were treated with at least one experimental drug for COVID-19. Azithromycin, alone (42.78%) or in combination (27.44%), was the most widely used experimental anti-COVID drug in outpatient settings. Low Molecular Weight Heparin and Cortisone were prescribed in 24.87% and 19.4% of the study population, respectively. At multivariate regression model, diabetes (risk ratio (RR): 3.74; 95% CI 1.05 to 13.34; p = 0.04) and hypertension (RR: 1.69; 95% CI 1.05 to 2.7; p = 0.03) were significantly associated with the experimental anti-COVID drug administration. Moreover, only diabetes (RR: 2.43; 95% CI 1.01 to 5.8; p = 0.03) was significantly associated with heparin administration.

Clinical spectrum of ischaemic arterial diseases associated with COVID-19: a series of four illustrative cases

European Heart Journal, December 25, 2020

Severe coronavirus-induced disease 2019 (COVID-19) leads to acute respiratory distress syndrome with an increased risk of venous thrombo-embolic events. To a much lesser extent, arterial thrombo-embolic events have also been reported in this setting. This case report describes four different cases of COVID-19 infection with ischaemic arterial events, such as a myocardial infarction with high thrombus load, ischaemic stroke on spontaneous thrombosis of the aortic valve, floating thrombus with mesenteric, splenic and renal infarction, and acute limb ischaemia. Cardiovascular risk factors such as hypertension, obesity, and diabetes are comorbidities most frequently found in patients with a severe COVID-19 infection and are associated with a higher death rate. Our goal is to provide an overview of the clinical spectrum of ischaemic arterial events that may either reveal or complicate COVID-19. Several suspected pathophysiological mechanisms could explain the association between cardiovascular events and COVID-19 (role of systemic inflammatory response syndrome, endothelial dysfunction, activation of coagulation cascade leading to a hypercoagulability state, virus-induced secondary antiphospholipid syndrome). We need additional studies of larger size, to estimate the incidence of these arterial events and to assess the efficacy of anticoagulation therapy.

Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus

Critical Care, December 24, 2020

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. We searched Medline, Pubmed Central, Embase, Cochrane, Scopus and online pre-print databases from 01/01/2020 to 01/08/2020, and collected all English language publications on PoCUS in adult COVID-19 patients, using the MeSH query: [(“lung” AND “ultrasound”) OR “echocardiography” OR “Focused cardiac ultrasound” OR “point-of-care ultrasound” OR “venous ultrasound”] AND [“COVID-19” OR “SARS-CoV2”]. This systematic search strategy identified 214 records. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.

Hypertension delays viral clearance and exacerbates airway hyperinflammation in patients with COVID-19

Nature Biotechnology, December 24, 2020

In coronavirus disease 2019 (COVID-19), hypertension and cardiovascular diseases are major risk factors for critical disease progression. However, the underlying causes and the effects of the main anti-hypertensive therapies—angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs)—remain unclear. Combining clinical data (n = 144) and single-cell sequencing data of airway samples (n = 48) with in vitro experiments, we observed a distinct inflammatory predisposition of immune cells in patients with hypertension that correlated with critical COVID-19 progression. ACEI treatment was associated with dampened COVID-19-related hyperinflammation and with increased cell intrinsic antiviral responses, whereas ARB treatment related to enhanced epithelial–immune cell interactions. Macrophages and neutrophils of patients with hypertension, in particular under ARB treatment, exhibited higher expression of the pro-inflammatory cytokines CCL3 and CCL4 and the chemokine receptor CCR1. Although the limited size of our cohort does not allow us to establish clinical efficacy, our data suggest that the clinical benefits of ACEI treatment in patients with COVID-19 who have hypertension warrant further investigation.

Calcification of the thoracic aorta on low-dose chest CT predicts severe COVID-19

PLOS ONE, December 23, 2020

Cardiovascular comorbidity anticipates poor prognosis of SARS-CoV-2 disease (COVID-19) and correlates with the systemic atherosclerotic transformation of the arterial vessels. The amount of aortic wall calcification (AWC) can be estimated on low-dose chest CT. We suggest quantification of AWC on the low-dose chest CT, which is initially performed for the diagnosis of COVID-19, to screen for patients at risk of severe COVID-19. Seventy consecutive patients (46 in center 1, 24 in center 2) with parallel low-dose chest CT and positive RT-PCR for SARS-CoV-2 were included in our multi-center, multi-vendor study. The outcome was rated moderate (no hospitalization, hospitalization) and severe (ICU, tracheal intubation, death), the latter implying a requirement for intensive care treatment. The amount of AWC was quantified with the CT vendor’s software. Of 70 included patients, 38 developed a moderate, and 32 a severe COVID-19. The average volume of AWC was significantly higher throughout the subgroup with severe COVID-19, when compared to moderate cases (771.7 mm3 (Q1 = 49.8 mm3, Q3 = 3065.5 mm3) vs. 0 mm3 (Q1 = 0 mm3, Q3 = 57.3 mm3)). Within multivariate regression analysis, including AWC, patient age and sex, as well as a cardiovascular comorbidity score, the volume of AWC was the only significant regressor for severe COVID-19 (p = 0.004). For AWC > 3000 mm3, the logistic regression predicts risk for a severe progression of 0.78. If there are no visually detectable AWC risk for severe progression is 0.13, only.

COVID-19 update: the first 6 months of the pandemic

Human Genomics, December 23, 2020

The COVID-19 pandemic is sweeping the world and will feature prominently in all our lives for months and most likely for years to come. We review here the current state 6 months into the declared pandemic. Specifically, we examine the role of the pathogen, the host and the environment along with the possible role of diabetes. We also firmly believe that the pandemic has shown an extraordinary light on national and international politicians whom we should hold to account as performance has been uneven. We also call explicitly on competent leadership of international organizations, specifically the WHO, UN and EU, informed by science. Finally, we also condense successful strategies for dealing with the current COVID-19 pandemic in democratic countries into a developing pandemic playbook and chart a way forward into the future. This is useful in the current COVID-19 pandemic and, we hope, in a very distant future again when another pandemic might arise.

Myocarditis-associated necrotizing coronary vasculitis: incidence, cause, and outcome

European Heart Journal, December 23, 2020

Necrotizing coronary vasculitis (NCV) is a rare entity usually associated to myocarditis which incidence, cause, and response to therapy is unreported. Among 1916 patients with biopsy-proven myocarditis, 30 had NCV. Endomyocardial samples were retrospectively investigated with immunohistochemistry for toll-like receptor 4 (TLR4) and real-time polymerase chain reaction (PCR) for viral genomes. Serum samples were processed for anti-heart autoantibodies (Abs), IL-1β, IL-6, IL-8, tumour necrosis factor (TNF)-α. Identification of an immunologic pathway (including virus-negativity, TLR4-, and Ab-positivity) was followed by immunosuppression. Myocarditis-NCV cohort was followed for 6 months with 2D-echo and/or cardiac magnetic resonance and compared with 60 Myocarditis patients and 30 controls. Increase in left ventricular ejection fraction ≥10% was classified as response to therapy. Control endomyocardial biopsy followed the end of treatment. Twenty-six Myocarditis-NCV patients presented with heart failure; four with electrical instability. Cause of Myocarditis-NCV included infectious agents (10%) and immune-mediated causes (chest trauma 3%; drug hypersensitivity 7%; hypereosinophilic syndrome 3%; primary autoimmune diseases 33%, idiopathic 44%). Abs were positive in immune-mediated Myocarditis-NCV and virus-negative Myocarditis; Myocarditis-NCV patients with Ab+ presented autoreactivity in vessel walls. Toll-like receptor 4 was overexpressed in immune-mediated forms and poorly detectable in viral. Interleukin-1β was significantly higher in Myocarditis-NCV than Myocarditis, the former presenting 24% in-hospital mortality compared with 1.5% of Myocarditis cohort. Immunosuppression induced improvement of cardiac function in 88% of Myocarditis-NCV and 86% of virus-negative Myocarditis patients. Necrotizing coronary vasculitis is histologically detectable in 1.5% of Myocarditis. Necrotizing coronary vasculitis includes viral and immune-mediated causes. Intra-hospital mortality is 24%. The immunologic pathway is associated with beneficial response to immunosuppression.

Echocardiographic Features of Cardiac Injury Related to COVID-19 and Their Prognostic Value: A Systematic Review

Journal of Intensive Care Medicine, December 22, 2020

The available information on the echocardiographic features of cardiac injury related to the novel coronavirus disease 2019 (COVID-19) and their prognostic value are scattered in the different literature. Therefore, the aim of this study was to investigate the echocardiographic features of cardiac injury related to COVID-19 and their prognostic value. Published studies were identified through searching PubMed, Embase (Elsevier), and Google scholar databases. The search was performed using the different combinations of the keywords “echocard*,” “cardiac ultrasound,” “TTE,” “TEE,” “transtho*,” or “transeso*” with “COVID-19,” “sars-COV-2,” “novel corona, or “2019-nCOV.” Two researchers independently screened the titles and abstracts and full texts of articles to identify studies that evaluated the echocardiographic features of cardiac injury related to COVID-19 and/or their prognostic values. Of 783 articles retrieved from the initial search, 11 (8 cohort and 3 cross-sectional studies) met our eligibility criteria. Rates of echocardiographic abnormalities in COVID-19 patients varied across different studies as follow: RV dilatation from 15.0% to 48.9%; RV dysfunction from 3.6% to 40%; and LV dysfunction 5.4% to 40.0%. Overall, the RV abnormalities were more common than LV abnormalities. The majority of the studies showed that there was a significant association between RV abnormalities and the severe forms and death of COVID-19. The available evidence suggests that RV dilatation and dysfunction may be the most prominent echocardiographic abnormality in symptomatic patients with COVID-19, especially in those with more severe or deteriorating forms of the disease. Also, RV dysfunction should be considered as a poor prognostic factor in COVID-19 patients.

Potential protective effects of antihypertensive treatments during the Covid-19 pandemic: from inhibitors of the renin-angiotensin system to beta-adrenergic receptor blockers

Blood Pressure, December 21, 2020

From the beginning of the pandemic hypertension appeared as one of the most common comorbidities in patients hospitalised with a Covid-19 infection. Hypertension, diabetes, overweight, chronic pulmonary disease and heart failure, together with advanced age were the typical characteristics of patients who suffered a fatal outcome of severe Covid-19 disease. However, hypertension is highly prevalent in the adult population, particularly among the elderly, overweight people, and patients with diabetes. Therefore, it remains unclear, whether hypertension per se predisposes patients to develop Covid-19 disease, to make it more severe or to predict a poor outcome, or whether the other comorbidities or patient characteristics such as overweight or advanced age, confound the data. A major consideration in the management of hypertensive patients in the time of the Covid-19 pandemic regards the choice of antihypertensive medications and their potential impact on the disease outcome. It started with the question of whether treatment with angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are safe. ACEIs and ARBs may up-regulate ACE2, the receptor used by the severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) to enter host cells. Therefore, treatment with ACEIs and ARBs could potentially increase the risk of SARS-CoV-2 infection. However, cardiopulmonary diseases are associated with decreased ACE2 activity. By limiting the effects of angiotensin II on the heart and vasculature, ACE2 could protect against the more severe complications of Covid-19 infection.

Top in cardiology: Icosapent ethyl and COVID-19, impact of BP on cognitive decline

Helio | Cardiology, December 21, 2020

Early data presented at the virtual National Lipid Association Scientific Sessions suggest that icosapent ethyl may reduce inflammation and improve symptoms in patients with COVID-19. It was the top story in cardiology last week. Another top story was about a study that found hypertension and prehypertension were associated with declines in various markers of cognitive function. In a first-in-human study, icosapent ethyl (Vascepa, Amarin) reduced levels of inflammatory biomarkers and improved symptoms in patients with COVID-19, researchers reported. BP control may be critical for the preservation of cognitive function, according to a study published in Hypertension.

Positive association of angiotensin II receptor blockers, not angiotensin-converting enzyme inhibitors, with an increased vulnerability to SARS-CoV-2 infection in patients hospitalized for suspected COVID-19 pneumonia

PLOS ONE, December 21, 2020

Angiotensin-converting enzyme 2 is the receptor that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) uses for entry into lung cells. Because ACE-2 may be modulated by angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs), there is concern that patients treated with ACEIs and ARBs are at higher risk of coronavirus disease 2019 (COVID-19) pneumonia. This study sought to analyze the association of COVID-19 pneumonia with previous treatment with ACEIs and ARBs. We retrospectively reviewed 684 consecutive patients hospitalized for suspected COVID-19 pneumonia and tested by polymerase chain reaction assay. Patients were split into two groups, according to whether (group 1, n = 484) or not (group 2, n = 250) COVID-19 was confirmed. Multivariable adjusted comparisons included a propensity score analysis. The mean age was 63.6 ± 18.7 years, and 302 patients (44%) were female. Hypertension was present in 42.6% and 38.4% of patients in groups 1 and 2, respectively (P = 0.28). Treatment with ARBs was more frequent in group 1 than group 2 (20.7% vs. 12.0%, respectively; odds ratio [OR] 1.92, 95% confidence interval [CI] 1.23–2.98; P = 0.004). No difference was found for treatment with ACEIs (12.7% vs. 15.7%, respectively; OR 0.81, 95% CI 0.52–1.26; P = 0.35). Propensity score-matched multivariable logistic regression confirmed a significant association between COVID-19 and previous treatment with ARBs (adjusted OR 2.36, 95% CI 1.38–4.04; P = 0.002). Significant interaction between ARBs and ACEIs for the risk of COVID-19 was observed in patients aged > 60 years, women, and hypertensive patients.

Cardiovascular implications of COVID-19 versus influenza infection: a review

BMC Medicine, December 18, 2020

Due to the overlapping clinical features of coronavirus disease 2019 (COVID-19) and influenza, parallels are often drawn between the two diseases. Patients with pre-existing cardiovascular diseases (CVD) are at a higher risk for severe manifestations of both illnesses. Considering the high transmission rate of COVID-19 and with the seasonal influenza approaching in late 2020, the dual epidemics of COVID-19 and influenza pose serious cardiovascular implications. This review highlights the similarities and differences between influenza and COVID-19 and the potential risks associated with coincident pandemics. COVID-19 has a higher mortality compared to influenza with case fatality rate almost 15 times more than that of influenza. Additionally, a significantly increased risk of adverse outcomes has been noted in patients with CVD, with ~ 15 to 70% of COVID-19 related deaths having an underlying CVD. The critical care need have ranged from 5 to 79% of patients hospitalized due to COVID-19, a proportion substantially higher than with influenza. Similarly, the frequency of vascular thrombosis including deep venous thrombosis and pulmonary embolism is markedly higher in COVID-19 patients compared with influenza in which vascular complications are rarely seen. Unexpectedly, while peak influenza season is associated with increased cardiovascular hospitalizations, a decrease of ~ 50% in cardiovascular hospitalizations has been observed since the first diagnosed case of COVID-19, owing in part to deferred care.

Impact of COVID-19 pandemic and diabetes on mechanical reperfusion in patients with STEMI: insights from the ISACS STEMI COVID 19 Registry

Cardiovascular Diabetology, December 18, 2020

It has been suggested the COVID pandemic may have indirectly affected the treatment and outcome of STEMI patients, by avoidance or significant delays in contacting the emergency system. No data have been reported on the impact of diabetes on treatment and outcome of STEMI patients, that was therefore the aim of the current subanalysis conducted in patients included in the International Study on Acute Coronary Syndromes–ST Elevation Myocardial Infarction (ISACS-STEMI) COVID-19. The ISACS-STEMI COVID-19 is a retrospective registry performed in European centers with an annual volume of > 120 primary percutaneous coronary intervention (PCI) and assessed STEMI patients, treated with primary PCI during the same periods of the years 2019 versus 2020 (March and April). Main outcomes are the incidences of primary PCI, delayed treatment, and in-hospital mortality. A total of 6609 patients underwent primary PCI in 77 centers, located in 18 countries. Diabetes was observed in a total of 1356 patients (20.5%), with similar proportion between 2019 and 2020. During the pandemic, there was a significant reduction in primary PCI as compared to 2019, similar in both patients with (Incidence rate ratio (IRR) 0.79 (95% CI: 0.73–0.85, p < 0.0001) and without diabetes (IRR 0.81 (95% CI: 0.78–0.85, p < 0.0001) (p int = 0.40). We observed a significant heterogeneity among centers in the population with and without diabetes (p < 0.001, respectively). The heterogeneity among centers was not related to the incidence of death due to COVID-19 in both groups of patients. Interaction was observed for Hypertension (p = 0.024) only in absence of diabetes. Furthermore, the pandemic was independently associated with a significant increase in door-to-balloon and total ischemia times only among patients without diabetes, which may have contributed to the higher mortality, during the pandemic, observed in this group of patients.

Ventricular arrhythmia burden during the coronavirus disease 2019 (COVID-19) pandemic

European Heart Journal, December 16, 2020

Our objective was to determine the ventricular arrhythmia burden in implantable cardioverter-defibrillator (ICD) patients during COVID-19. In this multicentre, observational, cohort study over a 100-day period during the COVID-19 pandemic in the USA, we assessed ventricular arrhythmias in ICD patients from 20 centres in 13 states, via remote monitoring. Comparison was via a 100-day control period (late 2019) and seasonal control period (early 2019). The primary outcome was the impact of COVID-19 on ventricular arrhythmia burden. The secondary outcome was correlation with COVID-19 incidence. During the COVID-19 period, 5963 ICD patients underwent remote monitoring, with 16 942 episodes of treated ventricular arrhythmias (2.8 events per 100 patient-days). Ventricular arrhythmia burden progressively declined during COVID-19 (P < 0.001). The proportion of patients with ventricular arrhythmias amongst the high COVID-19 incidence states was significantly reduced compared with those in low incidence states [odds ratio 0.61, 95% confidence interval (CI) 0.54–0.69, P < 0.001]. Comparing patients remotely monitored during both COVID-19 and control periods (n = 2458), significantly fewer ventricular arrhythmias occurred during COVID-19 [incident rate ratio (IRR) 0.68, 95% CI 0.58–0.79, P < 0.001]. This difference persisted when comparing the 1719 patients monitored during both the COVID-19 and seasonal control periods (IRR 0.69, 95% CI 0.56–0.85, P < 0.001).

FDA finds Moderna vaccine 95% effective

Modern Healthcare, December 15, 2020

The Food and Drug Administration on Tuesday has found the COVID-19 vaccine from drugmaker Moderna safe and 95% effective, moving it closer to federal approval for distribution. On Thursday, a group of experts will convene in a public hearing to advise the agency on whether to grant the vaccine emergency authorization use. The agency’s report found the vaccine has “no specific safety concerns identified that would preclude issuance of an EUA.” Minor side effects, including pain at the site of injection, fatigue and headaches were common but the FDA did not report any major side effects. The vaccine, however, is less effective (86%) in people age 65 and older. Moderna’s vaccine would be the second to receive FDA approval in one week. Last Thursday, Pfizer’s vaccine received emergency authorization use. Hospitals across the country began to administer that shot yesterday.

Impact of COVID-19 on health-related quality of life in patients with cardiovascular disease: a multi-ethnic Asian study

Health and Quality of Life Outcomes, December 14, 2020

Little is known about the impact of the global coronavirus disease-2019 (COVID-19) pandemic on patients with cardiovascular disease (CVD), the biggest global killer and major risk factor for severe COVID-19 infections. We aim to explore the indirect consequences of COVID-19 on health-related quality of life (HRQoL) of patients with CVD. Eighty-one adult outpatients with CVD were assessed using the EQ-5D, a generic health status instrument with five dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression), before and during the pandemic. Changes in the EQ-5D dimensional responses were compared categorically as well as using the dimension-specific sum-score (range 1–3, with a higher score indicating worse health). The responses and sum-score were compared using the exact test of symmetry and the paired t-test, respectively. These patients [mean age (SD) 59.8 (10.5); 92.6% males; 56% New York Heart Association (NYHA) functional class I] had coronary artery disease (69%), heart failure (28%), or arrhythmias (15%). None experienced change in NYHA class between assessments. About 30% and 38% of patients reported problems with at least one of the EQ-5D dimensions pre-pandemic and during the pandemic, respectively. The highest increase in health problems was reported for anxiety/depression (12.5% pre-pandemic vs 23.5% during pandemic; p = 0.035) with mean domain-specific score from 1.12 (SD 0.33) to 1.25 (SD 0.46) (standardized effect size = 0.373, p = 0.012). There was no meaningful change in other dimensions as well as overall HRQoL.

Use of out-of-hospital cardiac arrest registries to assess COVID-19 home mortality

BMC Medical Research Methodology, December 14, 2020

In most countries, the official statistics for the coronavirus disease 2019 (COVID-19) take account of in-hospital deaths but not those that occur at home. The study’s objective was to introduce a methodology to assess COVID-19 home deaths by analysing the French national out-of-hospital cardiac arrest (OHCA) registry (RéAC). We performed a retrospective multicentre cohort study based on data recorded in the RéAC by 20 mobile medical teams (MMTs) between March 1st and April 15th, 2020. The participating MMTs covered 10.1% of the French population. OHCA patients were classified as probable or confirmed COVID-19 cases or as non-COVID-19 cases. To achieve our primary objective, we computed the incidence and survival at hospital admission of cases of COVID-19 OHCA occurring at home. Cardiac arrests that occurred in retirement homes or public places were excluded. Hence, we estimated the number of at-home COVID-19-related deaths that were not accounted for in the French national statistics. We included 670 patients with OHCA. The extrapolated annual incidence of OHCA per 100,000 inhabitants was 91.9 overall and 17.6 for COVID-19 OHCA occurring at home. In the latter group, the survival rate after being taken to the hospital after an OHCA was 10.9%. We estimated that 1322 deaths were not accounted in the French national statistics on April 15, 2020.

A historical perspective on ACE2 in the COVID-19 era

Journal of Human Hypertension, December 14, 2020
Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Lessons learned from severe acute respiratory syndrome coronavirus (SARS-CoV) have facilitated a better understanding of the COVID-19 pandemic and efforts to develop targeted therapies. In particular, COVID-19 reminds us of the importance of the renin-angiotensin-aldosterone system (RAAS) in cardiovascular, pulmonary, and kidney physiology. After decades of RAAS research, we can apply this knowledge to better understand COVID-19 pathophysiology and to inform rigorous studies. In 2020, the rapid spread of SARS-CoV-2 has made us again reflect on the risk/benefit ratio of these important drug classes and their mechanisms of action. Based on the interaction between SARS-CoV-2 and ACE2, many postulated that possible RAAS inhibitor-induced ACE2 expression and thus viral propagation could be an important mechanism for the apparent associations between SARS-CoV-2 infection and COVID-19 severity and hypertension, cardiovascular disease, and chronic kidney disease. On the other hand, ACE inhibitors and ARBs may be novel therapeutic agents to treat patients with COVID-19 by shifting the RAAS back toward the ACE2—Ang-(1–7)Ang-(1–7) pathway. Several, albeit limited, observational studies have not shown an association between severity of COVID-19 with use of ACE inhibitors or ARBs.

Air cardiology is now on air: The Time for a Green Heart New Deal in Cardiology is now

European Heart Journal, December 14, 2020

Air pollution is a chronic risk factor for cardiovascular mortality, an acute trigger for coronary syndromes, an important co-factor for COVID-19 mortality, a modulator of results of cardiac functional stress testing, and an actionable therapeutic target at the population, community, and individual levels. Pozzer et al. add yet another piece of key evidence linking air pollution to detrimental health effects. They characterized global exposures to fine particulates based on satellite data and calculated the anthropogenic fraction with an atmospheric chemistry model. The conclusion is that particulate air pollution contributed 15% to COVID-19 mortality worldwide and 19% in Europe. Of this significant fraction, ∼50% is due to fossil fuel use, which is at least in principle avoidable with alternate energy choices. There is biological plausibility for the observed epidemiological link. Fine particulate matter and the SARS-CoV-2 virus both enter the body through the bronchial system, activate the inflammatory system, oxidative stress, and immune reaction, target endothelium, and induce a systemic pro-thrombotic state. There is increased susceptibility to viral infections from exposure to air pollution and fine particulates prolong the atmospheric lifetime of infectious viruses.

Screening of Potential Cardiac Involvement in Competitive Athletes Recovering From COVID-19: An Expert Consensus Statement

JACC: Cardiovascular Imaging, December 13, 2020

As our understanding of the complications of coronavirus disease-2019 (COVID-19) evolve, subclinical cardiac pathology such as myocarditis, pericarditis, and right ventricular dysfunction in the absence of significant clinical symptoms represents a concern. The potential implications of these findings in athletes are significant given the concern that exercise, during the acute phase of viral myocarditis, may exacerbate myocardial injury and precipitate malignant ventricular arrhythmias. Such concerns have led to the development and publication of expert consensus documents aimed at providing guidance for the evaluation of athletes after contracting COVID-19 in order to permit safe return to play. Cardiac imaging is at the center of these evaluations. This review seeks to evaluate the current evidence regarding COVID-19–associated cardiovascular disease and how multimodality imaging may be useful in the screening and clinical evaluation of athletes with suspected cardiovascular complications of infection. Guidance is provided with diagnostic “red flags” that raise the suspicion of pathology. Specific emphasis is placed on the unique challenges posed in distinguishing athletic cardiac remodeling from subclinical cardiac disease. The strengths and limitations of different imaging modalities are discussed and an approach to return to play decision making for athletes post–COVID-19, as informed by multimodality imaging, is provided.

Coronavirus disease 2019 in adults with congenital heart disease: a position paper from the ESC working group of adult congenital heart disease, and the International Society for Adult Congenital Heart Disease

European Heart Journal, December 12, 2020

We are witnessing an unparalleled pandemic caused by the novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) associated with coronavirus disease 2019 (COVID-19). Current data show that SARS-CoV-2 results in mild flu-like symptoms in the majority of healthy and young patients affected. Nevertheless, the severity of COVID-19 respiratory syndrome and the risk of adverse or catastrophic outcomes are increased in patients with pre-existing cardiovascular disease. Patients with adult congenital heart disease (ACHD)—by definition—have underlying cardiovascular disease. Many patients with ACHD are also afflicted with residual haemodynamic lesions such as valve dysfunction, diminished ventricular function, arrhythmias or cyanosis, have extracardiac comorbidities, and face additional challenges regarding pregnancy. Currently, there are emerging data of the effect of COVID-19 on ACHD patients, but many aspects, especially risk stratification and treatment considerations, remain unclear. In this article, we aim to discuss the broad impact of COVID-19 on ACHD patients, focusing specifically on pathophysiology, risk stratification for work, self-isolation, hospitalization, impact on pregnancy, psychosocial health, and longer-term implications for the provision of ACHD care.

Low LDL, high triglycerides may indicate mortality risk in COVID-19 hospitalization

Helio | Cardiology Today, December 12, 2020

Among patients hospitalized with COVID-19, LDL level below 50 mg/dL and triglycerides above 150 mg/dL were individually associated with increased odds for mortality, according to a presentation. “Prior studies have demonstrated lipid abnormalities in patients with SARS-CoV-2 that were mainly analyzing total cholesterol levels. Our study suggests that patients with COVID-19 who have unusually low LDL levels and yet elevated TG levels have more increased mortality,” Karolyn Teufel MD, assistant professor of medicine at the George Washington University Hospital in Washington D.C., and colleagues wrote in a poster presented at the virtual National Lipid Association Scientific Sessions. “These lipid biomarkers may act as an independent prognostic marker for patients on admission. Additionally, it is unusual to see low LDL and high TG in a patient with metabolic syndrome — one would expect to see elevated LDL levels in such patients.” This retrospective analysis included 254 patients hospitalized with COVID-19 (mean age, 62 years; 54% men; 70% Black) who underwent random lipid measurements performed during their stay at the George Washington University Hospital. The researchers evaluated the association between lipid biomarkers and mortality among patients hospitalized with COVID-19. “Future studies would further compare lipid biomarkers on a longer longitudinal timeline, as well as multivariate analysis to investigate the role of other conditions and biomarkers in conjunction with these lipid abnormalities in COVID-19 infection,” Teufel and colleagues wrote.

Impact of the shift to a fibrinolysis-first strategy on care and outcomes of patients with ST-segment–elevation myocardial infarction during the COVID-19 pandemic—The experience from the largest cardiovascular-specific centre in China

International Journal of Cardiology, December 11, 2020

The impact of fibrinolysis-first strategy on outcomes of patients with ST-segment-elevation myocardial infarction (STEMI) during the COVID-19 pandemic was unknown. Data from STEMI patients presenting to Fuwai Hospital from January 23 to April 30, 2020 were compared with those during the equivalent period in 2019. The primary end-point was net adverse clinical events (NACE; a composite of death, non-fatal myocardial reinfarction, stroke, emergency revascularization, and bleeding over BARC type 3). The secondary outcome was a composite of recurrent ischaemia, cardiogenic shock, and exacerbated heart failure. The final analysis included 164 acute STEMI patients from 2020 and 240 from 2019. Eighteen patients (20.2% of those with indications) received fibrinolysis therapy in 2020 with a median door-to-needle time of 60.0 (43.5, 92.0) minutes. Patients in 2020 underwent primary PCI less frequently than their counterparts (14 [14.2%] vs. 144 [86.8%] in 2019, P < 0.001), and had a longer median door-to-balloon time (175 [121,213] minutes vs. 115 [83, 160] minutes in 2019, P = 0.009). Patients were more likely to undergo elective PCI (86 [52.4%] vs. 28 [11.6%] in 2019, P < 0.001). The in-hospital NACE was similar between 2020 and 2019 (14 [8.5%] vs. 25 [10.4%], P = 0.530), while more patients developed a secondary outcome in 2020 (20 [12.2%] vs. 12 [5.0%] in 2019, P = 0.009).

Using Cardiovascular Cells from Human Pluripotent Stem Cells for COVID-19 Research: Why the Heart Fails

Stem Cell Reports, December 10, 2020

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led to the coronavirus disease (COVID-19) outbreak that became a pandemic in 2020, causing more than 30 million infections and 1 million deaths to date. As the scientific community has looked for vaccines and drugs to treat or eliminate the virus, unexpected features of the disease have emerged. Apart from respiratory complications, cardiovascular disease has emerged as a major indicator of poor prognosis in COVID-19. It has therefore become of utmost importance to understand how SARS-CoV-2 damages the heart. Human pluripotent stem cell (hPSC) cardiovascular derivatives were rapidly recognized as an invaluable tool to address this, not least because one of the major receptors for the virus is not recognized by SARS-CoV-2 in mice. Here, we outline how hPSC-derived cardiovascular cells have been utilized to study COVID-19, and their potential for further understanding the cardiac pathology and in therapeutic development.

Incidence rate and clinical impacts of arrhythmia following COVID-19: a systematic review and meta-analysis of 17,435 patients

Critical Care, December 10, 2020

Arrhythmia is a potential cardiovascular complication of Coronavirus Disease 2019 (COVID-19). In one case series of patients hospitalized with COVID-19, 16.7% developed unspecified arrhythmia, while another case series indicated sustained ventricular tachycardia or ventricular fibrillation among 5.9% of patients hospitalized with COVID-19. However, incidence rates of arrhythmia and mortality rates after incident arrhythmia in COVID-19 patients have not been systematically established. We searched for relevant studies cited in PubMed or Embase up to September 15, 2020, using the terms “COVID-19”, “arrhythmia”, “incidence”, “mortality,” and “prognosis” with suitable MeSH terms. All studies were selected and reviewed by two reviewers (SCL and SCS). The final list of included studies and data extractions were derived through extensive discussion with agreement from both authors. Outcomes were reported as proportions with 95% confidence interval (CI), based on the random effects model. The heterogeneity among studies was detected by the Cochran Q test with p value and the I2 statistic. Of 645 potential studies screened, we excluded 143 duplicate studies, 66 irrelevant studies, 12 conference abstracts, 241 other types of publications (e.g., pre-prints, protocols, opinions, recommendations, editorials, commentaries, retractions and reviews), 114 studies without incidence or mortality data, and 13 non-English studies. We included 56 studies from 11 countries comprising 17,435 patients with COVID-19. Compared to the incident arrhythmia in patients with community-acquired pneumonia (4.7%, 95% CI: 2.4–8.9), the present study indicates higher incidence of arrhythmia in COVID-19 patients (16.8%) with 2 out of 10 patients dying after developing arrhythmia.

A small contribution to mitigate the collision of transmissible and chronic diseases, exemplified by the management of hypertension during the COVID-19 pandemic

Journal of Human Hypertension, December 10, 2020

We want to take up the challenge posed by Nadar and cols. in their May editorial about managing hypertension during the COVID-19 pandemic. Their concern that patients with chronic illnesses would be forgotten in the fight against the paradigm of a transmissible virus and result in collateral damage reached the public domain since June. In mid October the number of new confirmed cases is still increasing in the Americas, South-East Asia and Europe according to the World Health Organization; lockdowns have been reinstalled in various zones and widely available vaccines are far from around the corner. In the present situation it is urgent to mitigate the collision of non-transmissible conditions with the rapid spread of the novel COVID infection by new patterns of interaction between all the protagonists involved in health care. An unexpected and beneficial collateral effect of the prolonged worldwide sanitary crisis is the shift in the balance between critical and stable health conditions by addressing most of the control of hypertension and other chronic conditions to the virtual attention. The American Society of Preventive Cardiology has proposed virtual team care in order to override the pandemic. This relatively new mode has been well accepted by patients and validated by randomized clinical trials, meta-analysis and systematic reviews that show similar blood pressure control than the conventional form, but if accompanied by education and counselling obtains extra benefits. In addition, telemedicine offers several advantages, including more equal and patient-centered health care in times in which vulnerable groups increase, receive the greatest economic and sanitary toll and require individual support.

Telemedicine in Heart Failure During COVID-19: A Step Into the Future

Frontiers in Cardiovascular Medicine, December 9, 2020

During the Coronavirus Disease 2019 worldwide pandemic, patients with heart failure are a high-risk group with potential higher mortality if infected. Although lockdown represents a solution to prevent viral spreading, it endangers regular follow-up visits and precludes direct medical assessment in order to detect heart failure progression and optimize treatment. Furthermore, lifestyle changes during quarantine may trigger heart failure decompensations. During the pandemic, a paradoxical reduction of heart failure hospitalization rates was observed, supposedly caused by patient reluctance to visit emergency departments and hospitals. This may result in an increased patient mortality and/or in more complicated heart failure admissions in the future. In this scenario, different telemedicine strategies can be implemented to ensure continuity of care to patients with heart failure. Patients at home can be monitored through dedicated apps, telephone calls, or devices. Virtual visits and forward triage screen the patients with signs or symptoms of decompensated heart failure. In-hospital care may benefit from remote communication platforms. After discharge, patients may undergo remote follow-up or telerehabilitation to prevent early readmissions. This review provides a comprehensive appraisal of the many possible applications of telemedicine for patients with heart failure during Coronavirus disease 2019 and elucidates practical limitations and challenges regarding specific telemedicine modalities.

Cardiovascular care delivery during the second wave of COVID-19 in Canada

Canadian Journal of Cardiology, December 8, 2020

Hospitals and ambulatory facilities significantly reduced cardiac care delivery in response to the first wave of the COVID-19 pandemic. The deferral of elective cardiovascular procedures led to a marked reduction in healthcare delivery with a significant impact on optimal cardiovascular care. International and Canadian data have reported dramatically increased wait-times for diagnostic tests and cardiovascular procedures, as well as associated increased cardiovascular morbidity and mortality.
In the wake of the demonstrated ability to rapidly create critical care and hospital ward capacity, we advocate a different approach during the second and possible subsequent COVID-19 pandemic waves. We suggest an approach, informed by local data and experience, which balances the need for an expected rise in demand for healthcare resources to ensure appropriate COVID-19 surge capacity, with continued delivery of essential cardiovascular care. Incorporating cardiovascular care leaders into pandemic planning and operations will help healthcare systems minimize cardiac care delivery disruptions, while maintaining critical care and hospital ward surge capacity and continuing measures to reduce transmission risk in healthcare settings. Specific recommendations targeting the main pillars of cardiovascular care are presented: ambulatory, inpatient, procedural, diagnostic, surgical and rehabilitation.

Thromboembolic complications in critically ill COVID-19 patients are associated with impaired fibrinolysis

Critical Care, December 7, 2020

There is emerging evidence for enhanced blood coagulation in coronavirus 2019 (COVID-19) patients, with thromboembolic complications contributing to morbidity and mortality. The mechanisms underlying this prothrombotic state remain enigmatic. Further data to guide anticoagulation strategies are urgently required. We used viscoelastic rotational thromboelastometry (ROTEM) in a single-center cohort of 40 critically ill COVID-19 patients. Clear signs of a hypercoagulable state due to severe hypofibrinolysis were found. Maximum lysis, especially following stimulation of the extrinsic coagulation system, was inversely associated with an enhanced risk of thromboembolic complications. Combining values for maximum lysis with D-dimer concentrations revealed high sensitivity and specificity of thromboembolic risk prediction. This study identifies a reduction in fibrinolysis as an important mechanism in COVID-19-associated coagulopathy. The combination of ROTEM and D-dimer concentrations may prove valuable in identifying patients requiring higher intensity anticoagulation.

Acute thrombosis of the right coronary artery in a patient with COVID-19

European Society of Cardiology, December 7, 2020

[Case Report] A 49-year-old man without cardiovascular risk factors presented to the emergency department with an acute ST-elevation myocardial infarction (STEMI). The patient has had fever and dry cough in the previous 10 days. Emergency coronary angiography (Videos 1-3) showed critical thrombotic stenosis of the proximal right coronary artery. Abundant thrombotic material was distally embolized. Aspiration thrombectomy was performed and it removed the proximal thrombus entirely and the artery appeared angiographically normal, so we decided not to perform angioplasty. Enoxaparin sodium was administered at a rate of 1 mg/kg of body weight every 12 h in addition to the double antiplatelet therapy with acetylsalicylic acid 100 mg and clopidogrel 75 mg/day for the first 10 days. Read more about this exceptional case as a result of the special resistance of the coronary arteries to the formation of spontaneous thrombosis. This case strengthens the theory of the increased risk of thrombotic events in patients with COVID-19 and gives a relevant role to anticoagulant treatments for these patients.

Reduced cardiac function is associated with cardiac injury and mortality risk in hospitalized COVID-19 Patients

Clinical Cardiology, December 7, 2020

Cardiac injury is common in COVID-19 patients and is associated with increased mortality. However, it remains unclear if reduced cardiac function is associated with cardiac injury, and additionally if mortality risk is increased among those with reduced cardiac function in COVID-19 patients. The aim of this study was to assess cardiac function among COVID-19 patients with and without biomarkers of cardiac injury and to determine the mortality risk associated with reduced cardiac function. This retrospective cohort study analyzed 143 consecutive COVID-19 patients who had an echocardiogram during hospitalization between March 1, 2020 and May 5, 2020. The mean age was 67 +/- 16 years. Cardiac troponin-I was available in 131 patients and an increased value (>0.03 ng/dL) was found in 59 patients (45%). Reduced cardiac function, which included reduced left or right ventricular systolic function, was found in 40 patients (28%). Reduced cardiac function was found in 18% of patients without troponin-I elevation, 42% with mild troponin increase (0.04-5.00 ng/dL) and 67% with significant troponin increase (>5 ng/dL). Reduced cardiac function was also present in more than half of the patients on mechanical ventilation or those deceased. The in-hospital mortality of this cohort was 28% (N = 40). Using logistic regression analysis, we found that reduced cardiac function was associated with increased mortality with adjusted odds ratio (95% confidence interval) of 2.65 (1.18 to 5.96).

Vascular medicine in the COVID-19 era: The Vanderbilt experience

Journal of Vascular Nursing, December 7, 2020

Coronavirus disease of 2019 poses significant risks for patients with vascular disease. Telemedicine can help clinicians provide care for patients with vascular disease while adhering to social-distancing guidelines. In this article, we review the components of telemedicine used in the vascular medicine practice at the Vanderbilt University Medical Center. In addition, we describe inpatient and outpatient diagnosis-based algorithms to help select patients for telemedicine versus in-person evaluation.

Collaboration During Crisis: A Novel Point-of-Care Ultrasound Alliance Between Emergency Medicine, Internal Medicine, and Cardiology in the COVID-19 Era

Journal of the American Society of Echocardiography, December 6, 2020

The COVID-19 pandemic may be the greatest public health emergency we will experience in our lifetimes. It has both exposed major shortcomings in the American medical system and revealed our capacity for innovation and collaboration. Early in disaster planning at our institution, we identified several issues regarding echocardiography: 1) personal protective equipment shortages 2) large ultrasound machines posed an infection control risk, 3) heterogenous knowledge of basic point-of-care ultrasound (POCUS) echocardiography, and 4) a need for cardiac diagnostics beyond the scope of basic POCUS (eg. regional wall motion abnormalities).(1-4) Prior to COVID-19, an enterprise-level multidisciplinary POCUS committee had been organized to address POCUS training, credentialing, and image archival. With multi-specialty agreement, including members of this committee, the default method of cardiac ultrasound imaging became POCUS in COVID-19 positive or suspected patients. Echocardiography lab sonographers were available to remotely support and direct front-line providers during bedside echocardiographic image acquisition using either in-room ICU cameras when the provider was using a cart-based machine or the teleguidance feature on the handheld ultrasound systems. Echocardiography faculty, with access to the POCUS image archive, offered remote real-time image interpretation assistance. This initiative minimized the number of providers exposed to COVID-19 patients, maximized infection control precautions, while also appropriately triaging the need for comprehensive echocardiography.

Spectrum of cardiovascular diseases in children during high peak COVID-19 period infection in Northern Italy: is there a link?

Journal of Pediatric Infectious Diseases Society, December 6, 2020

Children with COVID-19 have a milder clinical course than adults. We describe the spectrum of cardiovascular manifestations during a COVID-19 outbreak in Emilia-Romagna, Italy. Cross-sectional multicenter study including all diagnosis of KD, myocarditis and multisystem inflammatory syndrome in children (MIS-C) from February to April2020. KD patients were compared to those diagnosed before the epidemic. KD: 8 patients (6/8 boys, all negative for SARS-CoV-2); complete presentation in 5/8; 7/8 IVIG-responders; 3/8 showed transient coronary lesions (CALs). One 5-year-old girl negative for SARS-CoV-2, positive for Parvovirus B19. She responded to IVIG. Four SARS-CoV-2 positive boys (3 patients with positive swab and serology, 1 patient with negative swab and positive serology). Three presented myocardial dysfunction and pericardial effusion, one developed multicoronary aneurysms and hyperinflammation; all responded to treatment. The fourth boy had mitral and aortic regurgitation that rapidly regressed after steroids. In the end, KD, myocarditis and MIS-C were distinguishable cardiovascular manifestations. KD did not show a more aggressive form compared to previous years: coronary involvement was frequent, but always transient. MIS-C and myocarditis rapidly responded to treatment without cardiac sequelae despite high markers of myocardial injury at onset suggesting a myocardial depression due to systemic inflammation rather than focal necrosis. Evidence of actual or previous SARS-CoV-2 infection was documented only in patients with MIS-C.

ACE inhibitors, ARBs do not pose additional risk in COVID-19 in two meta-analyses

Helio | Cardiology Today, December 4, 2020

Use of ACE inhibitors and angiotensin receptor blockers was not associated with an increased rate of COVID-19 infection or mortality, according to two meta-analyses reported at the virtual American Heart Association Scientific Sessions. Yujiro Yokoyama, MD, surgeon at St. Luke’s University Health Network’s Easton Hospital, Bethlehem, Pennsylvania, and colleagues conducted two meta-analyses to compare mortality and susceptibility to COVID-19 infection between patients treated and not treated with ACE inhibitors and/or angiotensin receptor blocker. The first meta-analysis evaluated the impact on rate of positive COVID-19 testing and the second meta-analysis evaluated the impact on in-hospital mortality for patients with COVID-19. “Our study results confirm that patients already taking ACE inhibitors and angiotensin receptor blockers should not discontinue takin them due to COVID-19 infection,” Yokoyama said in a press release. “Both medications have proven benefits for heart and kidney disease, and this further confirms previous findings that ACE inhibitors do not pose additional risk with COVID-19.” Earlier this year, the AHA, Heart Failure Society of America and American College of Cardiology issued a joint statement calling for the continuation of ACE inhibitors and angiotensin receptor blockers during the COVID-19 pandemic in patients prescribed these medications for HF, hypertension and/or ischemic heart disease, and recommended that patients with COVID-19 should be fully evaluated before any treatment changes.

Echocardiography Abnormal Findings and Laboratory Operations during the COVID-19 Pandemic at a High Volume Center in New York City

Healthcare, December 3, 2020

This study sought to explore how the novel coronavirus (COVID-19) pandemic affected the echocardiography (TTE) laboratory operations at a high volume medical center in New York City. Changes in cardiac imaging study volume, turn-around time, and abnormal findings were analyzed and compared to a pre-pandemic period. Volume of all cardiac imaging studies and TTE reports between 11 March 2020 to 5 May 2020 and the same calendar period in 2019 were retrospectively identified and compared. During the pandemic, our center experienced a 46.72% reduction in TTEs, 82.47% reduction in transesophageal echocardiograms, 83.16% reduction in stress echo, 70.32% reduction in nuclear tests, 46.25% reduction in calcium score, 73.91% reduction in coronary computed tomography angiography, and 87.23% reduction in cardiac magnetic resonance imaging. TTE findings were overall similar between 2020 and 2019 (all p ≥ 0.05), except for a significantly higher right ventricular systolic pressure in 2020 (39.8 ± 14.2 vs. 34.6 ± 11.2 mmHg, p = 0.012). Despite encountering an influx of critically ill patients, our hospital center experienced a reduction in the number of cardiac imaging studies, which likely represents a change in both patient mindset and physician management approach.

Reversible Myocardial Injury Associated With SARS-CoV-2 in an Infant

JACC: Case Reports, December 2, 2020

Coronavirus disease-2019 is caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) and has been associated with myocardial dysfunction and heart failure in adult patients. We report a case of reversible myocardial injury and heart failure in an infant with SARS-CoV-2 infection. A 2-month-old infant presented with an episode of choking and cyanosis after feeding. There was no history of fever, cough, upper respiratory tract infection symptoms, diarrhea, vomiting, or decreased oral intake prior to the initial presentation. On arrival of emergency medical service, the patient had a pulse but poor respiratory effort and was treated with oxygen and bag mask ventilation. A transthoracic echocardiogram on DOI 1 demonstrated severely depressed left ventricular (LV) systolic function (ejection fraction [EF] 30%), severe mitral regurgitation (MR), and normal right ventricular systolic function. The origins of the coronary arteries were normal. There were no other cardiac abnormalities or pericardial effusion. Multiplex viral panel polymerase chain reaction to rule out other viral etiologies for acute myocarditis was negative. Acute myocardial injury as an atypical presentation of SARS-CoV-2 infection is currently being recognized in the adult population. Our case highlights the potential for myocardial involvement in infants with SARSCoV-2 infection.

Challenges in activation of remote monitoring in patients with cardiac rhythm devices during the coronavirus (COVID-19) pandemic

International Journal of Cardiology, December 1, 2020

Remote monitoring (RM) technology embedded in cardiac rhythm devices permits continuous monitoring of device function, and recording of selected cardiac physiological parameters and cardiac arrhythmias and may be of utmost utility during Coronavirus (COVID-19) pandemic, when in-person office visit for regular follow-up were postponed. However, patients not alredy followed-up via RM represent a challenging group of patients to be managed during the lockdown. We reviewed patient files scheduled for an outpatient visit between January 1, 2020 and May 11th, 2020 to assess the proportion of patients in whom RM activation was possible without office visit, and compared them to those scheduled for visit before the lockdown. During COVID-19 pandemic, RM activation was feasible in a minority of patients (7.8% of patients) expected at outpatient clinic for a follow-up visit and device check-up. This was possible in a good proportion of complex implantable devices such as cardiac resynchronization therapy and implantable cardioverter defibrillator but only in 3 patients with a pacemaker the RM function could be activated during the period of restricted access to hospital. Our experience strongly suggest to consider the systematic activation of RM function at the time of implantation or – by default programming – in all cardiac rhythm management devices.

A Survey-based Estimate of COVID-19 Incidence and Outcomes among Patients with Pulmonary Arterial Hypertension or Chronic Thromboembolic Pulmonary Hypertension and Impact on the Process of Care

Annals of the American Thoracic Society, December 1, 2020

Patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) typically undergo frequent clinical evaluation. The incidence and outcomes of coronavirus disease (COVID-19) and its impact on routine management for patients with pulmonary vascular disease is currently unknown. Our objective was to assess the cumulative incidence and outcomes of recognized COVID-19 for patients with PAH/CTEPH followed at accredited pulmonary hypertension centers, and to evaluate the pandemic’s impact on clinic operations at these centers. A survey was e-mailed to program directors of centers accredited by the Pulmonary Hypertension Association. Seventy-seven center directors were successfully e-mailed a survey, and 58 responded (75%). The cumulative incidence of COVID-19 recognized in individuals with PAH/CTEPH was 2.9 cases per 1,000 patients, similar to the general U.S. population. In patients with PAH/CTEPH for whom COVID-19 was recognized, 30% were hospitalized and 12% died. These outcomes appear worse than the general population. A large impact on clinic operations was observed including fewer clinic visits and substantially increased use of telehealth. A majority of centers curtailed diagnostic testing and a minority limited new starts of medical therapy. Most centers did not use experimental therapies in patients with PAH/CTEPH diagnosed with COVID-19. The cumulative incidence of COVID-19 recognized in patients with PAH/CTEPH appears similar to the broader population, although outcomes may be worse. Although the total number of patients with PAH/CTEPH recognized to have COVID-19 was small, the impact of COVID-19 on broader clinic operations, testing, and treatment was substantial.

Breaking pandemic chain reactions: telehealth psychosocial support in cardiovascular disease during COVID-19

European Journal of Cardiovascular Nursing, December 1, 2020

[Editorial: This editorial refers to ‘Delivering healthcare remotely to cardiovascular patients during COVID-19: A rapid review of the evidence’, by L. Neubeck et al.] Can one pandemic intensify the existence of another? The outlook for patients with cardiovascular disease (CVD) during COVID-19 is grim. Evidence indicates a relationship exists between COVID-19 and the onset or exacerbation of heart disease; two conditions are categorized as pandemics by the World Health Organization. Pre-diagnosed CVD increases the risk of death from COVID-19 by almost 70% following acute myocardial injury and patient behaviours are compounding this risk. Initially, patients were not presenting to the hospital, and activity in cardiology units decreased anywhere from 50% to 80%. ‘Time is heart’ and time from symptom onset to first medical contact has in some instances quadrupled since late January 2020. In the context of healthcare systems being pushed to their limits in countries with adequate infrastructure and unimaginable outcomes in countries without it, our response to the array of existing and rebound cardiovascular conditions is crucial. As a global society, how do we begin to address or even consider preventing pandemic chain reactions?

Takotsubo Syndrome: Cardiotoxic Stress in the COVID Era

Mayo Clinic Proceedings: Innovations, Quality & Outcomes, November 30, 2020

Takotsubo syndrome (TTS), also known as stress cardiomyopathy and broken heart syndrome, is a neurocardiac condition that is among the most dramatic manifestations of psychosomatic disorders. This paper is based on a systematic review of TTS and stress cardiomyopathy using a PubMed literature search. Typically, an episode of severe emotional or physical stress precipitates regions of left ventricular hypokinesis or akinesis, which are not aligned with a coronary artery distribution and are out of proportion to the modest troponin leak. A classic patient with TTS is described; one who had chest pain and dyspnea while watching an anxiety-provoking evening news program on the coronavirus disease 2019 (COVID-19) pandemic. An increase in the incidence of TTS appears to be a consequence of the COVID-19 pandemic, with the TTS incidence rising 4.5-fold during the COVID-19 pandemic even in individuals without severe acute respiratory syndrome coronavirus 2 infection. Takotsubo syndrome is often mistaken for acute coronary syndrome because they both typically present with chest pain, electrocardiographic changes suggesting myocardial injury/ischemia, and troponin elevations. Recent studies report that the prognosis for TTS is similar to that for acute myocardial infarction. This review is an update on the mechanisms underlying TTS, its diagnosis, and its optimal management.

The coronavirus disease 2019 proves transformability of the cardiac surgery specialty

European Journal of Cardio-Thoracic Surgery, November 30, 2020

[Letter to the Editor] Forced by the implications of the coronavirus disease 2019 (COVID-19) crisis, the staff at the New York Presbyterian Hospital managed to rearrange their system of healthcare delivery to improve conditions to deal with the crisis. They showed what potential for evolvement lies underneath the surface in a time of need. Even though this transformation came with an economic burden due to the loss of elective cases, this is an impressive development that shall serve as an example of transformation capacity within our specialty. One area that could profit from a change in perception as shown in the COVID-19 crisis is global cardiac surgery. In 2018, the ‘Cape Town Declaration on Access to Cardiac Surgery in the Developing World’ encouraged commitment to increase the access to cardiac surgery. Cardiac surgery aims to facilitate a better and healthier world. Social components are a threat to this aim generated by inequality. There is an estimated financial benefit of $12 trillion for low- and middle-income countries based on an investment of $350 billion over 15 years. This includes the fight against burdens of society such as rheumatic heart diseases, which can affect over 80% of the world’s population. COVID-19 proved the importance of global health in all parts of medicine and society. Therefore, we should take it as a trigger to deal with global health issues in a world where 93% still lack cardiac surgical care. Hopefully, the ability of transformation prompted by the COVID-19 crisis as shown by George et al. will affect new aspects of our global cardiac community.

What Happened to Electrocardiogram as a Screening Test to Recognize Cardiovascular Complications in COVID-19 Patients?

Journal of the American College of Cardiology, November 30, 2020

[Letter to the Editor] We read with great interest the paper from Lala et al. The authors must be congratulated for focusing attention on the clinical relevance of troponin I as a marker of myocardial injury in patients with coronavirus disease 2019 (COVID-19) and on the strong prognostic implications of this simple and easily available biomarker. Unfortunately, troponin is a generic marker of myocardial damage and cannot provide any valuable insight into the pathophysiological mechanism of the damage. We believe that this limitation could have been partly resolved by the systematic evaluation of standard electrocardiogram (ECG). Paradoxically and unexpectedly, 5 months after the beginning of the “COVID-19 era,” data on standard ECG as a screening tool for cardiovascular complications are almost completely missing in the literature—1 recently published and 1 in-press paper—whereas ECG details are available only for selected patients diagnosed with myocarditis or acute coronary syndrome. The extreme lack of ECG data is all the stranger considering it is a broadly available, low-cost diagnostic test that can be quickly performed without exposing a large number of personnel to the virus. This ECG eclipse has contributed to generate the misconception that “myocardial injury” diagnosed by elevated serum troponin is synonymous with myocarditis or acute coronary syndrome, neglecting the fact, for instance, that acute pressure overload of the right ventricle can also cause an increase of this biomarker. Indeed, compared to troponin, ECG can provide not only a generic diagnosis of myocardial injury or damage but can also orient to the specific pathophysiological mechanism and foster suspicion of pulmonary thromboembolic or in situ thrombosis of the pulmonary circulation, which are being described with increasing frequency.

COVID-19 with Cardiovascular Disease: Can It Help Predict Prognosis?

The Heart Surgery Forum, November 30, 2020

Two recent articles both found that cardiovascular disease was the major comorbidity in patients with COVID-19. In a recent issue of The Lancet, Huang et al [2020] reported epidemiological, clinical, laboratory, and radiological characteristics of 41 patients with COVID-19, treatments, and clinical outcomes. Some of the infected patients had cardiovascular disease (CVD) (n = 12; 29.3%). The authors found that CVD was the most common comorbidity of patients with COVID-19 in their research. Similarly, in a recent study published in the British Medical Journal, Chen et al [2019] analyzed deceased (n = 113) and recovered (n = 161) patients with COVID-19 pneumonia among 799 symptomatic patients. The authors found that CVD was more frequent in deceased patients (n = 70; 61.9%) than recovered patients (n = 46; 28.6%). More deceased patients (n = 50; 44.2%) had arterial pressure ≥140 mmHg than recovered patients (n = 33; 20.5%). Inflammation of the cardiovascular system and hypoxemia in patients with COVID-19 are the important causes of cardiovascular system dysfunction. Through detailed analyses of the cardiovascular system, clinicians may identify specific patterns of cardiovascular abnormalities. If such a model can been established, the prognosis of COVID-19 patients with cardiovascular disease may be predicted. Judging the prognosis of patients can help clinicians formulate detailed clinical observations and effective treatment methods to improve the cure rate and reduce the mortality rate of patients with COVID-19.

Right ventricular-arterial uncoupling independently predicts survival in COVID-19 ARDS

Critical Care, November 30, 2020

Our aim was to investigate the prevalence and prognostic impact of right heart failure and right ventricular-arterial uncoupling in Corona Virus Infectious Disease 2019 (COVID-19) complicated by an Acute Respiratory Distress Syndrome (ARDS). Ninety-four consecutive patients (mean age 64 years) admitted for acute respiratory failure on COVID-19 were enrolled. Coupling of right ventricular function to the pulmonary circulation was evaluated by a comprehensive trans-thoracic echocardiography with focus on the tricuspid annular plane systolic excursion (TAPSE) to systolic pulmonary artery pressure (PASP) ratio. The majority of patients needed ventilatory support, which was noninvasive in 22 and invasive in 37. There were 25 deaths, all in the invasively ventilated patients. Survivors were younger (62 ± 13 vs. 68 ± 12 years, p = 0.033), less often overweight or usual smokers, had lower NT-proBNP and interleukin-6, and higher arterial partial pressure of oxygen (PaO2)/fraction of inspired O2 (FIO2) ratio (270 ± 104 vs. 117 ± 57 mmHg, p < 0.001). In the non-survivors, PASP was increased (42 ± 12 vs. 30 ± 7 mmHg, p < 0.001), while TAPSE was decreased (19 ± 4 vs. 25 ± 4 mm, p < 0.001). Accordingly, the TAPSE/PASP ratio was lower than in the survivors (0.51 ± 0.22 vs. 0.89 ± 0.29 mm/mmHg, p < 0.001). At univariate/multivariable analysis, the TAPSE/PASP (HR: 0.026; 95%CI 0.01–0.579; p: 0.019) and PaO2/FIO2 (HR: 0.988; 95%CI 0.988–0.998; p: 0.018) ratios were the only independent predictors of mortality, with ROC-determined cutoff values of 159 mmHg and 0.635 mm/mmHg, respectively. COVID-19 ARDS is associated with clinically relevant uncoupling of right ventricular function from the pulmonary circulation; bedside echocardiography of TAPSE/PASP adds to the prognostic relevance of PaO2/FIO2 in ARDS on COVID-19.

COVID-19 vaccine developed by Moderna, NIH gets FDA review date

Helio | Infectious Disease News, November 30, 2020

The FDA’s vaccine advisory committee will meet on Dec. 17 to review an emergency use authorization (EUA) request for the COVID-19 vaccine candidate codeveloped by Moderna and the NIH, Moderna announced. It will be the second such meeting in 8 days of the FDA’s Vaccines and Related Biological Products Advisory Committee (VRBPAC), which will review an EUA request filed by Pfizer and BioNTech for their COVID-19 vaccine candidate on Dec. 10. Moderna announced the VRBPAC date at the same time it reported that preliminary data from a primary efficacy analysis showed its messenger RNA (mRNA)-based vaccine, mRNA-1273, was 94.1% efficacious overall and 100% efficacious against severe COVID-19, with no serious safety concerns identified to date. According to a press release, the phase 3 COVE study exceeded the 2-month median follow-up following vaccination required for an EUA submission, which Moderna said it was filing Monday. “We believe that our vaccine will provide a new and powerful tool that may change the course of this pandemic and help prevent severe disease, hospitalizations and death,” Moderna CEO Stéphane Bancel said in the press release. “I want to thank the thousands of participants in our phase 1, phase 2 and phase 3 studies, as well as the staff at clinical trial sites who have been on the front lines of the fight against the virus.”

The endothelium as Achilles’ heel in COVID-19 patients

Cardiovascular Research, November 27, 2020

The COVID-19 pandemic undoubtedly influenced the focus of many scientific fields, including cardiovascular research, and is still a global challenge for healthcare systems. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) predominantly affects the respiratory tract, and in severe cases, also other organs, including the liver, kidney, heart, and intestine. The leading cause of mortality in patients with COVID-19 is a hypoxic respiratory failure caused by acute respiratory distress syndrome (ARDS). It is well established that SARS-CoV-2 hijacks angiotensin-converting enzyme 2 (ACE2) receptors to infect host cells. ACE2 receptors are widely expressed in various tissues, suggesting the broad clinical consequences of SARS-CoV-2 infection that make COVID-19 a multiorgan disease. Endothelial cells have recently been implicated as the primary cell type involved in the initiation and propagation of ARDS caused by SARS-CoV-2, resulting in severe endothelial injury and widespread thrombosis. In fact, the first reports from Wuhan, China reported an increase in D-dimers (reporting thrombosis and/or disseminated intravascular coagulation) as a very early biomarker predicting an adverse outcome in COVID-19 patients, even preceding elevations of troponin or interleukin-6. Accordingly, patients with pre-existing conditions such as hypertension, obesity, and diabetes, which are all associated with endothelial dysfunction, are more susceptible to an adverse course of COVID-19. While the exact mechanisms are incompletely resolved, SARS-CoV-2 impinging on endothelial cell function has evolved as a key unifying candidate.

Cardiac Troponin Testing in Patients with COVID-19: A Strategy for Testing and Reporting Results

Clinical Chemistry, November 25, 2020

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged late in 2019 causing COVID-19 (coronavirus disease-2019) may adversely affect the cardiovascular system. Publications from Asia, Europe, and North America have identified cardiac troponin as an important prognostic indicator for patients hospitalized with COVID-19. We recognized from publications within the first 6 months of the pandemic that there has been much uncertainty on the reporting, interpretation, and pathophysiology of an increased cardiac troponin concentration in this setting. The purpose of this mini-review is: a) to review the pathophysiology of SARS-CoV-2 and the cardiovascular system, b) to overview the strengths and weaknesses of selected studies evaluating cardiac troponin in patients with COVID-19, and c) to recommend testing strategies in the acute period, in the convalescence period and in long-term care for patients who have become ill with COVID-19. This review provides important educational information and identifies gaps in understanding the role of cardiac troponin and COVID-19. Future, properly designed studies will hopefully provide the much-needed evidence on the path forward in testing cardiac troponin in patients with COVID-19.

Testing IgG antibodies against the RBD of SARS-CoV-2 is sufficient and necessary for COVID-19 diagnosis

PLOS ONE, November 23, 2020

The COVID-19 pandemic and the fast global spread of the disease resulted in unprecedented decline in world trade and travel. A critical priority is, therefore, to quickly develop serological diagnostic capacity and identify individuals with past exposure to SARS-CoV-2. In this study serum samples obtained from 309 persons infected by SARS-CoV-2 and 324 of healthy, uninfected individuals as well as serum from 7 COVID-19 patients with 4–7 samples each ranging between 1–92 days post first positive PCR were tested by an “in house” ELISA which detects IgM, IgA and IgG antibodies against the receptor binding domain (RBD) of SARS-CoV-2. Sensitivity of 47%, 80% and 88% and specificity of 100%, 98% and 98% in detection of IgM, IgA and IgG antibodies, respectively, were observed. IgG antibody levels against the RBD were demonstrated to be up regulated between 1–7 days after COVID-19 detection, earlier than both IgM and IgA antibodies. Study of the antibody kinetics of seven COVID 19 patients revealed that while IgG levels are high and maintained for at least 3 months, IgM and IgA levels decline after a 35–50 days following infection. Altogether, these results highlight the usefulness of the RBD based ELISA, which is both easy and cheap to prepare, to identify COVID-19 patients even at the acute phase. Most importantly, our results demonstrate that measuring IgG levels alone is both sufficient and necessary to diagnose past exposure to SARS-CoV-2.

CPR success, survival to discharge in out-of-hospital cardiac arrest dropped amid COVID-19

Helio | Cardiology Today, November 23, 2020

Rates of return of spontaneous circulation and survival to discharge for out-of-hospital cardiac arrest declined in the U.S. early during the COVID-19 pandemic compared with the previous year, researchers reported. These findings were consistent throughout the U.S, even in counties with low rates of COVID-19 deaths, according to the study presented at the virtual American Heart Association Scientific Sessions. “It [was] unclear what the effects of the COVID-19 pandemic on out-of-hospital cardiac arrest outcomes have been in communities that were not as severely affected, with low and moderate COVID-19 disease burden,” Paul Chan, MD, MSc, clinical scholar at Saint Luke’s Mid America Heart Institute and professor of medicine at the University of Missouri-Kansas City, said during his presentation. “Moreover, initial reports only reported on rates of sustained return of spontaneous circulation, and rates of overall rates of survival to discharge remained unknown.” The primary outcome was sustained return of spontaneous circulation for 20 minutes or more. Secondary outcomes included in-field termination of CPR, survival to discharge and incidence of out-of-hospital cardiac arrest.

The Potential Benefit of Beta-Blockers for the Management of COVID-19 Protocol Therapy-Induced QT Prolongation: A Literature Review

Scientia Pharmaceutica, November 23, 2020

The World Health Organization (WHO) officially announced coronavirus disease 2019 (COVID-19) as a pandemic in March 2020. Unfortunately, there are still no approved drugs for either the treatment or the prevention of COVID-19. Many studies have focused on repurposing established antimalarial therapies, especially those that showed prior efficacy against Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) and Middle East Respiratory Syndrome Coronavirus (MERS-CoV), such as chloroquine and hydroxychloroquine, against COVID-19 combined with azithromycin. These classes of drugs potentially induce prolongation of the QT interval, which might lead to lethal arrhythmia. Beta-blockers, as a β-adrenergic receptor (β-AR) antagonist, can prevent an increase in the sympathetic tone, which is the most important arrhythmia trigger. In this literature review, we aimed to find the effect of administering azithromycin, chloroquine, and hydroxychloroquine on cardiac rhythm disorders and our findings show that bisoprolol, as a cardio-selective beta-blocker, is effective for the management of the QT (i.e., the start of the Q wave to the end of the T wave) interval prolongation in COVID-19 patients.

Gov’t Prepares to Distribute Regeneron COVID-19 Drug

MedPage Today, November 23, 2020

Following the FDA’s weekend authorization of Regeneron’s monoclonal antibody cocktail for mild-moderate COVID-19, the federal government’s Operation Warp Speed (OWS) is swinging into action, officials said Monday. Department of Health and Human Services (HHS) Secretary Alex Azar said OWS would ship 30,000 doses on Tuesday — each eligible COVID-19 patient receives one dose — with thousands more to go out in the days ahead. On a phone call with reporters, he also reiterated the government’s promise that the drug would be provided to patients at no cost (Facilities may still charge for administration of the intravenous product, however). Regeneron’s CEO told CNBC on Monday that the company currently has 80,000 doses on hand and expects to ship 300,000 by early January, with 100,000 additional doses per month to come thereafter. Getting the product to patients is a major logistical challenge, officials explained, as has been the case with Eli Lilly’s bamlanivimab, another infusion therapy that received emergency authorization 2 weeks ago. Both drugs are to be used in non-hospitalized patients at risk for illness progression — meaning they are for outpatient administration. Because patients by definition have COVID-19, they need to be isolated, and sites must be prepared to provide infusions to large numbers of them given the current surge in cases.

Prevalence of Pulmonary Hypertension in Patients With Myeloproliferative Neoplasms

Pulmonology Advisor, November 23, 2020

Estimates of the prevalence of pulmonary hypertension (PH) as a complication of myeloproliferative neoplasms (MPNs) vary broadly, according to a systematic review and meta-analysis that was recently published in the European Journal of Haematology. PH is linked to a higher MPN disease burden and poorer survival, but little has been known about the prevalence and factors associated with PH in MPNs, according to the study investigators. The investigators performed searches of EMBASE, MEDLINE, and ClinicalTrials.gov databases for studies involving pulmonary hypertension, myeloproliferative disorders, polycythemia vera, essential thrombocytopenia, and/or myelofibrosis (MF) dated between 1999 and 2019. The goal was to assess the prevalence of, and risk factors associated with, PH in patients with MPNs, in addition to patient characteristics and outcomes. The searches identified 221 records, of which 17 reports met criteria for inclusion. Results for 935 patients were found, of whom 309 had PH. The prevalence of PH varied greatly across studies; PH prevalence was less than 5% in 3 studies, 11% to 14% in 3 studies, and greater than 36% in 7 studies. The prevalence of pulmonary hypertension could not be evaluated in analyses that only included patients with pulmonary hypertension, of those that were case control studies in which pulmonary hypertension was an exposure variable; therefore, 13 of the 17 reports were used as “prevalence sets” that investigated the factors that affected the prevalence of pulmonary hypertension at a study level.

Impact of the COVID-19-pandemic on thrombectomy services in Germany

Neurological Research and Practice, November 23, 2020

The outcome of patients with ischemic stroke and myocardial infarction depends on optimized pre- and intrahospital emergency workflows to minimize the time to reperfusion. The rapidly expanding Coronavirus Disease 2019 (COVID-19) pandemic has caused a reorganization of established workflows to limit spread of the disease. In addition, recent reports have also indicated that patients with acute stroke or myocardial infarction might resist or delay seeking help because of fear of COVID-19, raising concerns about worse outcomes of these conditions during the pandemic. Hence, monitoring of time-to-treatment intervals and disease outcomes during the pandemic is highly relevant for policymakers as it allows to assess and act upon the potential collateral effect of implemented COVID-19-related algorithms in the emergency sector. Here, we aimed to analyze workflow time intervals and functional outcomes of LVO patients treated with endovascular thrombectomy (ET) during the COVID-19 pandemic in a large German cohort.

FDA authorizes emergency use of casirivimab, imdevimab for COVID-19

Helio | Primary Care, November 23, 2020

The FDA granted emergency use authorization for the monoclonal antibodies casirivimab and imdevimab to be administered together intravenously for the treatment of mild to moderate COVID-19. According to a press release, this EUA pertains to adults and children aged 12 years and older with positive SARS-CoV-2 viral test results who weigh 88 pounds or more and are at high risk for progressing to severe COVID-19. Adults aged older than 65 years who have certain chronic medical conditions may also receive the treatment. The authorization does not extend to patients who are hospitalized or require oxygen therapy due to COVID-19. According to the release, the EUA for casirivimab and imdevimab is based on a randomized, double-blind, placebo-controlled clinical trial of 799 nonhospitalized adults with mild to moderate COVID-19 symptoms. The FDA said the “most important evidence” to emerge from the trial was that only 3% of the monoclonal antibody recipients were hospitalized or visited an ED compared with 9% of those who received placebo. The agency also noted that viral load reduction in patients who were treated with casirivimab and imdevimab was larger compared with patients treated with placebo at day 7. The effects on viral load, reduction in hospitalizations and ED visits were similar in patients receiving either of the two casirivimab and imdevimab doses in the study.

Dosing of thromboprophylaxis and mortality in critically ill COVID-19 patients

Critical Care, November 23, 2020

A substantial proportion of critically ill COVID-19 patients develop thromboembolic complications, but it is unclear whether higher doses of thromboprophylaxis are associated with lower mortality rates. The purpose of the study was to evaluate the association between initial dosing strategy of thromboprophylaxis in critically ill COVID-19 patients and the risk of death, thromboembolism, and bleeding. In this retrospective study, all critically ill COVID-19 patients admitted to two intensive care units in March and April 2020 were eligible. Patients were categorized into three groups according to initial daily dose of thromboprophylaxis. Thromboprophylaxis dosage was based on local standardized recommendations, not on degree of critical illness or risk of thrombosis. Multivariable models were adjusted for sex, age, body mass index, Simplified Acute Physiology Score III, invasive respiratory support, and initial dosing strategy of thromboprophylaxis. A total of 152 patients were included: 67 received low-, 48 medium-, and 37 high-dose thromboprophylaxis. Baseline characteristics did not differ between groups. For patients who received high-dose prophylaxis, mortality was lower (13.5%) compared to those who received medium dose (25.0%) or low dose (38.8%), p = 0.02. The hazard ratio of death was 0.33 (95% confidence intervals 0.13–0.87) among those who received high dose, and 0.88 (95% confidence intervals 0.43–1.83) among those who received medium dose, as compared to those who received low-dose thromboprophylaxis. There were fewer thromboembolic events in the high (2.7%) vs medium (18.8%) and low-dose thromboprophylaxis (17.9%) groups, p = 0.04.

Prevalence and prognostic value of elevated troponins in patients hospitalised for coronavirus disease 2019: a systematic review and meta-analysis

Journal of Intensive Care, November 23, 2020

The clinical significance of cardiac troponin measurement in patients hospitalised for coronavirus disease 2019 (covid-19) is uncertain. We investigated the prevalence of elevated troponins in these patients and its prognostic value for predicting mortality. Studies were identified by searching electronic databases and preprint servers. We included studies of hospitalised covid-19 patients that reported the frequency of troponin elevations above the upper reference limit and/or the association between troponins and mortality. Meta-analyses were performed using random-effects models. Fifty-one studies were included. Elevated troponins were found in 20.8% (95% confidence interval [CI] 16.8–25.0 %) of patients who received troponin test on hospital admission. Elevated troponins on admission were associated with a higher risk of subsequent death (risk ratio 2.68, 95% CI 2.08–3.46) after adjusting for confounders in multivariable analysis. The pooled sensitivity of elevated admission troponins for predicting death was 0.60 (95% CI 0.54–0.65), and the specificity was 0.83 (0.77–0.88). The post-test probability of death was about 42% for patients with elevated admission troponins and was about 9% for those with non-elevated troponins on admission. There was significant heterogeneity in the analyses, and many included studies were at risk of bias due to the lack of systematic troponin measurement and inadequate follow-up. Elevated troponins were relatively common in patients hospitalised for covid-19. Troponin measurement on admission might help in risk stratification, especially in identifying patients at high risk of death when troponin levels are elevated.

Risk and Severity of COVID-19 and ABO Blood Group in Transcatheter Aortic Valve Patients

Journal of Clinical Medicine, November 22, 2020

While cardiovascular disease has been associated with an increased risk of coronavirus disease 2019 (COVID-19), no studies have described its clinical course in patients with aortic stenosis who had undergone transcatheter aortic valve replacement (TAVR). Numerous observational studies have reported an association between the A blood group and an increased susceptibility to SARS-CoV-2 infection. Our objective was to investigate the frequency and clinical course of COVID-19 in a large sample of patients who had undergone TAVR and to determine the associations of the ABO blood group with disease occurrence and outcomes. Patients who had undergone TAVR between 2010 and 2019 were included in this study and followed-up through the recent COVID-19 outbreak. The occurrence and severity (hospitalization and/or death) of COVID-19 and their associations with the ABO blood group served as the main outcome measures. Of the 1125 patients who had undergone TAVR, 403 (36%) died before 1 January 2020, and 20 (1.8%) were lost to follow-up. The study sample therefore consisted of 702 patients. Of them, we identified 22 cases (3.1%) with COVID-19. Fourteen patients (63.6%) were hospitalized or died of disease. Multivariable analysis identified the A blood group (vs. others) as the only independent predictor of COVID-19 in patients who had undergone TAVR (odds ratio (OR) = 6.32; 95% confidence interval (CI) = 2.11−18.92; p = 0.001). The A blood group (vs. others; OR = 8.27; 95% CI = 1.83−37.43, p = 0.006) and a history of cancer (OR = 4.99; 95% CI = 1.64−15.27, p = 0.005) were significantly and independently associated with disease severity (hospitalization and/or death). We conclude that patients who have undergone TAVR frequently have a number of cardiovascular comorbidities that may work to increase the risk of COVID-19. The subgroup with the A blood group was especially prone to developing the disease and showed unfavorable outcomes.

ACE2 Interaction Networks in COVID-19: A Physiological Framework for Prediction of Outcome in Patients with Cardiovascular Risk Factors

Journal of Clinical Medicine, November 21, 2020

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (coronavirus disease 2019; COVID-19) is associated with adverse outcomes in patients with cardiovascular disease (CVD). The aim of the study was to characterize the interaction between SARS-CoV-2 and Angiotensin-Converting Enzyme 2 (ACE2) functional networks with a focus on CVD. Using the network medicine approach and publicly available datasets, we investigated ACE2 tissue expression and described ACE2 interaction networks that could be affected by SARS-CoV-2 infection in the heart, lungs and nervous system. We compared them with changes in ACE-2 networks following SARS-CoV-2 infection by analyzing public data of human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs). This analysis was performed using the Network by Relative Importance (NERI) algorithm, which integrates protein-protein interaction with co-expression networks. We also performed miRNA-target predictions to identify which miRNAs regulate ACE2-related networks and could play a role in the COVID19 outcome. Finally, we performed enrichment analysis for identifying the main COVID-19 risk groups. Results: We found similar ACE2 expression confidence levels in respiratory and cardiovascular systems, supporting that heart tissue is a potential target of SARS-CoV-2.

Possible Correlations between Atherosclerosis, Acute Coronary Syndromes and COVID-19

Journal of Clinical Medicine, November 21, 2020

An outbreak of SARS-CoV-2 infection in December 2019 became a major global concern in 2020. Since then, several articles analyzing the course, complications and mechanisms of the infection have appeared. However, there are very few papers explaining the possible correlations between COVID-19, atherosclerosis and acute coronary syndromes. We performed an analysis of PubMed, Cochrane, Google Scholar, and MEDLINE databases. As of September 15, 2020, the results were as follows: for “COVID-19” and “cardiovascular system” we obtained 687 results; for “COVID-19” and “myocardial infarction” together with “COVID-19” and “acute coronary syndrome” we obtained 328 results; for “COVID-19” and “atherosclerosis” we obtained 57 results. Some of them did not fulfill the search criteria or concerned the field of neurology. Only articles written in English, German and Polish were analyzed for a total number of 432 papers. While the link between inflammatory response, COVID- 19 and atherosclerosis still remains unclear, there is evidence that suggests a more likely correlation between them. Practitioners’ efforts should be focused on the prevention of excessive inflammatory response and possible complications, while there are limited specific therapeutic options against SARS-CoV-2. Furthermore, special attention should be paid to cardioprotection during the pandemic.

COVID-19 patient with coronary thrombosis supported with ECMO and Impella 5.0 ventricular assist device: a case report

European Heart Journal, November 20, 2020

COVID-19 can present with cardiovascular complications. We present a case report of a 43-year-old previously fit patient who suffered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection with thrombosis of the coronary arteries causing acute myocardial infarction. These were treated with coronary stenting during which the patient suffered cardiac arrest. He was supported with automated chest compressions followed by peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO). No immediate recovery of the myocardial function was observed and, after insufficient venting of the left ventricle was diagnosed, an Impella 5 pump was implanted. The cardiovascular function recovered sufficiently and ECMO was explanted and inotropic infusions discontinued. Due to SARS-CoV-2 pulmonary infection, hypoxia became resistant to conventional mechanical ventilation and the patient was nursed prone overnight. After initial recovery of respiratory function, the patient received a tracheostomy and was allowed to wake up. Following a short period of agitation his neurological function recovered completely. During the third week of recovery, progressive multisystem dysfunction, possibly related to COVID-19, developed into multiorgan failure, and the patient died. We believe that this is the first case report of coronary thrombosis related to COVID-19. Despite the negative outcome in this patient, we suggest that complex patients may in the future benefit from advanced cardiovascular support, and may even be nursed safely in the prone position with Impella devices.

Cardiovascular Manifestations of COVID-19 Infection

Cells, November 19, 2020

SARS-CoV-2 induced the novel coronavirus disease (COVID-19) outbreak, the most significant medical challenge in the last century. COVID-19 is associated with notable increases in morbidity and death worldwide. Preexisting conditions, like cardiovascular disease (CVD), diabetes, hypertension, and obesity, are correlated with higher severity and a significant increase in the fatality rate of COVID-19. COVID-19 induces multiple cardiovascular complexities, such as cardiac arrest, myocarditis, acute myocardial injury, stress-induced cardiomyopathy, cardiogenic shock, arrhythmias and, subsequently, heart failure (HF). The precise mechanisms of how SARS-CoV-2 may cause myocardial complications are not clearly understood. The proposed mechanisms of myocardial injury based on current knowledge are the direct viral entry of the virus and damage to the myocardium, systemic inflammation, hypoxia, cytokine storm, interferon-mediated immune response, and plaque destabilization. The virus enters the cell through the angiotensin-converting enzyme-2 (ACE2) receptor and plays a central function in the virus’s pathogenesis. A systematic understanding of cardiovascular effects of SARS-CoV2 is needed to develop novel therapeutic tools to target the virus-induced cardiac damage as a potential strategy to minimize permanent damage to the cardiovascular system and reduce the morbidity. In this review, we discuss our current understanding of COVID-19 mediated damage to the cardiovascular system.

Business of cardiology ‘severely disrupted’ by COVID-19 pandemic

Helio | Cardiology Today, November 19, 2020

The COVID-19 pandemic has disrupted our current way of life, comparable in magnitude perhaps to transformations that followed the Great Plague of the Middle Ages and the Spanish influenza pandemic of 1918-1920. The pandemic may well be one of the seminal events of the 21st century, prompting wide-ranging and long-lasting changes in the economy, public health policy and health care delivery. The business of medicine and cardiology has been severely disrupted by the COVID-19 pandemic. Just as the rest of society adjusts to the economic and human ramifications of this crisis, we cardiologists will also change our practice operations to accommodate the new environment. The pandemic has forced society and the medical community to acknowledge the many inefficiencies and inequities in our current systems of health care delivery, not only as directly related to caring for patients infected with SARS-CoV-2, but also to make the fundamental, systemic changes needed to deliver effective, high-value care to all of our patients, finally honoring our society’s promise of health care as a basic human right. Changes is practice, use of telehealth and compensation/financial issues are all discussed.

COVID’s Heart Complications Modest in Large Registry

MedPage Today, November 18, 2020

The first results emerging from the American Heart Association (AHA) COVID-19 registry showed fewer cardiovascular complications than expected from some series, but reemphasized the higher risk with obesity and among minorities. Multiple analyses of the more than 22,500-patient database were presented at a press conference at the virtual AHA meeting by James de Lemos, MD, of UT Southwestern Medical Center in Dallas, on behalf of the researchers. The 109 participating hospitals and medical centers retrospectively abstracted all consecutive adults hospitalized with COVID-19 into the registry, which piggybacks on the Get With the Guidelines quality improvement program. In-hospital cardiac complications overall were “somewhat less common than we thought they would be when we launched the registry” in April, with just over an 8% composite rate of CV death, MI, stroke, heart failure, and shock across the January 1 to July 22 period studied, de Lemos said. The most common such event was atrial fibrillation, reported in about 8% of patients. In their analysis of 7,606 patients with BMI data, in-hospital death or mechanical ventilation was a relative 28% more likely with class I obesity, 57% more likely with class II obesity, and 80% more likely with class III obesity, which also correlated with a 26% higher likelihood of in-hospital death. Of the 7,868 patients with completed race or ethnicity data, Black and Hispanic people were overrepresented among COVID-19 cases and deaths compared with local census data for their zip code. Black people represented 25.5% of cases and 24% of deaths vs 10.6% in the census, while Hispanic people comprised 33.0% of cases and 29% of deaths vs 9.0% of the census.

Factors associated with disease severity and mortality among patients with COVID-19: A systematic review and meta-analysis

PLOS ONE, November 18, 2020

Understanding the factors associated with disease severity and mortality in Coronavirus disease (COVID-19) is imperative to effectively triage patients. We performed a systematic review to determine the demographic, clinical, laboratory and radiological factors associated with severity and mortality in COVID-19. We searched PubMed, Embase and WHO database for English language articles from inception until May 8, 2020. We included Observational studies with direct comparison of clinical characteristics between a) patients who died and those who survived or b) patients with severe disease and those without severe disease. Data extraction and quality assessment were performed by two authors independently. Among 15680 articles from the literature search, 109 articles were included in the analysis. The risk of mortality was higher in patients with increasing age, male gender (RR 1.45, 95%CI 1.23–1.71), dyspnea (RR 2.55, 95%CI 1.88–2.46), diabetes (RR 1.59, 95%CI 1.41–1.78), hypertension (RR 1.90, 95%CI 1.69–2.15). Congestive heart failure (OR 4.76, 95%CI 1.34–16.97), hilar lymphadenopathy (OR 8.34, 95%CI 2.57–27.08), bilateral lung involvement (OR 4.86, 95%CI 3.19–7.39) and reticular pattern (OR 5.54, 95%CI 1.24–24.67) were associated with severe disease. Clinically relevant cut-offs for leukocytosis (>10.0 x109/L), lymphopenia (< 1.1 x109/L), elevated C-reactive protein (>100mg/L), LDH (>250U/L) and D-dimer (>1mg/L) had higher odds of severe disease and greater risk of mortality.

Hypertension, diabetes ‘common’ in patients with neurological complications of COVID-19

Helio | Primary Care, November 18, 2020

Among patients with COVID-19, those who had hypertension or type 2 diabetes were more likely to develop neurological conditions associated with the infectious disease, data from a small study show. “We recommend that physicians include a neurological exam as part of their patients’ physical exams and consider the complications described in patients with COVID-19,” Colbey W. Freeman, MD, chief resident in the department of radiology at Penn Medicine in Philadelphia, told Healio Primary Care. Freeman and colleagues analyzed head images from 81 patients (mean age, 66.3 years; 36 women) within a tertiary health system who tested positive for SARS-CoV-2. The patients’ demographic, comorbidity information, laboratory values and neuroimaging findings from CTs and/or MRIs were also recorded. According to the researchers, 18 of the patients’ (mean age, 60.5 years; nine women, 12 Black) laboratory values and neuroimaging results showed what researchers deemed “critical” findings: 12 had acute/subacute infarct; four had large vessel intracranial occlusion; three had subarachnoid and intraparenchymal hemorrhage; and one had hypoxic-ischemic encephalopathy.

The right ventricle in COVID-19 patients: A forgotten essential chamber that may be involved in the cardiac complications of COVID-19

European Heart Journal, November 18, 2020

The right ventricle seems to have been forgotten among heart chambers, although some studies have shown its crucial role in coronavirus disease 2019 (COVID-19). Interestingly, both its size and function are believed to be associated with cardiac complications and mortality in COVID-19. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which spread globally after the first case was observed in Wuhan at the end of 2019. Recent studies suggested that COVID-19 may be accompanied by cardiac complications, including acute coronary syndrome, cardiac arrhythmia, myocarditis, pericarditis, and heart failure in nearly 20% of patients, which are associated with an increased risk of mortality. Laboratory data such as cardiac troponin as well as echocardiography parameters can be effective means of cardiac assessment in these patients. Transthoracic echocardiography (TTE) is the optimum method of cardiac imaging used in COVID-19 patients, which is able to diagnose different cardiac abnormalities including haemodynamic dysfunction. Also, it is useful for the prediction of future cardiac morbidity in these patients. Reduced right ventricular (RV) activity is a good predictor for heart failure and cardiac mortality. The effect of COVID-19 on the right ventricle activity is in the main unknown. It seems that the pathophysiological pathways of COVID-19 including increased afterload after acute respiratory distress syndrome, pulmonary embolism, cytokine-negative inotropic effects, and renin–angiotensin system dysfunction are possible mechanisms for RV dysfunction in COVID-19 patients.

Highlights from the American Heart Virtual Scientific Sessions

JAMA Medical News, November 18, 2020

[Podcast, 38:09] From the American Heart Association’s first-ever virtual Scientific Sessions conference, host Jennifer Abbasi chats with conference chair and AHA president-elect Donald Lloyd-Jones, MD, ScM. Hear about this year’s hottest clinical trials and themes: fish oil vs corn oil placebo for primary or secondary prevention; Polycap polypill with or without aspirin for primary prevention; statins, side effects, and the nocebo effect; ferric carboxymaltose iron infusion in acute heart failure; omecamtiv mecarbil, a novel cardiac myosin activator, in HFrEF; sotagliflozin, an SGLT2/1 inhibitor, in diabetes with recent worsening heart failure or in diabetes and chronic kidney disease; MINOCA’s underlying cause in women; rilonacept, an IL-1α and IL-1β Trap, in recurrent pericarditis; COVID-19’s cardiovascular effects, risk factors, and racial/ethnic disparities.

T Cells May Tell Us More About COVID Immunity

MedPage Today, November 18, 2020

While antibodies have been the focus of testing for past infection with COVID-19, T cells will also provide some insights — potentially better ones, experts say. These lymphocytes are the first responders that then coordinate the immune response while building an imprint, a memory, so that subsequent infections fade quickly, often unnoticed. T cell tests are more complex and typically reserved for research, but some may be coming to the clinic soon, with at least one company seeking FDA emergency use authorization (EUA). Recent studies indicate that assaying T cells can even improve diagnostic accuracy and possibly predict how COVID-19 will unfold. “Testing T cell responses can accelerate detection of an infection by as much as a week. The cells come in on day 2 and they divide very quickly, to detectable levels as early as 3 or 4 days from infection,” said Dawn Jelley-Gibbs, PhD, who investigated T cells in influenza at the Trudeau Institute in Saranac Lake, New York. The good news is that in COVID-19, T cells appear a day or two after symptoms start, bind the virus at several sites, and persist – so far. “Since we did not observe a substantial decline during the follow-up, we assume that the memory CD8 T cell response remains sustained for a longer period, more than a year. But only longitudinal studies over a long time will prove this assumption right or wrong,” said corresponding author Christoph Neumann-Haefelin, MD.

Meta-analysis Comparing Outcomes in Patients With and Without Cardiac Injury and Coronavirus Disease 2019 (COVID 19)

American Journal of Cardiology, November 17, 2020

Current evidence is limited to small studies describing the association between cardiac injury and outcomes in patients with COVID-19. To address this, we performed a comprehensive meta-analysis of studies in COVID-19 patients to evaluate the association between cardiac injury and all-cause mortality, intensive care unit (ICU) admission, mechanical ventilation, acute respiratory distress syndrome (ARDS), acute kidney injury (AKI) and coagulopathy. Further, studies comparing cardiac biomarker levels in survivors versus non-survivors were included. A total of 14 studies (3175 patients) were utilized for the final analysis. Cardiac 2 injury in patients with COVID-19 was associated with higher risk of mortality [RR:7.79 ; 95%CI: 4.69-13.01; I2 =58%], ICU admission [RR: 4.06; 95% CI: 1.50-10.97; I2 =61%], mechanical ventilation [RR: 5.53; 95% CI: 3.09-9.91; I2 =0%], and developing coagulopathy [RR: 3.86 ; 95% CI:2.81-5.32; I2 =0%]. However, cardiac injury was not associated with increased risk of ARDS [RR:3.22; 95% CI:0.72-14.47; I2 =73%] or AKI [RR:11.52, 95% CI:0.03-4159.80; I2 =0%]. The levels of hs-cTnI [MD:34.54 pg/ml; 95% CI: 24.67- 44.40 pg/ml; I2 =88%], myoglobin [MD:186.81 ng/ml; 95% CI: 121.52-252.10 ng/ml; I2 =88%], NT-pro BNP [MD:1183.55 pg/ml; 95% CI: 520.19-1846.91 pg/ml: I2 =96%] and CK-MB [MD:2.49 ng/ml; 95% CI: 1.86-3.12 ng/ml; I2 =90%], were significantly elevated in nonsurvivors compared with survivors with COVID-19 infection. The results of this meta-analysis suggest that cardiac injury is associated with higher mortality, ICU admission, mechanical ventilation and coagulopathy in patients with COVID-19.

Prognostic Impact of Prior Heart Failure in Patients Hospitalized With COVID-19

Journal of the American College of Cardiology, November 17, 2020

Patients with pre-existing heart failure (HF) are likely at higher risk for adverse outcomes in coronavirus disease-2019 (COVID-19), but data on this population are sparse. OBJECTIVES This study described the clinical profile and associated outcomes among patients with HF hospitalized with COVID-19. This study conducted a retrospective analysis of 6,439 patients admitted for COVID-19 at 1 of 5 Mount Sinai Health System hospitals in New York City between February 27 and June 26, 2020. Clinical characteristics and outcomes (length of stay, need for intensive care unit, mechanical ventilation, and in-hospital mortality) were captured from electronic health records. For patients identified as having a history of HF by International Classification of Diseases-9th and/or 10th Revisions codes, manual chart abstraction informed etiology, functional class, and left ventricular ejection fraction (LVEF). Mean age was 63.5 years, and 45% were women. Compared with patients without HF, those with previous HF experienced longer length of stay (8 days vs. 6 days; p < 0.001), increased risk of mechanical ventilation (22.8% vs. 11.9%; adjusted odds ratio: 3.64; 95% confidence interval: 2.56 to 5.16; p < 0.001), and mortality (40.0% vs. 24.9%; adjusted odds ratio: 1.88; 95% confidence interval: 1.27 to 2.78; p ¼ 0.002). Outcomes among patients with HF were similar, regardless of LVEF or renin-angiotensin-aldosterone inhibitor use.

Response to: How important is the assessment of soluble ACE-2 in COVID-19?

American Journal of Hypertension, November 17, 2020

The role of angiotensin converting enzyme 2 (ACE2) in coronavirus disease 2019 (COVID19) is matter of debate, because severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) utilizes ACE2 on host cells as its entry receptor. We recently reported that activity of the renin-angiotensin-aldosterone system and expression of ACE2 were not changed in patients with non-severe COVID-19 as compared to SARS-CoV-2 negative control subjects with similar symptoms. Rojas and collaborators expand this view and demonstrate that ACE2 expression is likewise unaltered in patients with more severe COVID-19 (sequential organ failure assessment score 2.043; 4C mortality score 6.174) as compared to recovered COVID-19 patients or a historic control group.3 Noteworthy, the authors found no correlation of ACE2 levels and viral load. ACE2 is a peptidase that mediates the breakdown of angiotensin II. The full-length form of ACE2 contains an extracellular catalytic domain, a structural transmembrane domain, and a small intracellular C-terminal domain. After binding of SARS-CoV-2 to the extracellular domain of membrane-bound ACE2, the virus/protein complex is internalized by the host cell. Accordingly, the affection of multiple organs in COVID-19 might be explained by the wide expression of ACE2 in different tissues, including lung, heart, kidney, or intestine. In contrast, the soluble form of ACE2 may bind SARS-CoV-2, but is not internalized due to the lack of the transmembrane domain.

Impact of COVID-19 Pandemic on Mechanical Reperfusion for Patients With STEMI

Journal of the American College of Cardiology, November 17, 2020

The fear of contagion during the coronavirus disease-2019 (COVID-19) pandemic may have potentially refrained patients with ST-segment elevation myocardial infarction (STEMI) from accessing the emergency system, with subsequent impact on mortality. The ISACS-STEMI COVID-19 registry aims to estimate the true impact of the COVID-19 pandemic on the treatment and outcome of patients with STEMI treated by primary percutaneous coronary intervention (PPCI), with identification of “at-risk” patient cohorts for failure to present or delays to treatment. This retrospective registry was performed in European high-volume PPCI centers and assessed patients with STEMI treated with PPPCI in March/April 2019 and 2020. Main outcomes are the incidences of PPCI, delayed treatment, and in-hospital mortality. A total of 6,609 patients underwent PPCI in 77 centers, located in 18 countries. In 2020, during the pandemic, there was a significant reduction in PPCI as compared with 2019 (incidence rate ratio: 0.811; 95% confidence interval: 0.78 to 0.84; p < 0.0001). The heterogeneity among centers was not related to the incidence of death due to COVID-19. A significant interaction was observed for patients with arterial hypertension, who were less frequently admitted in 2020 than in 2019. Furthermore, the pandemic was associated with a significant increase in door-to-balloon and total ischemia times, which may have contributed to the higher mortality during the pandemic.

Cardiac catheterizations declined during COVID-19 surge at New York center

Helio | Cardiology Today, November 16, 2020

In a single-center analysis, cardiac catheterization procedures decreased during a 6-week period of the COVID-19 lockdown compared with the same span in 2019, researchers reported. However, outcomes not attributed to COVID-19 were no different during the lockdown compared with the year before at Montefiore Medical Center in Bronx, New York, according to the researchers. “We hypothesized that the COVID-19 pandemic postponed patients’ decision to seek hospital medical attention, leading to increased cardiovascular-related mortality and infrequent cardiovascular complications,” Cristina Sanina, MD, clinical fellow in cardiology at Montefiore Medical Center and Albert Einstein College of Medicine, said during a presentation at the virtual American Heart Association Scientific Sessions. Results showed a significant decrease in incidence of the outcomes of interest overall (P < .05) for the period in 2020. Cardiac catheterization procedures for non-STEMI decreased from 37 in 2019 to nine in 2020 (P = .002). “We treated a very small number of patients with non-STEMI in 2020,” Sanina said. Importantly, the mortality rates for non-STEMI were 0% in both 2019 and 2020. Similarly, 58 patients were treated with cardiac catheterization for congestive HF in 2019, whereas just 18 underwent this procedure in 2020 (P < .0001). “More patients were admitted in 2020 for systolic heart failure and not diastolic,” Sanina said. The mortality rate from HF in 2020 was 22%, according to Sanina. “It was an extremely high rate,” she said.

COVID-19 vaccine developed by Moderna, NIH is 94.5% effective, early data show

Helio | Infectious Disease News, November 16, 2020

An interim review of phase 3 data showed that a COVID-19 vaccine codeveloped by Moderna Inc. and the NIH had an efficacy rate of 94.5% with no significant safety concerns, Moderna said. The efficacy and safety data were reported by an NIH-appointed data safety monitoring board and were based on 95 cases of COVID-19, of which 90 occurred in the placebo group vs. five in the vaccine group. These included 11 cases of severe COVID-19 — all in the placebo group. The announcement was more good news for COVID-19 vaccine programs following Pfizer and BioNTech’s announcement last week that its mRNA vaccine candidate was shown to be more than 90% effective based on interim phase 3 data. “Since the vaccines are very, very similar, we can conclude that repeating the experiment led to the same outcome, which increases confidence,” Florian Krammer, PhD, a professor of vaccinology at the Icahn School of Medicine at Mount Sinai in New York, told Healio.

The second life of the ambiguous angiotensin-converting enzyme 2 as a predictive biomarker for cardiometabolic diseases and death

European Heart Journal, November 16, 2020

This nested case-cohort analysis from the multinational Prospective Urban Rural Epidemiology (PURE) study analyzed plasma levels of a component of the renin-angiotensin system (RAS), angiotensin-converting enzyme 2 (ACE2), as a predictor of cardiovascular (CV) events [CV mortality, myocardial infarction (MI), stroke, heart failure (HF)] and all-cause mortality. From a total population of 55 246 PURE participants from 14 countries across five continents, the authors took a random sample (the subcohort). The final sample consisted of participants who were members of the subcohort (n = 5084) and those who had incident events outside the subcohort (n = 5669). The median follow-up was 9.4 years (IQR, 8.7–10.5). The strongest determinants of ACE2 concentrations were sex, geographic ancestry, and body-mass index (BMI). When compared with CV risk factors (diabetes, BMI, smoking status, non-HDL cholesterol, and systolic blood pressure), plasma ACE2 was the highest-ranked predictor of all-cause mortality [hazard ratio (HR) 1.35 per 1 SD increase (95% confidence interval (CI) 1.29–1.43)], with similar HR values fort CV death (1.40 per 1 SD increase) and non-CV death (1.34 per 1 SD increase); the third-highest ranked predictor of MI, and the third-highest ranked predictor of both stroke and HF. Plasma ACE2 concentration was also associated with higher risk of diabetes [HR 1.44 per 1SD increase (95% CI 1.36–1.52)]. These results were confirmed after adjustment for clinical risk factors, age, sex, and ancestry.

Decreased admissions and change in arrival mode in patients with cerebrovascular events during the first surge of the COVID-19 pandemic

Neurological Research and Practice, November 16, 2020

[Letter to the Editor] Declining rates of admissions for cerebrovascular events (CVEs) and an impact on reperfusion therapy rates were observed during the first surge of the coronavirus disease 2019 (COVID-19) pandemic earlier this year. Given the current increase in the number of COVID-19 cases and an incipient second wave, it is paramount to take appropriate measures to prevent this particular aspect of recent history from repeating. Obtaining detailed demographic and clinical information of patients presenting with CVEs during the pandemic may provide valuable information to this end.We analyzed data of patients admitted for CVEs (transient ischemic attack (TIA), ischemic stroke, intracerebral hemorrhage) to the Department of Neurology, University Medical Centre Mannheim, Germany, in weeks 1–17/2020. Week 12/2020, when extended measures for social distancing were implemented, was designated as the beginning of the COVID-19 epoch. Poisson regression was used to test if the rate of admissions and reperfusion therapies for ischemic stroke changed as a function of year, epoch and year-by-epoch interaction (reflecting the impact of the pandemic). We found a significant reduction of the number of admissions due to a CVE during the COVID-19 epoch by 35.9% (rate ratio 0.64, 95% confidence interval (CI) 0.43–0.96, p = 0.005). During the observational period of 2019 and 2020, 115 and 69 CVE patients, respectively, presented. The number of reperfusion therapies decreased non-significantly by 27.8% (rate ratio 0.72, 95% CI 0.44–1.19, p = 0.20): 23 intravenous thrombolyses (IVT) were performed in 2019, 11 in the respective period in 2020. Mechanical thrombectomy (with/without IVT), was performed in 9 and 8 patients, respectively.

Large-Scale Plasma Analysis Revealed New Mechanisms and Molecules Associated with the Host Response to SARS-CoV-2

International Journal of Molecular Sciences, November 16, 2020

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread to nearly every continent, registering over 1,250,000 deaths worldwide. The effects of SARS-CoV-2 on host targets remains largely limited, hampering our understanding of Coronavirus Disease 2019 (COVID-19) pathogenesis and the development of therapeutic strategies. The present study used a comprehensive untargeted metabolomic and lipidomic approach to capture the host response to SARS-CoV-2 infection. We found that several circulating lipids acted as potential biomarkers, such as phosphatidylcholine 14:0_22:6 (area under the curve (AUC) = 0.96), phosphatidylcholine 16:1_22:6 (AUC = 0.97), and phosphatidylethanolamine 18:1_20:4 (AUC = 0.94). Furthermore, triglycerides and free fatty acids, especially arachidonic acid (AUC = 0.99) and oleic acid (AUC = 0.98), were well correlated to the severity of the disease. An untargeted analysis of non-critical COVID-19 patients identified a strong alteration of lipids and a perturbation of phenylalanine, tyrosine and tryptophan biosynthesis, phenylalanine metabolism, aminoacyl-tRNA degradation, arachidonic acid metabolism, and the tricarboxylic acid (TCA) cycle. The severity of the disease was characterized by the activation of gluconeogenesis and the metabolism of porphyrins, which play a crucial role in the progress of the infection. In addition, our study provided further evidence for considering phospholipase A2 (PLA2) activity as a potential key factor in the pathogenesis of COVID-19 and a possible therapeutic target.

Canakinumab fails to improve outcomes at 14 days in COVID-19, myocardial injury

Helio | Cardiology Today, November 15, 2020

In a new study, interleukin-1-beta inhibition with IV canakinumab in patients hospitalized with COVID-19, myocardial injury and elevated inflammation markers did not appear to improve clinical recovery at 14 days. However, there was a trend toward clinical improvement at 28 days among patients who received higher-dose canakinumab (Ilaris, Novartis) compared with placebo, according to results of the Three C trial presented at the virtual American Heart Association Scientific Sessions. “Although COVID-19 is predominantly a respiratory illness, cardiovascular complications result in substantial morbidity and mortality,” Paul Cremer, MD, cardiologist at Cleveland Clinic, said. “Myocardial injury [may] occur in as many as one-third of patients hospitalized with severe COVID-19 infection. Myocardial injury is also associated with higher mortality and an increased systemic inflammatory response … [which may] result in a so-called cytokine storm. In the cardiovascular system, the consequences are predominantly endothelial cell dysfunction with capillary leak, thrombosis and local tissue injury. Canakinumab is an anti-inflammatory drug. In the CANTOS trial, canakinumab was shown to reduce recurrent CV events in patients with prior MI and elevated C-reactive protein levels.

BP control, frequency of measurements minimally impacted during COVID-19 pandemic

Helio | Cardiology Today, November 14, 2020

The number of BP readings performed by adults in a home BP management program and overall BP control were not impacted during the COVID-19 pandemic compared with data from 2019, according to new reserch. “In a nationwide sample of patients enrolled in a home BP management program, contrary to my initial beliefs, we did not see huge changes in either the number of [BP] readings being done — not a huge increase or decrease — [and] that BP control was similar, or even slightly better, in the COVID-19 period, rather than pre-COVID-19,” Eric D. Peterson, MD, MPH, distinguished professor at the Duke Clinical Research Institute, said during a presentation at the virtual American Heart Association Scientific Sessions. Peterson and colleagues assessed how quarantines and lockdowns during the COVID-19 pandemic impacted home BP readings at both the individual patient and population levels and also compared BP levels during before and during the pandemic. “Beyond its direct effects on morbidity and mortality, COVID-19 has also reduced our patients’ ability to see us in clinic,” Peterson said. He noted that these indirect effects of the pandemic could have long-lasting consequences. “For example, if prevention of cardiovascular disease risk factors were to fall off, then there may be large downstream effects that will be seen for years to come.”

‘Corona’ versus ‘coronary’: The similarities and differences of CORONA virus and Coronary Artery Diseases are presented and discussed.

European Heart Journal, November 14, 2020

Both COVID-19 and CVD predominantly affect the elderly but can also occur in the young. Both are present worldwide. Both are the consequences of drastic cultural and social changes and ways of living. Both affect the whole society rather than a single individual but with a difference. COVID-19 is a communicable disease, and its outbreak requires immediate and drastic measures, such as a population lockdown along with all the related consequences including the economic crisis that will follow. This, of course, is immediately perceived by the whole society. The same is not true for CVD, which is perceived as a disease of a single person rather than a global problem although it is even a bigger global problem than COVID-19. Governments do not impose drastic measures to reduce the known causes of CVD. They simply suggest to patients how to prevent CVD. Paradoxically, measures to reduce risk factors for diabetes, obesity, and hypertension are less drastic than a lockdown and yet, would save significantly more lives! The question is: why? Why are people more worried about COVID-19 than a CVD epidemic or other more deadly diseases? Mainly for three reasons: habits, knowledge, and care.

Myocardial Injury in Severe COVID-19 Compared to Non-COVID Acute Respiratory Distress Syndrome

Circulation, November 13, 2020

Knowledge gaps remain in the epidemiology and clinical implications of myocardial injury in COVID-19. Our goal was to determine the prevalence and outcomes of myocardial injury in severe COVID-19 compared to acute respiratory distress syndrome (ARDS) unrelated to COVID-19. We included intubated COVID-19 patients from 5 hospitals between March 15 and June 11, 2020 with troponin levels assessed. We compared them to patients from a cohort study of myocardial injury in ARDS. We performed survival analysis with primary outcome of in-hospital death associated with myocardial injury. We performed linear regression to identify clinical factors associated with myocardial injury in COVID-19. Of 243 patients intubated with COVID-19, 51% had troponin levels > upper limit of normal (ULN). Chronic kidney disease, lactate, ferritin and fibrinogen were associated with myocardial injury. Mortality was 22.7% among COVID-19 patients with troponin < ULN and 61.5% for those with troponin levels > 10xULN (P< 0.001). The association of myocardial injury with mortality was not statistically significant after adjusting for age, sex and multi-system organ dysfunction. Compared to non-COVID ARDS patients, patients with COVID-19 were older with higher creatinine and less favorable vital signs. After adjustment, COVID-19 was associated with lower odds of myocardial injury compared to non-COVID ARDS (OR 0.55 95% CI 0.36-0.84, P=0.005).

Fatal SARS-CoV-2 Inflammatory Syndrome and Myocarditis in an Adolescent: A Case Report

The Pediatric Infectious Disease Journal, November 13, 2020

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), an entity in children initially characterized by milder case presentations and better prognoses as compared with adults. Recent reports, however, raise concern for a new hyperinflammatory entity in a subset of pediatric COVID-19 patients. METHODS: We report a fatal case of confirmed COVID-19 with hyperinflammatory features concerning for both multi-inflammatory syndrome in children (MIS-C) and primary COVID-19. RESULTS: This case highlights the ambiguity in distinguishing between these two entities in a subset of pediatric patients with COVID-19-related disease and the rapid decompensation these patients may experience. CONCLUSIONS: Appropriate clinical suspicion is necessary for both acute disease and MIS-C. SARS-CoV-2 serologic tests obtained early in the diagnostic process may help to narrow down the differential but does not distinguish between acute COVID-19 and MIS-C. Better understanding of the hyperinflammatory changes associated with MIS-C and acute COVID-19 in children will help delineate the roles for therapies, particularly if there is a hybrid phenotype occurring in adolescents.

Cardiology Update 20 India: An Indo-European Online Experience for more than 7000 participants in 2020

European Heart Journal, November 13, 2020

During Covid times, education is more difficult because face-to-face meetings are almost impossible; particularly, in countries where a first or second wave has occurred recently or is about to occur. Unfortunately, India, where a Cardiology Update Course was held in Mumbai in 2019 with over 700 participants, was severely hit by Covid-19 recently. Indeed, in mid-September India had almost 6 million infected individuals and over 91 000 deaths to deplore. Therefore, a face-to-face post-graduate course was clearly impossible. Furthermore, many eminent faculty members are currently unable to travel, particularly those from the USA and the UK. As such, it was decided to run the Cardiology Update 20 India—similar to the ESC 2020 Congress as a fully online course with shorter talks over two afternoons on 19 and 20 September 2020. Importantly, panel discussion was assigned half an hour and hence was longer than usual. The course was run by distinguished chairpersons, shortened to allow for the online format and consisted of four sessions over two afternoons on Saturday and Sunday 19 and 20 September. Read more about the session topics: Prevention, Coronary Artery Disease, Cardiovascular Disease and Cardiometabolic Disorders.

Electrocardiographic Findings and Clinical Outcome in Patients with COVID-19 or Other Acute Infectious Respiratory Diseases

Journal of Clinical Medicine, November 12, 2020

Cardiac involvement in coronavirus SARS-CoV-2 infection (COVID-19) has been reported in a sizeable proportion of patients and associated with a negative outcome; furthermore, a pre-existing heart disease is associated with increased mortality in these patients. In this prospective single-center case-control study we investigated whether COVID-19 patients present different rates and clinical implications of an abnormal electrocardiogram (ECG) compared to patients with an acute infectious respiratory disease (AIRD) caused by other pathogens. We studied 556 consecutive patients admitted to the emergency department of our hospital with symptoms of AIRD; 324 were diagnosed to have COVID-19 and 232 other causes of AIRD (no-COVID-19 group). Standard 12-lead ECG performed on admission was assessed for various kinds of abnormalities, including ST segment/T wave changes, atrial fibrillation, ventricular arrhythmias, and intraventricular conduction disorders. ECG abnormalities were found in 120 (37.0%) and 101 (43.5%) COVID-19 and no-COVID-19 groups, respectively (p = 0.13). No differences in ECG abnormalities were found between the 2 groups after adjustment for clinical and laboratory variables. During a follow-up of 45 ± 16 days, 51 deaths (15.7%) occurred in the COVID-19 and 30 (12.9%) in the no-COVID-19 groups (p = 0.39). ST segment depression ≥ 0.5 mm (p = 0.016), QRS duration (p = 0.016) and presence of any ECG abnormality (p = 0.027) were independently associated with mortality at multivariable Cox regression analysis.

Amiodarone in COVID-19: let’s not forget its potential for pulmonary toxicity

European Journal of Preventive Cardiology, November 12, 2020

[Letter to the Editor] Aimo et al. presented an elegant review of the antiviral mechanism of amiodarone, which is a commonly used antiarrhythmic drug. Although in vitro experiments demonstrated the ability of amiodarone to inhibit coronavirus, we are still wary of the authors’ recommendation to evaluate amiodarone for the treatment of coronavirus disease 2019 (COVID-19) in clinical trials. In fact, when authors commented that amiodarone has been used for decades in a large number of patients for its safety profile to be well-known, authors should have acknowledged the notorious potential for amiodarone to induce pulmonary toxicity. It has been hypothesized that amiodarone may sensitize patients to high concentrations of inspired oxygen since the accumulation of amiodarone in the lysosomes of macrophages results in destabilization of their membranes and release of free oxygen radicals. The mortality rate of patients in whom ARDS developed due to amiodarone could approach 50%, which is higher than that of patients with COVID-19 related ARDS (39% as reported in a meta-analysis). Therefore, it may be worth to wait for observational studies to report outcomes in COVID-19 patients who have received chronic treatment with amiodarone for its established indications before a recommendation to repurpose amiodarone for the treatment of COVID-19. In addition, dronedarone, which is a non-iodinated congener of amiodarone with a better safety profile, may worth for more evaluation on its antiviral activity against SARS-CoV-2.

Effects of COVID-19 lockdown on heart rate variability

PLOS ONE, November 12, 2020

Strict lockdown rules were imposed to the French population from 17 March to 11 May 2020, which may result in limited possibilities of physical activity, modified psychological and health states. This report is focused on HRV parameters kinetics before, during and after this lockdown period. 95 participants were included in this study (27 women, 68 men, 37 ± 11 years, 176 ± 8 cm, 71 ± 12 kg), who underwent regular orthostatic tests (a 5-minute supine followed by a 5-minute standing recording of heart rate (HR)) on a regular basis before (BSL), during (CFN) and after (RCV) the lockdown. HR, power in low- and high-frequency bands LF, HF, respectively) and root mean square of the successive differences (RMSSD) were computed for each orthostatic test, and for each position. Subjective well-being was assessed on a 0–10 visual analogic scale (VAS). The participants were split in two groups, those who reported an improved well-being (WB+, increase >2 in VAS score) and those who did not (WB-) during CFN. Out of the 95 participants, 19 were classified WB+ and 76 WB-. There was an increase in HR and a decrease in RMSSD when measured supine in CFN and RCV, compared to BSL in WB-, whilst opposite results were found in WB+ (i.e. decrease in HR and increase in RMSSD in CFN and RCV; increase in LF and HF in RCV). When pooling data of the three phases, there were significant correlations between VAS and HR, RMSSD, HF, respectively, in the supine position; the higher the VAS score (i.e., subjective well-being), the higher the RMSSD and HF and the lower the HR. In standing position, HRV parameters were not modified during CFN but RMSSD was correlated to VAS.

AHA 2020 topics: Systemic racism, novel research, COVID-19 discussion with Fauci

Helio | Cardiology Today, November 11, 2020

Trials of novel medications and conversations on systemic racism and the ongoing COVID-19 pandemic are set to be featured at the virtual American Heart Association Scientific Sessions, which start Friday. The conference, which will run until Tuesday, will feature a talk by Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, on the CV implications of the ongoing global pandemic. One late-breaker to be presented is the phase 3 GALACTIC-HF trial. This study evaluated the effect of omecamtiv mecarbil (Amgen/Cytokinetics) in patients with HF with reduced ejection fraction. Also being presentedare the results from the AFFIRM-AHF trial, which evaluated the use of iron supplementation in patients who present with HFrEF and are also iron-deficient at the time of hospitalization. The VITAL Rhythm trial, a follow-up to the VITAL trial presented at the 2019 AHA Scientific Sessions, analyzed the impact of vitamin D, low-dose fish oil or both on initial atrial fibrillation events. As Healio previously reported, interventions with vitamin D or omega-3 did not reduce rates of first HF hospitalization among healthy adults, but researchers noted a benefit in recurrent HF hospitalization in those on fish oil supplementation.

An increase in acute heart failure offsets the reduction in acute coronary syndrome during coronavirus disease 2019 (COVID‐19) outbreak

ESC Heart Failure, November 11, 2020

[Letter to the Editor] There are worldwide reports about an unexplained decline in the frequency of acute coronary syndrome (ACS) during the present coronavirus disease 2019 (COVID‐19) pandemic. Public health interventions to prevent the spread of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) and a particular concern of infections within the elderly population and those with pre‐existing co‐morbidities might have raised the threshold to seek medical attention in case of a cardiovascular emergency. Avoidance or delayed medical contact in case of ACS could result in significant consequential damage including cardiogenic shock. The aim of the present investigation was to determine changes in both the frequency of ACS and sequels of not‐adequately treated ACS during the COVID‐19 pandemic. In a population‐based prospective registry, patients receiving medical care via the Emergency Medical Service of the city of Vienna for ACS (ST‐elevation myocardial infarction, n = 282; and non‐ST‐elevation myocardial infarction, n = 123) were analysed during the COVID‐19 pandemic (March 13–10 April 2020) and compared with two time periods: immediately before the outbreak (1–28 February 2020) and the corresponding period in 2019 (13 March–10 April). ACS cases decreased significantly compared with those in the time period before the outbreak and in 2019 (P = 0.001). Time trends show an inverse association with increasing numbers of new COVID‐19 cases. Of note, parallel to the decline in ACS—with a delay of about 2 weeks—an increase of ACS patients presenting with acute heart failure was observed as compared with both of the control periods in 2020 (from 6.9% to 23.7%, P 60; 0.001) and in 2019 (from 13.1% to 23.7%, P 60; 0.001).

The Experience of a Plasma Donor: A cardiologist discusses the emotions of donating plasma to a fellow human being during this COVID-19 pandemic

European Heart Journal, November 11, 2020

A 50-year-old obese male with COVID, diabetes, and hypertension was transferred from an outside hospital with shortness of breath. He had been in this hospital for the past 2 days, but his clinical status had deteriorated. He was now on a ventilator in the ICU but still not saturating well. Several hours earlier, his nephew had contacted me and I could snse the hope and desperation in his voice.
It was a Sunday, and I walked into the hospital wearing my street clothes covered by protective clothing that we medical professionals are so used to nowadays. I had never met the nephew before and until a few hours ago neither of us knew we even existed. He had received my information from a registry. As I walked into the hospital, I felt different—this was not my hospital! We were supposed to meet at the side entrance close to the blood bank and he leapt with joy as he saw me walking in. As we talked, he became teary and said—‘Thank you so much for coming doctor, your plasma may be what will cure him’.

I did not go to the hospital in the capacity of a doctor to provide treatment but as a donor—A Plasma Donor. This is not about diagnostic skills. This is not about intelligence, problem-solving, or clinical experience. This is about being supportive of another human being during these tough times. In a pandemic, we are all in this together. Read more about the experience.

Cardiac damage in patients with the severe type of coronavirus disease 2019 (COVID-19)

BMC Cardiovascular Disorders, November 10, 2020

Coronavirus disease 2019 (COVID-19) has become a global pandemic. Studies showed COVID-19 affected not only the lung but also other organs. In this study, we aimed to explore the cardiac damage in patients with COVID-19. We collected data of 100 patients diagnosed as severe type of COVID-19 from February 8 to April 10, 2020, including demographics, illness history, physical examination, laboratory test, and treatment. In-hospital mortality were observed. Cardiac damage was defined as plasma hypersensitive troponin I (hsTnI) over 34.2 pg/ml and/or N-terminal-pro brain natriuretic peptide (NTproBNP) above 450 pg/ml at the age < 50, above 900 pg/ml at the age < 75, or above 1800 pg/ml at the age ≥ 75. The median age of the patients was 62.0 years old. 69 (69.0%) had comorbidities, mainly presenting hypertension, diabetes, and cardiovascular disease. Fever (69 [69.0%]), cough (63 [63.0%]), chest distress (13 [13.0%]), and fatigue (12 [12.0%]) were the common initial symptoms. Cardiac damage occurred in 25 patients. In the subgroups, hsTnI was significantly higher in elder patients (≥ 60 years) than in the young (median [IQR], 5.2 [2.2–12.8] vs. 1.9 [1.9–6.2], p = 0.018) and was higher in men than in women (4.2 [1.9–12.8] vs. 2.9 [1.9–7.4], p = 0.018). The prevalence of increased NTproBNP was significantly higher in men than in women (32.1% vs. 9.1%, p = 0.006), but was similar between the elder and young patients (20.0% vs. 25.0%, p = 0.554). After multivariable analysis, male and hypertension were the risk factors of cardiac damage. The mortality was 4.0%.

Impact of Prior Heart Failure on Hospitalized COVID-19 Patients

American College of Cardiology, November 9, 2020

This study questions, among patients with a prior diagnosis of heart failure (HF), what are the clinical outcomes during and immediately following hospitalization for coronavirus disease (COVID-19)? The retrospective cohort study included consecutive adult patients hospitalized with COVID-19 at five sites within the Mount Sinai Healthcare System in New York City. International Classification of Diseases, 9th and/or 10th Revision (ICD-9/10) codes were used to identify patients with a prior diagnosis of HF. Manual chart review was performed for all HF patients to collect data such as HF etiology and left ventricular ejection fraction (LVEF). Clinical outcomes of interest included in-hospital mortality, mechanical ventilation, intensive care unit (ICU) admission, length of stay (LOS), and 30-day readmission rate. A total of 6,439 patients were included (mean age 63.5 years, 45% women, 17.1% requiring ICU care, 12.6% mechanically ventilated), and 422 (6.6%) had a history of HF. Patients with HF were older (mean age 72.5 vs. 62.9 years, p < 0.001). Prevalence of major comorbidities such as obesity, hypertension, diabetes mellitus, atrial fibrillation, and chronic kidney disease was higher in the HF group (all p < 0.001). Median LOS for the HF group was 8 days, as compared with 6 days for the overall cohort. Based on a multivariable logistic regression model, HF was shown to be independently associated with ICU admission (adjusted odds ratio [OR], 1.71; 95% confidence interval [CI], 1.25-2.34; p = 0.001), mechanical ventilation (OR, 3.64; 95% CI, 2.56-5.16; p < 0.001), and in-hospital mortality (OR, 1.88; 95% CI, 1.27-2.78; p = 0.002). In analyses of HF patients stratified by LVEF, there were no significant differences in LOS, ICU admission, mechanical ventilation, or 30-day readmission rates.

The outcomes of the postulated interaction between SARS-CoV-2 and the renin-angiotensin system on the clinician’s attitudes toward hypertension treatment

Journal of Human Hypertension, November 9, 2020

Concern has arisen about the role played in coronavirus disease 2019 (COVID-19) infection by angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). This study was designed to assess the practice behaviors of physicians toward hypertension treatment with ACE-i or ARBs during the COVID-19 pandemic. A self-administered survey questionnaire consisting of 26 questions about current hypertension treatment with ACE-i/ ARBs was applied to cardiologists, internists, and family physicians in central and western Turkey, between 01 and 19 May 2020. A total of 460 physicians were approached, and 220 (47.8%) participated in the study. Of the total respondents, 78.7% reported that they had not changed their antihypertensive medication prescribing pattern, 8.6% of clinicians had changed ACE-i/ ARBs medicine of patients during the COVID-19 pandemic and 12.7% of them were undecided. The median (±interquartile range) score indicating general reliance level of physicians in ACE-i/ARBs therapy was 8 ± 4 (range, 1–10). In multiple comparison analyses, the general reliance level in ACE-i/ARBs, reliance level when starting a new ACEi/ARBs and changing behavior in heart failure patients were significantly different with regard to the specialties (p:0.02, p:0.009, p:0.005 respectively). Although most of the physicians found the publications about ACE-i/ ARBs during the COVID-19 pandemic untrustworthy, there were variable levels of knowledge and reliance among different physicians and specialty groups. In general, the ACE-i/ ARBs prescribing habits were not affected by safety concerns during the COVID-19 pandemic in Turkey.

A cohort study of 676 patients indicates D-dimer is a critical risk factor for the mortality of COVID-19

PLOS ONE, November 9, 2020

Coronavirus Disease 2019 (COVID-19) has recently become a public emergency and a worldwide pandemic. However, the information on the risk factors associated with the mortality of COVID-19 and of their prognostic potential is limited. In this retrospective study, the clinical characteristics, treatment and outcome data were collected and analyzed from 676 COVID-19 patients stratified into 140 non-survivors and 536 survivors. We found that the levels of Dimerized plasmin fragment D (D-dimer), C-reactive protein (CRP), lactate dehydrogenase (LDH), procalcitonin (PCT) were significantly higher in non-survivals on admission (non-survivors vs. survivors: D-Dimer ≥ 0.5 mg/L, 83.2% vs. 44.9%, P<0.01; CRP ≥10 mg/L, 50.4% vs. 6.0%, P <0.01; LDH ≥ 250 U/L, 73.8% vs. 20.1%, P <0.01; PCT ≥ 0.5 ng/ml, 27.7% vs. 1.8%, P <0.01). Moreover, dynamic tracking showed D-dimer kept increasing in non-survivors, while CRP, LDH and PCT remained relatively stable after admission. D-dimer has the highest C-index to predict in-hospital mortality, and patients with D-dimer levels ≥0.5 mg/L had a higher incidence of mortality (Hazard Ratio: 4.39, P<0.01). Our study suggested D-dimer could be a potent marker to predict the mortality of COVID-19, which may be helpful for the management of patients.

COVID-19 vaccine more than 90% effective, Pfizer says

Helio | Infectious Disease News, November 9, 2020

A vaccine candidate developed by Pfizer and BioNTech was more than 90% effective in preventing COVID-19 and showed no serious safety concerns, according to an interim analysis of phase 3 clinical trial results released by the companies. Pfizer and BioNTech said they plan to submit the mRNA-based vaccine candidate, now called BNT162b2, to the FDA for an emergency use authorization after a required safety milestone is met, likely in the third week of November. The analysis, which was conducted by an external and independent data monitoring committee, evaluated 94 confirmed cases of COVID-19 among more than 43,000 participants enrolled in the global trial, including more than 38,000 who have received two doses of the vaccine candidate. Around 42% of participants globally and 30% in the United States are from racially and ethnically diverse backgrounds, the companies said. At 7 days after the second dose, the vaccine was more than 90% effective compared with placebo among participants with no prior exposure to SARS-CoV-2. “This means that protection is achieved 28 days after the initiation of the vaccination, which consists of a 2-dose schedule. As the study continues, the final vaccine efficacy percentage may vary,” the companies said.

Elevated Troponin and Mortality Risk in Patients Hospitalized With COVID-19

Pulmonary Advisor, November 9, 2020

Patients who are hospitalized with coronavirus disease 2019 (COVID-19) and have an elevated vs normal troponin levels were found to be at higher risk for death, according to a study published in the American Journal of Cardiology. Researchers reviewed data for all patients with COVID-19 who were admitted to hospitals within the Northwell Health system in New York between March 1, 2020 and April 27, 2020, and had a troponin assessment within 48 hours of admission. They used logistic regression to calculate odds ratios (ORs) for mortality during hospitalization and controlled for demographic factors, comorbidities, and inflammation markers. The researchers suggested that multiple mechanisms of myocardial injury may be associated with COVID-19, including injury related to inflammation and cytokine storm, direct viral-mediated injury, hypoxic respiratory failure, downregulation of angiotensin-converting enzyme 2 receptors, hypercoagulability, diffuse myocardial endothelial injury, and acute plaque rupture. “While we did not measure changes in troponin over time, elevations in troponin likely reflected imbalance between myocardial oxygen supply and demand,” noted the investigators. “However, direct myocardial involvement cannot be excluded and myocarditis associated with COVID-19 remains poorly defined.”

Studies find mixed results for tocilizumab to treat COVID-19

Helio | Infectious Diseases, November 9, 2020

Three studies recently published in JAMA Internal Medicine evaluated the effects of tocilizumab against COVID-19. The studies were conducted in the United States, France and Italy, and all involved patients who were hospitalized with COVID-19. In an editorial accompanying the studies, Jonathan B. Parr, MD, MPH, assistant professor of medicine in the division of infectious diseases at the University of North Carolina School of Medicine, wrote that the “newly released randomized trials suggest a potential role for tocilizumab in COVID-19 but do not show clear evidence of efficacy, in contrast to observational studies.”

Infectious endocarditis of the prosthetic mitral valve after COVID-19 infection

European Heart Journal, November 7, 2020

A 24-year-old male, known case of rheumatic heart disease, who had undergone mechanical mitral valve replacement 4 years ago, was referred to our echocardiography laboratory, due to fever, chills, and severe anorexia, 3 weeks after being discharged due to COVID-19 infection. He had been diagnosed due to a chest X-ray suggestive of viral pneumonia and a positive RT–PCR for SARS-COV-2. On admission, he was febrile (38°C), had tachycardia (heart rate: 100/min), and a normal oxygen saturation in room air and his electrocardiogram displayed sinus tachycardia. Due to a high suspicion of infectious endocarditis (IE) on echocardiographic examination, a transoesophageal echocardiogram was performed, which revealed several typical vegetations on the posterior prosthetic mitral valve leaflet. His previous echocardiogram had demonstrated normal functioning mitral valve prosthesis and a left ventricular ejection fraction of 45%. Blood culture results came back positive for Staphylococcus aureus. Other noticeable laboratory tests included leucocytosis and an elevated C-reactive protein (72 mg/L, normal level <3). Patient was treated with Azithromycin, Hydroxychloroquine, and corticosteroids and was discharged 2 weeks later. After 6 weeks of antibiotic treatment, repeated trans-thoracic oesophageal echocardiogram (TEE) displayed healing of the vegetative lesions. Up till now, there has been limited evidence on COVID-19 and IE, but since the process of vegetation development begins through transient bacteraemia, followed by binding of bacteria to damaged endothelium, Coronavirus infection and the systemic inflammation caused by it can be a potential risk factor for IE, particularly in susceptible patients with underlying diseases.

Cardiovascular Active Peptides of Marine Origin with ACE Inhibitory Activities: Potential Role as Anti-Hypertensive Drugs and in Prevention of SARS-CoV-2 Infection

International Journal of Molecular Sciences, November 7, 2020

Growing interest in hypertension—one of the main factors characterizing the cardiometabolic syndrome (CMS)—and anti-hypertensive drugs raised from the emergence of a new coronavirus, SARS-CoV-2, responsible for the COVID19 pandemic. The virus SARS-CoV-2 employs the Angiotensin-converting enzyme 2 (ACE2), a component of the RAAS (Renin-Angiotensin-Aldosterone System) system, as a receptor for entry into the cells. Several classes of synthetic drugs are available for hypertension, rarely associated with severe or mild adverse effects. New natural compounds, such as peptides, might be useful to treat some hypertensive patients. The main feature of ACE inhibitory peptides is the location of the hydrophobic residue, usually Proline, at the C-terminus. Some already known bioactive peptides derived from marine resources have potential ACE inhibitory activity and can be considered therapeutic agents to treat hypertension. Peptides isolated from marine vertebrates, invertebrates, seaweeds, or sea microorganisms displayed important biological activities to treat hypertensive patients. Here, we reviewed the anti-hypertensive activities of bioactive molecules isolated/extracted from marine organisms and discussed the associated molecular mechanisms involved. We also examined ACE2 modulation in sight of SARS2-Cov infection prevention.

ILCOR’s revised Covid-19 defibrillation recommendation requires a new approach to training

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, November 7, 2020

In-hospital resuscitation practices have changed by necessity in the Covid-19 era, principally due to precautions intended to protect caregivers from infection. This has resulted in serious delays in resuscitation response. ILCOR has recently modified its guidelines to separate defibrillation from other interventions, recognizing that shock success is extremely time-dependent and that defibrillation poses relatively little risk of Covid-19 transmission. The new recommendation calls for sending one caregiver into the isolation room in order to initiate bedside monitoring and defibrillate if indicated, while the code team is donning their personal protective equipment. Implementing this change requires focused training in that specific role. This can be accomplished by intensively training a subset of clinical staff to assume the responsibility and act without hesitation when a code occurs. Focused defibrillation training promises to avoid compromising the care of patients experiencing tachyarrhythmic arrests in the setting of Covid-19. Such a training program might even result in better survival than before the pandemic for this subset of patients.

A mutation may have made COVID-19 more contagious

Medical News Today, November 6, 2020

Between March and July 2020, a particular mutation became almost ubiquitous in SARS-CoV-2 infections in Houston, TX. This strongly suggests that it makes the virus more infectious. However, there is no evidence to suggest that it makes the virus any more deadly. Metropolitan Houston reported its first case of COVID-19, which is the illness that develops due to SARS-CoV-2, on March 5, 2020. A week later, the virus was spreading within the community. A previous study found that strains of the virus containing a particular mutation, called G614, caused 71% of cases in Houston in the early phase of this first wave of infections. A follow-up study by the same team now reveals that by summer, during the second wave, this variant accounted for 99.9% of all COVID-19 infections in the area. The researchers at Houston Methodist Hospital — in collaboration with scientists at the University of Texas at Austin and the University of Chicago, IL — discovered that one of these mutations may allow the spike to evade a neutralizing antibody produced by the human immune system. It is unclear whether or not this mutation also increases infectivity. However, the researchers report that it is currently rare and does not appear to make the disease more severe. They also found no evidence to suggest that the virus has acquired mutations that might render either the vaccines in development or existing antibody treatments ineffective. Concluding their report, the authors write, “The findings will help us to understand the origin, composition, and trajectory of future infection waves and the potential effect of the host immune response and therapeutic maneuvers on SARS-CoV-2 evolution.”

Long-term sequelae following previous coronavirus epidemics

Clinical Medicine Journal, November 5, 2020

Before the current pandemic, there had been two global epidemics from major coronavirus outbreaks since the turn of the century: severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV). Both epidemics left survivors with fatigue, persistent shortness of breath, reduced quality of life and a significant burden of mental health problems.
It is likely that some of the chronic problems encountered by survivors of SARS and MERS may be relevant for medical planning of the services required for survivors of coronavirus disease 2019 (COVID-19) caused by the novel coronavirus SARS-CoV-2. Given the similarities between the diseases, the recovery and rehabilitation of the survivors of COVID-19 is likely to be focused around cardiopulmonary sequelae, fatigue and the psychological burden of COVID-19, but in a much larger population.

The Japanese version of the Fear of COVID-19 scale: Reliability, validity, and relation to coping behavior

PLOS ONE, November 5, 2020

COVID-19 is spreading worldwide, causing various social problems. The aim of the present study was to verify the reliability and validity of the Japanese version of the Fear of COVID-19 Scale (FCV-19S) and to ascertain FCV-19S effects on assessment of Japanese people’s coping behavior. After back-translation of the scale, 450 Japanese participants were recruited from a crowdsourcing platform. These participants responded to the Japanese FCV-19S, the Japanese versions of the Hospital Anxiety and Depression scale (HADS) and the Japanese versions of the Perceived Vulnerability to Disease (PVD), which assesses coping behaviors such as stockpiling and health monitoring, reasons for coping behaviors, and socio-demographic variables. Results indicated the factor structure of the Japanese FCV-19S as including seven items and one factor that were equivalent to those of the original FCV-19S. The scale showed adequate internal reliability (α = .87; ω = .92) and concurrent validity, as indicated by significantly positive correlations with the Hospital Anxiety and Depression Scale (HADS; anxiety, r = .56; depression, r = .29) and Perceived Vulnerability to Disease (PVD; perceived infectability, r = .32; germ aversion, r = .29). Additionally, the FCV-19S not only directly increased all coping behaviors (β = .21 – .36); it also indirectly increased stockpiling through conformity reason (indirect effect, β = .04; total effect, β = .31). These results suggest that the Japanese FCV-19S psychometric scale has equal reliability and validity to those of the original FCV-19S. These findings will contribute further to the investigation of various difficulties arising from fear about COVID-19 in Japan.

Cardiac Echoes Reveal COVID’s Toll on the Heart

MedPage Today, November 5, 2020

The goal of this study was to characterize echocardiographic abnormalities associated with myocardial injury and their prognostic impact in patients with COVID-19. This retrospective study suggests utility of TTE in patients with SARS-CoV-2 infection and myocardial injury. Myocardial injury is associated with critical conditions such as myocarditis, pulmonary embolism, heart attack, and heart failure. According to a recent retrospective study, hospitalized patients with COVID-19 and myocardial injury had a broad range of echocardiographic abnormalities that put them at higher risk of in-hospital mortality. Among 305 patients with lab-confirmed SARS-CoV-2 infection who underwent transthoracic echocardiography (TTE) and ECG evaluation, 62.6% had troponin elevations suggestive of myocardial injury (either at hospital admission or later during the hospitalization), reported Gennaro Giustino, MD, of Icahn School of Medicine at Mount Sinai in New York City, and colleagues in the Journal of the American College of Cardiology. These findings expand on previous Mount Sinai research, which showed a correlation between increasing levels of troponin and more heart damage among hospitalized patients with COVID-19. [CME Available]

Characteristics and outcomes of COVID-19-associated stroke: a UK multicentre case-control study

Journal of Neurology, Neurosurgery & Psychiatry, November 5, 2020

Ischemic strokes in COVID-19 patients tended to be more severe than those in other individuals, according to a case-control study from the U.K. Among 86 stroke patients with COVID-19, stroke characteristics and outcomes differed from uninfected stroke patients treated during the same period. The COVID-19-associated strokes:

  • Were more likely to involve multiple large vessel occlusions (17.9% vs 8.1%, P<0.03)
  • Were more severe (median NIH Stroke Scale score 8 vs 5, P<0.002
  •  Were associated with higher D-dimer levels (3.4 vs 3.0 ng/ml on the log10 scale, P<0.01
  •  Resulted in more severe disability on discharge (median modified Rankin Scale score 4 vs 3, P<0.0001
  •  Resulted in more deaths during index admission (19.8% vs 9.6%, P<0.0001)

Our study provides the most compelling evidence yet that COVID-19-associated ischaemic strokes are more severe and more likely to result in severe disability or death, although the outlook is not quite as bleak as previous studies have suggested. Our results suggest the following recommendations for management of stroke patients during the ongoing COVID-19 pandemic.

Cardiovascular Disease and SARS-CoV-2: the Role of Host Immune Response Versus Direct Viral Injury

LitCovid, November 5, 2020

The 2019 novel coronavirus [2019-nCoV], which started to spread from December 2019 onwards, caused a global pandemic. Besides being responsible for the severe acute respiratory syndrome 2 [SARS-CoV-2], the virus can affect other organs causing various symptoms. A close relationship between SARS-CoV-2 and the cardiovascular system has been shown, demonstrating an epidemiological linkage between SARS-CoV-2 and cardiac injury. There are emerging data regarding possible direct myocardial damage by 2019-nCoV. In this review, the most important available evidences will be discussed to clarify the precise mechanisms of cardiovascular injury in SARS-CoV-2 patients, even if further researches are needed.

Diagnosis of acute myocardial infaction in the time of the COVID-19 pandemic

European Heart Journal, November 4, 2020

Dyspnoea may occasionally represent an equivalent of angina in the case of acute myocardial infarction. In the time of COVID-19, the work up of patients presenting in the emergency department (ED) for dyspnoea may often include computed tomography (CT) scan; the diagnosis of acute myocardial infarction may therefore be occasionally incidental and unconventional. We report the case of a 46-year old hypertensive female patient admitted to the ED for suspected transitory ischaemic attack (referred dysarthria), dyspnoea, and fever 37.5°C. As this was during the time of the COVID-19 pandemic, an admission nasopharyngeal swab was performed. Admission electrocardiogram showed signs of left ventricular hypertrophy without acute ischaemia and significant ST-segment elevation. Despite normal neurological examination without focal signs, a head and chest CT scan was performed in order to exclude neurological acute lesions and COVID-19 interstitial pneumonia. Unexpectedly, CT scan showed normal lung findings but evident hypo-enhancement of the posterior left ventricular wall. A second electrocardiogram showed evident left ventricle hypertrophy with ST-segment elevation in inferior leads. After immediate cath lab admission, coronary angiography showed an occluded right coronary artery, treated with a drug-eluting stent. Although the standard 12-lead electrocardiogram is considered the first-line exam for the diagnosis of acute myocardial infarction, chest CT scan may provide detailed information on the presence and the extension of acute myocardial infarction. In the time of COVID-19, diagnosis of acute myocardial infarction may occasionally occur in radiology rather than in the ED.

Reimagining Cardiac Rehabilitation in the Era of Coronavirus Disease 2019

JAMA Network, November 4, 2020

The coronavirus pandemic has spurred significant growth in home-based cardiology care, facilitated by delivery and financing innovations. Since February2020, the Centers for Medicare & Medicaid Services have issued 190 ambulatory care waivers, including allowing virtual cardiology visits. As a result, 25% to 34% of Medicare beneficiaries have received telehealth care during the pandemic, compared with less than 1% in 2016. On October 14, in an unprecedented move, the Centers for Medicare and Medicaid Services initiated reimbursements for virtual cardiac rehabilitation. Lessons learned from virtual delivery during the pandemic should inform delivery and payment reform for cardiac rehabilitation going forward. Cardiac rehabilitation integrates patient education, behavior modification, and exercise. The traditional in-person, center-based cardiac rehabilitation model has been shown to reduce all-cause hospital readmissions by 31% and all-cause mortality by 24% over 1 to 3 years. For patients with a recent acute myocardial infarction, coronary revascularization, or acute heart failure exacerbation, cardiac rehabilitation reduces spending on future hospitalizations by approximately $900 per patient over 21 months. Yet uptake has been disappointing. Even before COVID-19, less than a third of eligible patients attended a single session. Supply-and-demand challenges have impeded uptake, and both must be addressed to expand this life-saving therapy. Although cardiovascular disease accounts for one-sixth of healthcare spending and affects half of American adults, cardiac rehabilitation—an effective prevention strategy with strong evidence of safety, efficacy, and cost savings—remains underused. As the ongoing pandemic changes how cardiac care is delivered, it provides an unprecedented opportunity to reimagine how cardiac rehabilitation is prescribed, delivered, and financed.

Questions and Answers on Practical Thrombotic Issues in SARS-CoV-2 Infection: A Guidance Document from the Italian Working Group on Atherosclerosis, Thrombosis and Vascular Biology

American Journal of Cardiovascular Drugs, November 3, 2020

In patients with coronavirus disease 2019 (COVID-19), the prevalence of pre-existing cardiovascular diseases is elevated. Moreover, various features, also including pro-thrombotic status, further predispose these patients to increased risk of ischemic cardiovascular events. Thus, the identification of optimal antithrombotic strategies in terms of the risk–benefit ratio and outcome improvement in this setting is crucial. However, debated issues on antithrombotic therapies in patients with COVID-19 are multiple and relevant. In this article, we provide ten questions and answers on risk stratification and antiplatelet/anticoagulant treatments in patients at risk of/with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection based on the scientific evidence gathered during the pandemic.

COVID-19 associated aortitis

Rheumatology Advances in Practice, November 3, 2020

Since the emergence of Coronavirus disease 2019 (COVID-19) there has been increasing recognition of the potential associated cardio-vascular manifestations. There have been reports of Kawasaki like disease in children. However, in adults there are very few reports of non-cutaneous vasculitis. Here we report the case of an adult male presenting with an inflammatory aortitis associated with COVID-19 infection. A 71-year-old Caucasian male with a background of cholecystectomy and rotator cuff repair presented to hospital in May 2020 with a 3-month history of feeling generally unwell, weight loss and worsening thoraco-lumbar back pain. Prior to the onset of these symptoms, he had had a 2-week illness in March 2020 clinically consistent with COVID-19 infection comprising fevers, hot sweats, dry cough, and chest tightness for which he had not sought medical attention. He had no recent travel history. Physical examination was unremarkable. On admission, COVID-19 tests revealed evidence of prior infection with negative SARS-CoV-2 polymerase chain reaction test but positive SARS-CoV-2 antibodies. Blood tests revealed a marked inflammatory state with a C- reactive protein of 122mg/L, plasmas viscosity of 2.76, Ferritin 777ug/L, Interleukin-6 of 25 ng/L and normocytic anaemia with a Haemoglobin of 77g/L.

Human recombinant soluble ACE2 (hrsACE2) shows promise for treating severe COVID¬19

Signal Transduction and Targeted Therapy, November 3, 2020

A recent study by Zoufaly et al. published in The Lancet Respiratory Medicine describes encouraging data from the first severe COVID-19 patient successfully treated with human recombinant soluble angiotensin-converting enzyme-2 (hrsACE2). The published data document upon treatment of an adaptive immune response, the disappearance of the virus swiftly from the serum, the nasal cavity and lungs, and a reduction of inflammatory cytokine levels that are critical for COVID-19 pathology. Notably, the use of hrsACE2 did not impede the generation of neutralizing antibodies, leading to a significant clinical improvement of the treated patient. ACE2 is a crucial receptor target of SARS-CoV-2, which plays a vital role in the pathogenesis of COVID-19, as it enables viral entry into target cells. The binding affinity between ACE2 and the receptor-binding domain (RBD) of the SARS-CoV-2 spike glycoprotein is 10- to 20-fold higher compared to that with the RBD of SARS-CoV, which likely underpins the higher pathogenesis of SARS-CoV-2 infections. ACE2 is a transmembrane protein typically known for its carboxypeptidase activity and its physiological role in the renin-angiotensin system. ACE2 hydrolyzes angiotensin II to its metabolite, angiotensin 1–7 and angiotensin I to angiotensin 1–9 to protect diverse tissues from injury. ACE2 is expressed in several human organs at varying levels. It is highly expressed in the lungs (on the surface of type II alveolar epithelial cells), heart (on myocardial cells, coronary vascular endothelial cells, and vascular smooth muscle), kidney (on proximal tubule cells), and small intestine (on the enterocytes).

The pivotal role of the angiotensin-II–NF-κB axis in the development of COVID-19 pathophysiology

Hypertension Research, November 2, 2020

Coronavirus disease 2019 (COVID-19) is caused by the virus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SARS-CoV-2 can infect host cells by interacting with membrane-bound angiotensin-converting enzyme 2 (ACE2) on the respiratory epithelium. ACE2 is part of the renin–angiotensin system (RAS), and treatment with RAS inhibitors can increase the tissue expression of ACE2 and its presentation at the cell surface. Thus, it has been suggested that treatment with ACE inhibitors or angiotensin receptor blockers might increase the risk of COVID-19 after exposure to SARS-CoV-2. However, there are several reports showing that the treatment of hypertension with RAS inhibitors is not associated with a substantial increase in the likelihood of a positive test for COVID-19 or in the risk of severe COVID-19. Recently, Matsuzawa et al. suggested that RAS inhibitors do not increase the risk of COVID-19. Furthermore, they propose that RAS inhibitors reduce the risk of disease severity among older age individuals and patients with diabetes. RAS inhibitors have been reported to play a role in the reduction of inflammation by blocking the downregulation of ACE2 and the hyperactivation of RAS. It is also suggested that elevated angiotensin II plays a crucial pathological role in the development of severe COVID-19.

Lack of Association of Antihypertensive Drugs with the Risk and Severity of COVID-19: A Meta-Analysis

Journal of Cardiology, November 2, 2020

The association of antihypertensive drugs with the risk and severity of COVID-19 remains unknown. We systematically searched PubMed, MEDLINE, The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and medRxiv for publications before July 13, 2020. Cohort studies and case-control studies that contain information on the association of antihypertensive agents including angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium-channel blockers (CCBs), β-blockers, and diuretics with the risk and severity of COVID-19 were selected. The random-effects or fixed-effects models were used to pool the odds ratio (OR) with 95% confidence interval (CI) for the outcomes. Our literature search yielded 53 studies that satisfied our inclusion criteria, which comprised 39 cohort studies and 14 case-control studies. These studies included a total of 2,100,587 participants. We observed no association between prior usage of antihypertensive medications including ACEIs/ARBs, CCBs, β-blockers, or diuretics and the risk and severity of COVID-19. Additionally, when only hypertensive patients were included, the severity and mortality were lower with prior usage of ACEIs/ARBs (overall OR of 0.81, 95% CI 0.66-0.99, p < 0.05 and overall OR of 0.77, 95% CI 0.66-0.91, p < 0.01).

Hypertension management in 2030: a kaleidoscopic view

Journal of Human Hypertension, November 2, 2020

The last decade has witnessed the healthcare system going paperless with increased use of electronic healthcare records. Artificial intelligence tools including smartphones and smart watches have changed the landscape of day-to-day lives. Digitisation, decentralisation of healthcare and empowerment of allied healthcare providers and patients themselves have made shared clinical decision-making a reality. The year 2020 quickly turned into an unprecedented time in our lives with the entry of COVID-19. Amidst a pandemic, healthcare systems rapidly adapted and transformed, and changes that otherwise would have taken a decade, took a mere few weeks (Webster, Lancet 395:1180–1, 2020). This essay reviews evidence of transformation in the realm of hypertension management, namely diagnosis, lifestyle changes, therapeutics and prevention of hypertension at both individual and population levels, and presents an extrapolation of how this transformation might shape the next decade.

Q&A: Is convalescent plasma effective for COVID-19?

Helio | Infectious Disease, November 2, 2020

Researchers reported recently in The BMJ that convalescent plasma was not associated with a reduction in progression to severe COVID-19 or all-cause mortality in adults with moderate disease. The results were from a phase 2 randomized controlled trial conducted at 39 hospitals in India. Healio spoke with Shmuel Shoham, MD, an associate professor of medicine at Johns Hopkins University School of Medicine, about the clinical implications of the new study, and how convalescent plasma has been used since receiving emergency use authorization (EUA) from the FDA in August.

Statins lower COVID-19 mortality rate for hospitalized adults with diabetes

Helio | Endocrinology, November 2, 2020

Adults with diabetes admitted to a New York City hospital with COVID-19 had a lower mortality risk if they received a statin, according to a study published in the Journal of the American Heart Association.
“In this analysis involving a large cohort of hospitalized patients with COVID-19, statin use was associated with reduced in-hospital mortality in patients with diabetes,” Omar Saeed, MD, attending cardiologist at Montefiore Medical Center and assistant professor of medicine at Albert Einstein College of Medicine in New York, and colleagues wrote. “This observation was made despite older age, higher prevalence of hypertension and atherosclerotic heart disease in diabetic statin users.” In the diabetes group, a greater number of statin recipients had a history of hypertension (91% vs. 84%; P < .01) and atherosclerotic heart disease (46% vs. 28%; P < .01) than nonrecipients. The statin recipient group also had lower C-reactive protein (10.2 mg/dL vs. 12.9 mg/dL; P < .01) and ferratin (683 ng/mL vs. 786 ng/mL; P = .048) at presentation when compared with nonrecipients. Blood glucose level was similar between the two groups.

Stay-At-Home Orders; Heart Injury and COVID-19

MedPage Today, October 31, 2020

[Podcast/Transcript] This podcast, TTHealthWatch, is a weekly feature from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary. This week’s topics include the impact of stay-at-home orders, taking care of sequelae of mild and moderate COVID, giving acute health problems a miss, and cardiac complications of COVID.

Noncoding RNAs implication in cardiovascular diseases in the COVID-19 era

Journal of Translational Medicine, October 31, 2020

COronaVIrus Disease 19 (COVID-19) is caused by the infection of the Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2). Although the main clinical manifestations of COVID-19 are respiratory, many patients also display acute myocardial injury and chronic damage to the cardiovascular system. Understanding both direct and indirect damage caused to the heart and the vascular system by SARS-CoV-2 infection is necessary to identify optimal clinical care strategies. The homeostasis of the cardiovascular system requires a tight regulation of the gene expression, which is controlled by multiple types of RNA molecules, including RNA encoding proteins (messenger RNAs) (mRNAs) and those lacking protein-coding potential, the noncoding-RNAs. In the last few years, dysregulation of noncoding-RNAs has emerged as a crucial component in the pathophysiology of virtually all cardiovascular diseases. Here we will discuss the potential role of noncoding RNAs in COVID-19 disease mechanisms and their possible use as biomarkers of clinical use.

Hyperthrombotic Milieu in COVID-19 Patients

Cells, October 31, 2020

COVID-19 infection has protean systemic manifestations. Experience from previous coronavirus outbreaks, including the current SARS-CoV-2, has shown an augmented risk of thrombosis of both macrovasculature and microvasculature. The former involves both arterial and venous beds manifesting as stroke, acute coronary syndrome and venous thromboembolic events. The microvascular thrombosis is an underappreciated complication of SARS-CoV-2 infection with profound implications on the development of multisystem organ failure. The telltale signs of perpetual on-going coagulation and fibrinolytic cascades underscore the presence of diffuse endothelial damage in the patients with COVID-19. These parameters serve as strong predictors of mortality. While summarizing the alterations of various components of thrombosis in patients with COVID-19, this review points to the emerging evidence that implicates the prominent role of the extrinsic coagulation cascade in COVID-19-related coagulopathy. These mechanisms are triggered by widespread endothelial cell damage (endotheliopathy), the dominant driver of macro- and micro-vascular thrombosis in these patients. We also summarize other mediators of thrombosis, clinically relevant nuances such as the occurrence of thromboembolic events despite thromboprophylaxis (breakthrough thrombosis), current understanding of systemic anticoagulation therapy and its risk–benefit ratio. We conclude by emphasizing a need to probe COVID-19-specific mechanisms of thrombosis to develop better risk markers and safer therapeutic targets.

Myopericarditis and myositis in a patient with COVID-19: a case report

European Heart Journal, October 30, 2020

[Case Report] Concurrent myopericarditis and myositis can present in patients with pre-existing systemic inflammatory diseases. Here we present a case of myopericarditis and myositis associated with COVID-19, in the absence of respiratory symptoms. This case presents a middle-aged female with a history of hypertension and previous myopericarditis. The patient was admitted with symptoms of central chest pain, and ECG and echocardiographic features of myopericarditis. Her symptoms did not improve, and CT thorax suggested possible SARS-CoV-2 infection for which she tested positive, despite no respiratory symptoms. Whilst on the ward, she developed bilateral leg weakness and a raised creatine kinase (CK), and magnetic resonance imaging (MRI) of her thighs confirmed myositis. A cardiac MRI confirmed myopericarditis. She was treated with colchicine 500 μg twice daily, ibuprofen 400 mg three times day, and prednisolone 30 mg per day, and her symptoms and weakness improved. We describe the first reported case of concurrent myopericarditis, and myositis associated with COVID-19. Conventional therapy with colchicine, non-steroidal anti-inflammatory drugs, and glucocorticoids improved her symptoms, and reduced biochemical markers of myocardial and skeletal muscle inflammation.

Osmotic Adaptation by Na+-Dependent Transporters and ACE2: Correlation with Hemostatic Crisis in COVID-19

Biomedicines, October 30, 2020

COVID-19 symptoms, including hypokalemia, hypoalbuminemia, ageusia, neurological dysfunctions, D-dimer production, and multi-organ microthrombosis reach beyond effects attributed to impaired angiotensin-converting enzyme 2 (ACE2) signaling and elevated concentrations of angiotensin II (Ang II). Although both SARS-CoV (Severe Acute Respiratory Syndrome Coronavirus) and SARS-CoV-2 utilize ACE2 for host entry, distinct COVID-19 pathogenesis coincides with the acquisition of a new sequence, which is homologous to the furin cleavage site of the human epithelial Na+ channel (ENaC). This review provides a comprehensive summary of the role of ACE2 in the assembly of Na+-dependent transporters of glucose, imino and neutral amino acids, as well as the functions of ENaC. Data support an osmotic adaptation mechanism in which osmotic and hemostatic instability induced by Ang II-activated ENaC is counterbalanced by an influx of organic osmolytes and Na+ through the ACE2 complex. We propose a paradigm for the two-site attack of SARS-CoV-2 leading to ENaC hyperactivation and inactivation of the ACE2 complex, which collapses cell osmolality and leads to rupture and/or necrotic death of swollen pulmonary, endothelial, and cardiac cells, thrombosis in infected and non-infected tissues, and aberrant sensory and neurological perception in COVID-19 patients. This dual mechanism employed by SARS-CoV-2 calls for combinatorial treatment strategies to address and prevent severe complications of COVID-19.

CT angiography for ischemic stroke accurate in COVID-19 screening

Helio | Cardiology Today, October 29, 2020

Lung evaluation by CT angiography is accurate for fast and early detection for COVID-19 infection in patients with acute ischemic stroke, researchers reported. “CTA of the head and neck done during emergency evaluation for large vessel occlusion typically includes visualization of lung apices, providing the first objective screen for peripheral ground-glass and consolidative opacities suggestive of COVID-19-related pneumonia,” Charles Esenwa, MD, MS, assistant professor and stroke neurologist at the Albert Einstein College of Medicine, and colleagues wrote. The retrospective analysis, published in Stroke, included 57 patients with CTA of the head and neck presenting with acute ischemic stroke at three Montefiore Health System hospitals in Bronx, New York, who were screened for COVID-19 using real-time reverse transcription polymerase chain reaction from March to April. In total, 30 patients tested positive for COVID-19 and 27 tested negative. In those positive for COVID-19, 67% had lung findings highly or very suspicious for COVID-19 pneumonia compared with 7% of patients negative for COVID-19 infection (P < .001). Self-reported clinical symptoms of cough or dyspnea were reported by 13 patients positive for COVID-19, five of whom did not have evidence of COVID-19 on CT angiography apical lung assessment.

New data on soluble ACE2 in patients with atrial fibrillation reveal potential value for treatment of patients with COVID-19 and cardiovascular disease

European Heart Journal, October 29, 2020

[Editorial] In this issue of the European Heart Journal, Wallentin et al. have explored the associations between sACE2, clinical factors, and genetic variability in two international cohorts of elderly patients with atrial fibrillation. They used pre-COVID-19 plasma samples from a subset of ARISTOTLE (n = 3999) and RE-LY (n = 1088). Plasma sACE2 was measured using the Olink Proteomics® Multiplex CVD II96 × 96 panel. Additional cardiovascular biomarkers such as high-sensitive cardiac troponin T (hs-cTnT), N-terminal pro brain natriuretic peptide (NT-proBNP), and growth differentiation factor 15 (GDF-15) were measured using immunoassays. Results from both cohorts were largely similar, with hypertension, diabetes, and chronic heart failure being predominant comorbidities. Importantly, male sex was the strongest independent predictor of sACE2 levels, thus corroborating previous reports. Furthermore, GDF-15, NT-proBNP, hs-cTnT, and D-dimer, which are indicators of cardiovascular disease, diabetes, biological ageing, coagulopathy, and mortality, were associated with higher sACE2 levels. Using DNA from whole blood samples, they further investigated genetic variability to explain plasma ACE2 levels by performing genome-wide association studies (GWAS) in a smaller portion of patients (ARISTOTLE subset n = 1583/3999 and RE-LY subset n = 289/1088). No significant genetic association was found.

Q&A: Navigating ‘the COVID literature tsunami’

Helio | Infectious Disease News, October 29, 2020

As COVID-19 continues to surge across the United States, researchers have been analyzing developments to determine what areas of research should be explored next. In a recent journal article, Ferric C. Fang, MD, professor of laboratory medicine, pathology and microbiology at the University of Washington, and other editors of Clinical Infectious Diseases explored previous research related to COVID-19 virology, epidemiology, presentation, diagnosis, complications, treatment and prevention and summarized the results from several related studies to help researchers and clinicians “surf the COVID literature tsunami.” Healio spoke with Fang about the state of COVID-19 diagnostic and vaccine research, and the role of peer-reviewed studies during the pandemic.

Similar Clinical Course and Significance of Circulating Innate and Adaptive Immune Cell Counts in STEMI and COVID-19

Journal of Clinical Medicine, October 28, 2020

This study aimed to assess the time course of circulating neutrophil and lymphocyte counts and their ratio (NLR) in ST-segment elevation myocardial infarction (STEMI) and coronavirus disease (COVID)-19 and explore their associations with clinical events and structural damage. Circulating neutrophil, lymphocyte and NLR were sequentially measured in 659 patients admitted for STEMI and in 103 COVID-19 patients. The dynamics detected in STEMI (within a few hours) were replicated in COVID-19 (within a few days). In both entities patients with events and with severe structural damage displayed higher neutrophil and lower lymphocyte counts. In both scenarios, higher maximum neutrophil and lower minimum lymphocyte counts were associated with more events and more severe organ damage. NLR was higher in STEMI and COVID-19 patients with the worst clinical and structural outcomes. A canonical deregulation of the immune response occurs in STEMI and COVID-19 patients. Boosted circulating innate (neutrophilia) and depressed circulating adaptive immunity (lymphopenia) is associated with more events and severe organ damage. A greater understanding of these critical illnesses is pivotal to explore novel alternative therapies.

Universal face shield use significantly reduces SARS-CoV-2 infections among HCP

Helio | Primary Care, October 28, 2020

Universal use of face shields by health care personnel at a Texas hospital led to a significant reduction in SARS-CoV-2 infections, data presented at IDWeek show. Mayar Al Mohajer, MD, MBA, FIDSA, FSHEA, an infectious disease specialist at Baylor Saint Luke’s Medical Center, told Healio Primary Care that in April, his institution began requiring health care professionals (HCPs) and patients to wear masks. It simultaneously implemented surveillance testing every 2 weeks for high-risk HCP and for all patients upon admission and prior to undergoing invasive procedures. “Around the end of June, we noticed an increase in the rate of health care personnel testing positive for COVID-19, even though we were implementing all of the basic methods to prevent it,” Al Mohajer said. Consequently, Baylor Saint Luke’s — a quaternary health care system with more than 500 beds and 8,000 HCP — added a requirement that all HCP wear face shields upon entry to the facility, he said. The researchers found that from April 17 to July 5, before face shields were required, Baylor Saint Luke’s weekly positive SARS-CoV-2 infection rates among HCP rose from 0% to 12.9%, and health care-associated infections increased from 0 to 5. From July 6 to July 26, the first few weeks after face shields were required, the positive SARS-CoV-2 infection rate dropped to 2.3%, and health care-associated infections decreased to 0.

Coronavirus Update With Anthony Fauci

JN Learning, October 28, 2020

[Video, 29:50] View/listen in as Howard Bauchner, MD, Editor in Chief, JAMA, interviews Anthony S. Fauci, MD, to discuss the latest developments in the COVID-19 pandemic, including the continued importance of nonpharmaceutical interventions (masking, handwashing, physical distancing) for managing rising case numbers in the US and globally.

Renin–Angiotensin System: An Important Player in the Pathogenesis of Acute Respiratory Distress Syndrome

International Journal of Molecular Science, October 28, 2020

Acute respiratory distress syndrome (ARDS) is characterized by massive inflammation, increased vascular permeability and pulmonary edema. Mortality due to ARDS remains very high and even in the case of survival, acute lung injury can lead to pulmonary fibrosis. The renin–angiotensin system (RAS) plays a significant role in these processes. The activities of RAS molecules are subject to dynamic changes in response to an injury. Initially, increased levels of angiotensin (Ang) II and des-Arg9-bradykinin (DABK), are necessary for an effective defense. Later, augmented angiotensin converting enzyme (ACE) 2 activity supposedly helps to attenuate inflammation. Appropriate ACE2 activity might be decisive in preventing immune-induced damage and ensuring tissue repair. ACE2 has been identified as a common target for different pathogens. Some Coronaviruses, including SARS-CoV-2, also use ACE2 to infiltrate the cells. A number of questions remain unresolved. The importance of ACE2 shedding, associated with the release of soluble ACE2 and ADAM17-mediated activation of tumor necrosis factor-α (TNF-α)-signaling is unclear. The roles of other non-classical RAS-associated molecules, e.g., alamandine, Ang A or Ang 1–9, also deserve attention. In addition, the impact of established RAS-inhibiting drugs on the pulmonary RAS is to be elucidated. The unfavorable prognosis of ARDS and the lack of effective treatment urge the search for novel therapeutic strategies. In the context of the ongoing SARS-CoV-2 pandemic and considering the involvement of humoral disbalance in the pathogenesis of ARDS, targeting the renin–angiotensin system and reducing the pathogen’s cell entry could be a promising therapeutic strategy in the struggle against COVID-19.

Characteristics of cardiac injury in critically ill patients with COVID-19

CHEST, October 27, 2020

Cardiac injury has been reported in up to 30% of COVID-19 patients. However, cardiac injury was mainly defined by troponin elevation without description of associated structural abnormalities and its time course has never been studied. The objective of the study was to answer the question: What are the electrocardiographic and echocardiographic abnormalities as well as their time course in critically ill COVID-19 patients? The cardiac function of 43 consecutive COVID-19 patients admitted in two intensive care units (ICU) was prospectively and repeatedly assessed combining electrocardiographic, cardiac biomarkers and transthoracic echocardiographic analyses from ICU admission (D0) to ICU discharge or death or to a maximum follow-up of 14 days. Cardiac injury was defined by troponin elevation and newly diagnosed electrocardiographic and/or echocardiographic abnormalities. At D0, 49% of patients had a cardiac injury and 70% of patients experienced cardiac injury within the first 14 days of ICU stay, with a median time of occurrence of 3[0-7] days. The most frequent abnormalities were electrocardiographic and/or echocardiographic signs of left ventricular (LV) abnormalities (87% of patients with cardiac injury), right ventricular (RV) systolic dysfunction (47%), pericardial effusion (43%), new-onset atrial arrhythmias (33%), LV relaxation impairment (33%) and LV systolic dysfunction (13%). Between D0 and D14, the incidence of pericardial effusion and of new-onset atrial arrhythmias increased, the incidence of electrocardiographic and/or echocardiographic signs of LV abnormalities as well as the incidence of LV relaxation impairment remained stable, whereas the incidence of RV and LV systolic dysfunction decreased.

Top in ID: COVID-19 case counts, spike in US death rate

Helio | Infectious Diseases, October 27, 2020

During a special session at IDWeek, Anthony S. Fauci, MD, said many countries, including the United States, are experiencing a surge in COVID-19 cases. It was the top story in infectious disease last week. Another top story was about new data showing a 20% spike in mortality during a 4-month period in the U.S. Many countries are seeing a spike in COVID-19, including the U.S., where a third wave has pushed the number of cases above 8.2 million, including 220,000 deaths. The U.S. had a mortality rate that was 20% higher than expected between March and July, and it experienced high COVID-19-related mortality and excess all-cause deaths into September, according to results from two JAMA studies. As scientists test treatments and vaccines against COVID-19, Healio spoke with Infectious Disease News Editorial Board Member Peter Chin-Hong, MD, about which populations are being left out of COVID-19 research and what needs to happen to make the process more inclusive.

Higher COVID Death Risk Spelled Out by Troponins, ECG

MedPage Today, October 26, 2020

Hospitalized patients with COVID-19 and myocardial injury had a broad range of echocardiographic abnormalities that put them at higher risk of in-hospital mortality, according to registry data from spring 2020. Among 305 patients with lab-confirmed SARS-CoV-2 infection who underwent transthoracic echocardiography (TTE) and ECG evaluation, 62.6% had troponin elevations suggestive of myocardial injury (either at hospital admission or later during the hospitalization), according to Gennaro Giustino, MD, of Icahn School of Medicine at Mount Sinai in New York City, and colleagues. Those with myocardial injury had more ECG abnormalities and higher levels of inflammatory and coagulation biomarkers. Additionally, they were more likely to have any major echocardiographic abnormalities (63.2% vs 21.7% in people without myocardial injury, OR 6.17, 95% CI 3.62-10.51).”The echocardiographic abnormalities were diverse and included global LV [left ventricular] dysfunction, regional wall motion abnormalities, diastolic dysfunction, RV [right ventricular] dysfunction, and pericardial effusions, among others,” Giustino’s group wrote in the Journal of the American College of Cardiology.

FDA clears cardiopulmonary bypass support system for use in COVID-19, other conditions

Helio | Cardiology Today, October 26, 2020

Abiomed announced its compact cardiopulmonary bypass system received 510(k) clearance from the FDA. During cardiopulmonary bypass, the compact new system (Breethe OXY-1, Abiomed) can help provide oxygenation in patients with cardiogenic shock or respiratory failure from causes such as acute respiratory distress syndrome, H1N1, SARS or COVID-19 for up to 6 hours, according to a press release from the company. “The Breethe system is a breakthrough technology because it supports transition from bed to ambulation via system portability,” Zachary Kon, MD, associate professor of cardiothoracic surgery at the NYU Grossman School of Medicine, said in the release. “This system has the potential to revolutionize the way we think about extracorporeal life support therapy and can improve patient care.” According to the release, in a study of 686 consecutive patients published in Circulation, use of the new system, in combination with Abiomed’s heart pump (Impella), was associated with increased 30-day survival (43% vs. 37%; P = .03).

Performance of 5 Immunoassays for SARS-CoV-2 Compared

Pulmonology Advisor, October 26, 2020

A comparative assessment of the performance of 4 widely available antibody immunoassays and 1 novel immunoassay showed that these assays can be used for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serologic testing to achieve sensitivity and specificity of at least 98%, according to study results published in The Lancet Infectious Diseases. Study authors conducted a head-to-head assessment of the following 4 commercial antibody assays, with the aim of evaluating the performance of each assay:

  • SARS-CoV-2 IgG assay (Abbott, Chicago, IL, USA)
  • LIAISON SARS-CoV-2 S1/S2 IgG assay (DiaSorin, Saluggia, Italy)
  • Elecsys Anti-SARS-CoV-2 assay (Roche, Basel, Switzerland)
  • SARS-CoV-2 Total assay (Siemens, Munich, Germany)

The Abbott and Roche assays are known to detect antibodies to the nucleoprotein, whereas the DiaSorin and Siemens assays detect antibodies to the spike glycoprotein. The Abbott and Diasorin assays detect immunoglobulin (Ig)G only, whereas the Roche and Siemens assays detect total antibody. Study authors compared these 4 assays and a novel 384-well ELISA (the Oxford immunoassay) that detects total IgG to a trimeric spike protein.

Hypertension and renin-angiotensin system blockers are not associated with expression of angiotensin-converting enzyme 2 (ACE2) in the kidney

European Heart Journal, October 26, 2020

Angiotensin-converting enzyme 2 (ACE2) is the cellular entry point for severe acute respiratory syndrome coronavirus (SARS-CoV-2)—the cause of coronavirus disease 2019 (COVID-19). However, the effect of renin-angiotensin system (RAS)-inhibition on ACE2 expression in human tissues of key relevance to blood pressure regulation and COVID-19 infection has not previously been reported. In this study, we examined how hypertension, its major metabolic co-phenotypes, and antihypertensive medications relate to ACE2 renal expression using information from up to 436 patients whose kidney transcriptomes were characterized by RNA-sequencing. We further validated some of the key observations in other human tissues and/or a controlled experimental model. Our data reveal increasing expression of ACE2 with age in both human lungs and the kidney. We show no association between renal expression of ACE2 and either hypertension or common types of RAS inhibiting drugs. We demonstrate that renal abundance of ACE2 is positively associated with a biochemical index of kidney function and show a strong enrichment for genes responsible for kidney health and disease in ACE2 co-expression analysis.

Thromboembolism, CV Complications Common in Hospitalized COVID-19 Patients

American College of Cardiology, October 26, 2020

Patients with COVID-19 have a high frequency of major arterial or venous thromboembolism, major adverse cardiovascular events and symptomatic venous thromboembolism, despite routine thromboprophylaxis. Gregory Piazza, MD, MS, FACC, et al., abstracted data from the electronic health records (EHRs) of the Mass General Brigham integrated health network. Researchers identified 1,114 patients age 18 years or older who tested positive for COVID-19 from March 13 to April 3, 2020. Of the total cohort, 170 were treated in the intensive care unit (ICU); 229 in non-ICU settings; and 715 in an outpatient clinic. The results show 22.3% of patients were Hispanic/Latinx and 44.2% were nonwhite. Common cardiovascular risk factors included hypertension (35.8%), hyperlipidemia (28.6%) and diabetes (18%). According to the researchers, arterial or venous thromboembolism and major adverse cardiovascular events are common among ICU patients with COVID-19. They note that COVID-19 patients hospitalized in non-ICU settings are also susceptible to cardiovascular complications. The high rates of thromboembolism despite prophylaxis “suggests the need for improved risk stratification and enhanced preventive efforts,” they conclude.

6% of US adults hospitalized with COVID-19 work in health care

Helio | Infectious Disease News, October 26, 2020

In the United States, 6% of adults hospitalized with COVID-19 are health care personnel, an analysis indicated. Almost 30% of health care personnel (HCP) with COVID-19 were admitted to the ICU, according to results published in MMWR. “Findings from this analysis of data from a multisite surveillance network highlight the prevalence of severe COVID-19-associated illness among HCP and potential for transmission of SARS-CoV-2 among HCP, which could decrease the workforce capacity of the health care system,” Anita K. Kambhampati, MPH, and colleagues from the CDC’s COVID-NET Surveillance Team, wrote. “HCP, regardless of any patient contact, should adhere strictly to recommended infection prevention and control guidance at all times in health care facilities to reduce transmission of SARS-CoV-2, including proper use of recommended personal protective equipment, hand hygiene, and physical distancing.” According to Kambhampati and colleagues, among 6,760 adults hospitalized with COVID-19 in 13 states between March 1 and May 31, 5.9% were HCP. Among the infected HCP, 36.3% worked in nursing-related occupations and 67.4% were expected to have direct contact with patients. A total of 89.8% of HCP had an underlying medical condition, with obesity being the most common one (72.5%).

Majority of COVID-19 Patients With Myocardial Injury Have Cardiac Structural Abnormalities

American College of Cardiology, October 26, 2020

Cardiac structural abnormalities were present in nearly two-thirds of patients with COVID-19 and myocardial injury, according to a study published October 26, 2020. Gennaro Giustino, MD, et al., sought to identify the echocardiographic abnormalities associated with myocardial injury and their prognostic impact in patients with COVID-19 by examining data from COVID-19 patients who underwent a transthoracic echocardiographic (TTE) evaluation during their hospitalization. The data was collected at seven clinical sites in New York City and Milan, Italy between March 5 and May 2, 2020. Of the 305 patients included in the study, 190 patients (62.6%) had biomarker evidence of myocardial injury. Patients with myocardial injury had higher inflammatory biomarkers and an increased prevalence of major echocardiographic abnormalities, including left ventricular wall motion abnormalities, global left ventricular dysfunction and more. Results showed the rate of in-hospital mortality was 5.2% in patients without myocardial injury; 18.6% in patients with myocardial injury without TTE; and 31.7% in patients with myocardial injury and TTE abnormalities. “Myocardial injury is associated with increased risk of in-hospital mortality particularly in the presence of cardiac structural abnormalities detected by TTE,” write the authors.

Cardiac Adverse Events With Remdesivir in COVID-19 Infection

Cureus, October 24, 2020

[Case Report] Since December 2019, coronavirus has gradually progressed to a pandemic with no efficacious treatment. Remdesivir is an antiviral medication and inhibitor of viral RNA dependent RNA polymerase with inhibitory action against SARS-CoV virus. Remdesivir was recently approved for compassionate use intravenously for COVID-19 patients. It functions as an adenosine analog that introduces itself into viral RNA, leading to premature chain termination and viral replication inhibition. The most common adverse effects of remdesivir are increased hepatic enzymes, diarrhea, anemia, rash, renal impairment, and hypotension. Elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST) have been shown to be reversible after discontinuation of remdesivir per studies. The purpose of our case reports is to highlight two cases of patients diagnosed with coronavirus infection with worsening respiratory status. They were initiated with multimodality therapy with antibiotics, steroids and remdesivir. After initiation of remdesivir, the patients’ developed bradycardia, with one of the two also showing signs of worsening QT interval. This reverted upon stopping remdesvir therapy. The prevalence of bradycardia with prolonged QT interval is not well-known yet with this medication.

Covid-19 and Major Organ Thromboembolism: Manifestations in Neurovascular and Cardiovascular Systems

Journal of Stroke & Cerebrovascular Diseases, October 24, 2020

COVID-19, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been shown to cause multisystemic damage. We undertook a systematic literature review and comprehensive analysis of a total of 55 articles on arterial and venous thromboembolism in COVID19 and articles on previous pandemics with respect to thromboembolism and compared the similarities and differences between them. The presence of thrombosis in multiple organ systems points to thromboembolism being an integral component in the pathogenesis of this disease. Thromboembolism is likely to be the main player in the morbidity and mortality of COVID -19 in which the pulmonary system is most severely affected. We also hypothesize that D-dimer values could be used as an early marker for prognostication of disease as it has been seen to be raised even in the pre-symptomatic stage. This further strengthens the notion that thromboembolism prevention is necessary. We also examined literature on the cerebrovascular and cardiovascular systems, as the manifestation of thromboembolic phenomenon in these two systems varied, suggesting different pathophysiology of damage. Further research into the role of thromboembolism in COVID-19 is important to advance the understanding of the virus, its effects and to tailor treatment accordingly to prevent further casualties from this pandemic.

Novel Behavior of the 2019 Novel Coronavirus With Invasion of the Cardiac Conduction System in the Young

Cureus, October 23, 2020

[Case Report] On January 7, 2020, a novel coronavirus, originally abbreviated as 2019-nCoV by the World Health Organization (WHO), was identified from a throat swab sample. This pathogen was later renamed the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) by the Coronavirus Study Group, and the disease was named coronavirus disease 2019 (COVID-19) by the WHO. Based on the report of the first 425 confirmed cases in Wuhan, common symptoms include fever, dry cough, myalgia, and fatigue; less common symptoms are sputum production, headache, hemoptysis, abdominal pain, and diarrhea. A descriptive, exploratory analysis of the first 72,314 cases of COVID-19 revealed that cardiovascular involvement was reported in just 10.5% of cases, but it was never the sole manifestation. We report the case of a 35-year-old man (an oil engineer) referred as a coronavirus disease-2019 (COVID-19) case with heart block and a four-day history of headache and fever. The patient was hemodynamically stable with normal respiratory effort and oxygen saturation. Three consecutive COVID-19 tests were positive since admission. Comprehensive clinical assessment investigations were performed. Apart from mild acute phase reactants elevation, all results were within reference limits. He had no leukocytosis and normal cardiac enzymes, chest x-ray findings, echocardiography findings, and healthy coronary arteries.

Statins and SARS-CoV-2 disease: Current concepts and possible benefits

Diabetes & Metabolic Syndrome: Clinical Research & Reviews, October 23, 2020

Inflammation-mediated tissue injury is the major mechanism involved in the pathogenesis of coronavirus disease 2019 (COVID-2019), caused by Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2). Statins have well-established anti-inflammatory, anti-thrombotic and immuno-modulatory effects. They may also influence viral entry into human cells. A literature search was done using PubMed and Google search engines to prepare a narrative review on this topic. Statins interact with several different signaling pathways to exert their anti-inflammatory and vasculoprotective effects. They also variably affect cholesterol content of cell membranes and interfere with certain coronavirus enzymes involved in receptor-binding. Both these actions may influence SARS-CoV-2 entry into human cells. Statins also upregulate expression of ACE2 receptors on cell surfaces which may promote viral entry into the cells but at the same time, may minimize tissue injury through production of angiotensin. The net impact of these different effects on COVID-19 pathogenesis is not clear. However, the retrospective clinical studies have shown that statin use is potentially associated with lower risk of developing severe illness and mortality and a faster time to recovery in patients with COVID-19.

COVID-19 can affect the heart COVID-19 has a spectrum of potential heart manifestations with diverse mechanisms

Science, October 23, 2020

The family of seven known human coronaviruses are known for their impact on the respiratory tract, not the heart. However, the most recent coronavirus, SARSCoV-2, has marked tropism for the heart and can lead to myocarditis (inflammation of the heart), necrosis of its cells, mimicking of a heart attack, arrhythmias, and acute or protracted heart failure (muscle dysfunction). Recent findings of heart involvement in young athletes, including sudden death, have raised concerns about the current limits of our knowledge and potentially high risk and occult prevalence of COVID-19 heart manifestations. What appears to structurally differentiate SARS-CoV-2 from SARS is a furin polybasic site that, when cleaved, broadens the types of cells (tropism) that the virus can infect. The virus targets the angiotensin-converting enzyme 2 (ACE2) receptor throughout the body, facilitating cell entry by way of its spike protein, along with the cooperation of the cellular serine protease transmembrane protease serine 2 (TMPRSS2), heparan sulfate, and other proteases. The heart is one of the many organs with high expression of ACE2. Moreover, the affinity of SARS-CoV-2 to ACE2 is significantly greater than that of SARS. The tropism to other organs beyond the lungs has been studied from autopsy specimens: SARS-CoV-2 genomic RNA was highest in the lungs, but the heart, kidney, and liver also showed substantial amounts, and copies of the virus were detected in the heart from 16 of 22 patients who died. In an autopsy series of 39 patients dying from COVID-19, the virus was not detectable in the myocardium in 38% of patients, whereas 31% had a high viral load above 1000 copies in the heart.

Relative Bradycardia in Patients with Mild-to-Moderate Coronavirus Disease, Japan

Center for Disease Control and Prevention | Emerging Infectious Diseases, October 23, 2020

Pulse rate usually increases 18 beats/min for each 1°C increase in body temperature. However, in some specific infectious diseases, pulse rate does not increase as expected, a condition called relative bradycardia. High fever (temperature >39°C) for patients with COVID-19 has been reported, but the association between fever and pulse rate has not been investigated. We investigated relative bradycardia as a characteristic clinical feature in patients with mild-to-moderate COVID-19. Retrospective analyses of routinely collected clinical records of COVID-19 patients were approved by the ethics committee of the Institute of Medical Science. During March 1–May 14, we identified all adult hospitalized patients with COVID-19 at a university hospital in Tokyo, Japan. We confirmed diagnoses of COVID-19 by using reverse transcription PCR. Patients who had known factors that could affect pulse rate (e.g., concurrent conditions or medications) were excluded. We obtained the highest body temperature in each day during hospitalization and the pulse rate at the time. To account for within-person correlation, we used 2-level mixed-effects linear regression (with random intercept) for analysis of factors associated with pulse rate: age, sex, time from first symptoms, systolic blood pressure, diastolic blood pressure, respiratory rate, and percutaneous oxygen saturation. We performed variable selection by backward elimination using a p value of 0.05 by likelihood ratio test as the cutoff value. We performed statistical analysis by using Stata MP 15.1. Relative bradycardia was defined as an increase in pulse rate <18 beats/min for each 1°C increase in body temperature. [Read the results.]

Acute kidney injury associated with COVID-19: a prognostic factor for pulmonary embolism or co-incidence?

European Heart Journal, October 23, 2020

[Case Study] An 81-year-old gentleman presented with fever (39.1°C), cough, dysuria, and urinary tract infection, which warranted antibiotic therapy. Medical history included insulin-dependent type 2 diabetes mellitus, arterial hypertension, and third-degree atrioventricular block with an implanted pacemaker. The patient was intubated and required mechanical ventilation for severe respiratory failure (Horowitz index of 64.2 mmHg) 6 days after hospitalization. SARS-CoV-2 polymerase chain reaction (PCR) test on nasopharyngeal swabs was positive and chest computed tomography (CT) illustrated bilateral ground-glass opacities (Panel A). Laboratory tests showed a remarkable increase in the inflammatory cytokine interleukin-6 (270.6 pg/mL) and C-reactive protein (CRP; 222.7 mg/L). In the second week, he developed acute kidney injury (AKI) [creatinine, 296 μmol/L; blood urea nitrogen (BUN), 14.6 μmol/L, and estimated glomerular filtration rate (eGFR) 16 mL/min/1.73 m2], and consequently continuous haemodialysis was initiated. Fifteen days later, D-dimer levels were strikingly elevated (15 293 μg/L), and CT pulmonary angiography revealed segmental pulmonary embolism (PE) in the right upper lobe (Panel B) without signs of right ventricular failure (Supplementary material online, Video 1). ECG showed new onset of atrial fibrillation. Anticoagulation with unfractionated heparin was implemented. The patient remained in the intensive care unit until recovery of pulmonary function, but dialysis continued for 24 days to be prepared for discharge.

FDA OKs Remdesivir, First Drug for COVID-19

MedPage Today, October 22, 2020

The FDA approved remdesivir (Veklury) on Thursday for treating hospitalized COVID-19 patients, a first for the disease that started a global pandemic. Remdesivir, an antiviral that works by limiting SARS-CoV-2 replication, is indicated for hospitalized patients age 12 and up (and at least 40 kg [88.2 lbs]). Previously, the intravenous drug was solely available under an emergency use authorization (EUA) from the agency. FDA also announced a new EUA for remdesivir in hospitalized kids age 12 and older weighing at least 3.5 kg (7.7 lbs) but less than 40 kg, and in kids under age 12 weighing at least 3.5 kg. The news comes exactly a week after a major international trial led by the World Health Organization (WHO) found no survival improvement for hospitalized COVID-19 patients treated with the drug, and no improvement in time to recovery. Approval was based on three randomized trials, including the National Institutes of Health-led ACTT-1 trial, a phase III trial that showed that patients with mild, moderate, and severe disease who were treated with up to 10 days of remdesivir recovered a median 5 days quicker than those on placebo (10 vs 15 days; rate ratio [RR] 1.29, 95% CI 1.12-1.49, P<0.001), and a median 7 days quicker in those requiring oxygen at baseline (11 vs 18 days; RR 1.31, 95% CI 1.12-1.52).

The Cross-Talk between Age, Hypertension and Inflammation in COVID-19 Patients: Therapeutic Targets

Drugs & Aging, October 21, 2020

This paper presents a brief overview of the complex interaction between age, hypertension, the renin–angiotensin–aldosterone system (RAAS), inflammation, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection. Coronavirus disease 2019 (COVID-19) is more frequent and more severe in comorbid elderly patients, especially those with hypertension, diabetes, obesity, or cardiovascular diseases. There are concerns regarding the use of RAAS inhibitors in patients with COVID-19. Some physicians have considered the need for interrupting RAAS inhibition in order to reduce the possibility of SARS-CoV2 entering lung cells after binding to angiotensin-converting enzyme 2 (ACE2) receptors. We offer a different point of view in relation to the need for continuing to use RAAS inhibitors in patients with COVID-19. We focused our article on elderly patients because of the distinctive imbalance between the immune response, which is depressed, and the exacerbated inflammatory response, ‘inflammaging’, which makes the geriatric patient an appropriate candidate for therapeutic strategies aimed at modulating the inflammatory response. Indeed, COVID-19 is an inflammatory storm that starts and worsens during the course of the disease. During the COVID-19 pandemic, various therapeutic approaches have been tested, including antiviral drugs, interferon, anti-interleukins, hydroxychloroquine, anti-inflammatories, immunoglobulins from recovered patients, and heparins. Some of these therapeutic approaches did not prove to be beneficial, or even induced serious complications. Based on current evidence, in the early stages of the disease modulation of the inflammatory response through the inhibition of neprilysin and modulation of the RAAS could affect the course and outcome of COVID-19.

The Impact of COVID-19 on Physician Burnout Globally: A Review

Healthcare, October 22, 2020

The current pandemic, COVID-19, has added to the already high levels of stress that medical professionals face globally. While most health professionals have had to shoulder the burden, physicians are not often recognized as being vulnerable and hence little attention is paid to morbidity and mortality within this group. Our objective was to analyse and summarise the current knowledge on factors/potential factors contributing to burnout amongst healthcare professionals amidst the pandemic. This review also makes a few recommendations on how best to prepare intervention programmes for physicians. In August 2020, a systematic review was performed using the database Medline and Embase (OVID) to search for relevant papers on the impact of COVID-19 on physician burnout–the database was searched for terms such as “COVID-19 OR pandemic” AND “burnout” AND “healthcare professional OR physician”. A manual search was done for other relevant studies included in this review. Results: Five primary studies met the inclusion criteria. A further nine studies were included which evaluated the impact of occupational factors (n = 2), gender differences (n = 4) and increased workload/sleep deprivation (n = 3) on burnout prior to the pandemic. Additionally, five reviews were analysed to support our recommendations. Results from the studies generally showed that the introduction of COVID-19 has heightened existing challenges that physicians face such as increasing workload, which is directly correlated with increased burnout. However, exposure to COVID-19 does not necessarily correlate with increased burnout and is an area for more research.

Bedside Evaluation of Pulmonary Embolism by Saline Contrast Enhanced Electrical Impedance Tomography: Considerations for Future Research

American Journal of Respiratory and Critical Care Medicine, October 22, 2020

[Letter to the Editor] We read with great interest the article by Huaiwu He et al. entitled “bedside evaluation of pulmonary embolism (PE) by saline contrast electrical impedance tomography method: A prospective observational study”. The authors found PE-envoked regional perfusion defection could be detected with saline-contrasted EIT and claimed that the method showed high sensitivity and specificity for diagnosis of PE. However, several factors potentially affecting the reported findings should be discussed. For measurement of pulmonary perfusion, a short apnea is needed during bolus injection of 10ml 10% NaCl to eliminate the interruption from cyclic breath. The conscious patients were required to hold their breath at the end of expiration for 8 seconds or longer. Although the shorter the apnea, the more feasible for conscious patients to hold their breath, it needs imperative time to allow blood mixed with saline to travel through the whole pulmonary circulation. Slutsky, et al. found mean pulmonary transit time (PTT) ranged from 4.3 to 12.6 seconds (mean 7.7 ±1.5 seconds) in human. In this context, it’s questionable that a period with a lower level of 8 seconds is enough for saline to pass through the lung in patients with PE. On the other hand, for those intubated, holding breath for even 8 seconds might be challenging as dyspnea is common among patients with PE, manual expiratory hold is likely to trigger spontaneous breath, which would dramatically impact the intrathoracic electric impedance. To avoid spontaneous breath, sometimes neuromuscular relaxant is needed, which was not detailed in this article. Recently, Mauri et al published a study exploring the ventilation-perfusion ratio in patients with COVID-19, in which a lower concentration (5%) of saline and end-inspiration occlusion for 20 seconds were implemented for determination of pulmonary perfusion.

Fauci: Case counts ‘stunning’ as many places see COVID-19 surge

Helio | Infectious Diseases, October 21, 2020

Many countries are seeing a spike in COVID-19, including the United States, where a third wave has pushed the number of cases above 8.2 million, including 220,000 deaths. “The numbers throughout the globe have been stunning, making this already the most disastrous pandemic that we have experienced in our civilization in over 102 years, since the 1918 influenza pandemic,” Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, said during a special session at IDWeek focused on COVID-19. Fauci noted the global case count: “40 million cases and over 1.1 million deaths.” “Unfortunately, for the United States, we have been hit harder than virtually any other country on the planet,” he said. The Johns Hopkins coronavirus resource center, which tracks state-level trends, has reported recent sharp increases in daily cases in states like North Dakota (803 cases per 100,000 people), Wisconsin (3,317 per 100,000 people), Rhode Island (293 per 100,000 people) and Wyoming (230 per 100,000 people), and declines in states including Arkansas, Kentucky and South Dakota.


International Journal of Clinical Practice, October 20, 2020

[Letter to the Editor] We have observed hypernatraemia and hypokalaemia with normal serum urea and creatinine associated with new-onset hypertension among COVID-19 patients. We assessed the reninangiotensin-aldosterone system (RAAS) of 2 patients during the pandemic and found elevated urinary potassium (without causal medications) and hyporeninaemic hypoaldosteronism in both. We fully investigated a fit 74-year-old woman with COVID-19 who developed hypertension (peak blood pressure (BP) 195/120 mmHg), hypokalaemia (range 2.7–3.2 mmol/L) and hypernatraemia (range 150-166 mmol/L) during the first week of admission. There was metabolic alkalosis with pH 7.50, bicarbonate 31mmol/L, partial pressure of carbon dioxide 5.3 kPa. Adjusted calcium and serum magnesium were normal. Urinary potassium (K+) was 19.72 mmol/L and 24.46 mmol/L (0-10) on 2 occasions. Plasma renin and aldosterone levels remained normal thereafter. Congenital forms of hypertension, glucocorticoid resistance and syndrome of apparent mineralocorticoid excess were excluded. There were no features of hypothalamic-pituitary dysfunction. She was treated with amiloride 5mg daily increased to 7.5mg after 3 days with normalisation of serum/urinary K+ and BP within 1 week (Table). After 3 weeks, amiloride was withdrawn and she remained normotensive. Plasma renin and aldosterone levels remained normal thereafter. Transient hyporeninaemic hypoaldosteronism may be related to dysregulated sodium (Na+) channel (ENaC) pathophysiology similar to that in Liddle’s syndrome. Enhanced ENaC activity (highly selective for Na+ over K+) leads to Na+ retention in the distal nephron and K+ and hydrogen ion secretion to maintain tubular neutrality. This results in intravascular volume expansion and hypokalaemic metabolic alkalosis. This hypothesis is supported by reversibility of electrolyte abnormalities and hypertension with the diuretic amiloride, which inhibits Na+ reabsorption by selectively blocking this channel.

The Costs of Coronavirus

Journal of the American Medical Association, October 20, 2020

View/listen in as Howard Bauchner, MD, Editor in Chief, JAMA, interviews authors of three recent features in JAMA:

  • David M. Cutler, PhD, of Harvard University discusses financial costs: the $16 trillion virus.
  • Lisa Cooper, MD, MPH, of Johns Hopkins University discusses the costs to communities of color in excess deaths and bereavement.
  • Charles R. Marmar, MD, of NYU Grossman School of Medicine discusses the mental health costs.

The overlooked tsunami of systemic inflammation in post-myocardial infarction cardiogenic shock

European Journal of Predictive Cardiology, October 20, 2020

The incidence of acute myocardial infarction (MI)-derived cardiogenic shock (CS) has increased remarkably over the past decade, from 6.5% in 2003 to 10.1% in 2010. During the same period, in-hospital mortality has remained stable in the range of 40–50% despite significant advances in revascularization and supportive care, such as the use of mechanical circulatory support (MCS). Post-MI CS is themost studied mode of CS because pump dysfunction onset in this setting is easily traceable. Nevertheless, nothing we have tried in the last 40 years has worked. In CS, we fool ourselves into thinking that we understand the problem, but what if the fundamental construct is wrong and CS is not just pump failure and low cardiac output? It may well be that our lack of understanding is actually preventing progress, for which alternative hypotheses are urgently needed before we end up insane (see quote above). Veno-arterial extracorporeal membrane oxygenation is the new kid on the block, and although it has shown some promise in survival in some series, large post-MI CS randomized controlled trials are still underway and it may be too early to claim victory. In sum, MCS devices aim to increase flow and restore macrohaemodynamics in a critical state situation characterized by low cardiac output and end-organ hypoperfusion. However, ∼50% of deaths after CS happen despite a cardiac index >2.2 L/min.

Deaths spike 20% in U.S. during 4-month period

Helio | Infectious Disease News, October 19, 2020

The United States had a mortality rate that was 20% higher than expected between March and July, and it experienced high COVID-19-related mortality and excess all-cause deaths into September, according to results from two JAMA studies. The first study explored excess deaths and their relationship to states’ reopening and easing of restrictions. “The number of deaths that are occurring as a result of the pandemic is larger than the COVID-19 death count that is being reported,” Steven Woolf, MD, MPH, director emeritus of the Center on Society and Health at Virginia Commonwealth University, told Healio. “Some of that excess is being produced by people who are dying from causes other than COVID-19 but from disruptions produced by the pandemic itself and our response to it.” In a separate study, Alyssa Bilinski, MSc, a health policy PhD candidate at Harvard University, and Ezekiel J. Emanuel, MD, PhD, vice provost for global initiatives at the University of Pennsylvania, compared COVID-19 deaths and excess all-cause mortality in the U.S. with that of 18 other countries. “The U.S. has experienced more deaths from COVID-19 than any other country and has one of the highest cumulative per capita death rates,” the researchers wrote. “An unanswered question is to what extent high U.S. mortality was driven by the early surge of cases prior to improvements in prevention and patient management vs. a poor longer-term response.”

Cardiology on the cutting edge: updates from the European Society of Cardiology (ESC) Congress 2020

BMC Cardiovascular Disorders, October 19, 2020

[Editorial] The 2020 annual Congress of the European Society of Cardiology (ESC) was the first ever to be held virtually. Under the spotlight of ‘the cutting edge of cardiology’, exciting and ground-breaking cardiovascular (CV) science was presented both in basic and clinical research. This commentary summarizes essential updates from ESC 2020—The Digital Experience. Despite the challenges that coronavirus disease 2019 (COVID-19) has posed on the conduct of clinical trials, the ESC Congress launched the results of major studies bringing innovation to the field of general cardiology, cardiac surgery, heart failure, interventional cardiology, and atrial fibrillation. In addition to three new ESC guidelines updates, the first ESC Guidelines on Sports Cardiology and Exercise in Patients with Cardiovascular Disease were presented. During the ESC 2020 Congress, BMC Cardiovascular Disorders updated to seven journal sections including Arrhythmias and Electrophysiology, CV Surgery, Coronary Artery Disease, Epidemiology and Digital health, Hypertension and Vascular biology, Primary prevention and CV Risk, and Structural Diseases, Heart Failure, and Congenital Disorders. To conclude, an important take-home message for all CV health care professionals engaged in the COVID-19 pandemic is that we must foresee and be prepared to tackle the dramatic, long-term CV complications of COVID-19 patients. In this commentary, we summarized the most important trials presented during the 2020 Virtual ESC Congress which we predict will improve our everyday clinical practice.

Plasma ACE2 and Risk of Death or Cardiometabolic Diseases

American College of Cardiology, October 19, 2020

The study aimed to answer the question, are plasma angiotensin-converting enzyme 2 (ACE2) concentrations associated with risk of death or cardiovascular (CV) events? In this case-cohort study of 10,753 subjects, determinants of plasma ACE2 levels included sex (men >women), ancestry (east Asians highest, south Asians lowest), higher BMI, older age, presence of diabetes, higher cholesterol, higher blood pressure, and smoking. The study included subjects from the PURE (Prospective Urban Rural Epidemiology) project, involving 14 countries across five continents (Africa, Asia, Europe, North America, and South America). Plasma concentrations of ACE2, a counter-regulator of the renin–angiotensin cascade that cleaves angiotensin II, were measured from biobank samples. Clinical outcomes of interest were all-cause and CV death, myocardial infarction (MI), stroke, heart failure (HF), and diabetes mellitus (DM).In models including clinical risk factors, ACE2 was the highest-ranked predictor of total deaths and cardiovascular deaths.

Fauci: No Quick End to Pandemic

MedPage Today, October 19, 2020

In a sobering message to physicians and their patients, the United States’ top infectious disease official suggests the rampaging SARS-CoV-2 pandemic is going to be with us for a while. “We are now in the middle of an explosive pandemic of historic proportions, the likes of which we have not experienced in the last 102 years with over a million deaths worldwide and 38 million cases – and the end is not in sight,” Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, said as keynote speaker at the virtual annual meeting of the American College of Chest Physicians. “Unfortunately for the United States, we are the worst hit country in the world,” Fauci said in his pre-recorded speech. The U.S. case count surpassed 8 million and the death count was nearing 220,000 over the weekend. Fauci noted that the U.S. government is deeply involved in vaccine development, supporting six different candidate vaccines, including five now in phase III trials. “Our strategic approach means we are harmonizing these vaccine trials so they have a common data monitoring and safety board, common primary and secondary endpoints, and common immunological parameters,” he said.

Acute Aortoiliac and Infrainguinal Arterial Thrombotic Events in Four Patients Diagnosed with the Novel Coronavirus 2019 (COVID-19)

Journal of Vascular Surgery Cases and Innovative Techniques, October 19, 2020

The novel coronavirus 2019 (COVID-19) pandemic is seriously challenging the healthcare system globally. Endothelial damage and increased coagulation activity have been reported in some patients with COVID-19 resulting in a variety of thrombotic events. We report on four patients with various severities of COVID-19 presenting with acute arterial thrombosis. While these are rare events, they carry high morbidity and mortality and require prompt diagnosis and treatment. These cases highlight major life and limb threatening clinical sequalae of COVID-19 that frontline medical providers must be aware occur even in the absence of prior cardiovascular disease. Infection with SARS-CoV-2 (COVID-19) has bee