The Impact of Arrhythmia on Prognosis in Hospitalized Covid-19 Patients. A Cardiac Telemetric Monitoring Study

Background: Cardiovascular abnormalities have been largely reported in patients with COVID-19. Among these, myocardial injury and rhythm disorders represent one of the most important complications in patients affected by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection. Moreover, a poorer prognosis has been documented in COVID-19 patients when complicated by arrhythmias, independently by age and sex. Objective(s): The aims of the present study were to identify some of non-cardiac and cardiac comorbidities and some myocardial electrical features (including QT dispersion) associated with arrhythmia in hospitalized COVID-19 patients. Moreover, another objective was to contribute in analyzing the impact of arrhythmias on outcome in this setting of patients. Method(s): At admission, each patient underwent cardiac telemetry monitoring through entire hospitalization period. In all the subjects, laboratory analyses, standard 12-lead electrocardiogram (both at admission and on discharge), and lung imaging examination (by means of both ultrasound scans and computed tomography) were performed. Patients exhibiting arrhythmia during in-hospital period were divided into three groups: i, with brady-arrhythmias;ii, with tachy-arrhythmias;and, iii, with tachy- and brady-arrhythmias. Result(s): Two-hundred patients completed the study (males, 123;mean age, 70.1 years);of these, 80 patients (40%) exhibited rhythm disorders on cardiac telemetry. Patients with arrhythmia resulted to be older (p<0.0001) than patients without arrhythmia. Moreover, patients with arrhythmia showed: i, greater number of comorbidities (p<0.0001);ii, higher values of creatinine (p=0.007), B-type natriuretic peptide (p<0.0001), troponin (p<0.0001), c-reactive protein (p=0.01), ferritin (p=0.001), d-dimer (p<0.0001), and procalcitonin (p=0.0008);iii, QT interval (p=0.002), QTc interval (p=0.04), and QTc dispersion (p=0.01);and, iiii, lower values of sodium (p=0.03), magnesium (p=0.04), glomerular filtration rate (p<0.0001), and hemoglobin (p=0.008) as compared to patients without arrhythmia. By comparing the three subgroups of patients, no significant differences were found. Multivariate analysis showed that age (OR=1.14 [95% CI: 1.07-1.22];p=0.0004), coronary artery disease (OR=12.7 [95% CI: 2.38-68.01];p=0.005), and circulating troponin (OR=1.05 [95% CI: 1.003-1.10];p=0.04) represented risk factors independently associated with arrhythmia. By analyzing allcause in-hospital mortality, it resulted a ~forty-fold higher among patients with arrhythmia (OR=39.66 [95% CI: 5.20-302.51];p=0.0004) when compared to patients without rhythm disorders. Conclusion(s): In the present study, arrhythmias have been to be associated with ageing, coronary artery disease, subtle myocardial injury, hyperinflammatory status, coagulative unbalance, and abnormalities in myocardial electrical impulse propagation in patients affected by SARS-CoV-2 infection. In alignment with previous reports, the presence of arrhythmia seems to be associated with a worse in-hospital prognosis. Given its usefulness, routinary use of cardiac telemetric monitoring should be encouraged in COVID wards.

Predictors of in-hospital mortality of COVID-19 patients and the role of telemetry in an internal medicine ward during the third phase of the pandemic.

OBJECTIVE: The first pandemic phase of COVID-19 in Italy was characterized by high in-hospital mortality ranging from 23% to 38%. During the third pandemic phase there has been an improvement in the management and treatment of COVID-19, so mortality and predictors may have changed. A prospective study was planned to identify predictors of mortality during the third pandemic phase. PATIENTS AND METHODS: From 15 December 2020 to 15 May 2021, 208 patients were hospitalized (median age: 64 years; males: 58.6%); 83% had a median of 2 (IQR,1-4) comorbidities; pneumonia was present in 89.8%. Patients were monitored remotely for respiratory function and ECG trace for 24 hours/day. Management and treatment were done following the timing and dosage recommended by international guidelines. RESULTS: 79.2% of patients necessitated O2-therapy. ARDS was present in 46.1% of patients and 45.4% received non-invasive ventilation and 11.1% required ICU treatment. 38% developed arrhythmias which were identified early by telemetry and promptly treated. The in-hospital mortality rate was 10%. At multivariate analysis independent predictors of mortality were: older age (R-R for≥70 years: 5.44), number of comorbidities ≥3 (R-R 2.72), eGFR ≤60 ml/min (RR 2.91), high d-Dimer (R-R for≥1,000 ng/ml:7.53), and low PaO2/FiO2 (R-R for <200: 3.21). CONCLUSIONS: Management and treatment adherence to recommendations, use of telemetry, and no overcrowding appear to reduce mortality. Advanced age, number of comorbidities, severe renal failure, high d-Dimer and low P/F remain predictors of poor outcome. The data help to identify current high-risk COVID-19 patients in whom management has yet to be optimized, who require the greatest therapeutic effort, and subjects in whom vaccination is mandatory.

Safety profile of pfizer-biontech COVID-19 vaccine in patients with rheumatic diseases: Preliminary assessment

Background: Efficacious vaccines are urgently needed to contain the ongoing coronavirus disease 2019 (Covid-19) pandemic of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). On December 11, 2020, the Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for Pfizer-BioNTech COVID-19 vaccine to prevent COVID-19, administered as 2 doses separated by 21 days (1) On December 27, 2020, Italy started use of Pfizer-BioNTech COVID-19 vaccine and initial doses were reserved for health care personnel Objectives: The primary end points were the safety of each administered dose in patients with Rheumatic diseases (RD's) Methods: In this multicenter, observational study, we interviewed by phone 27 patients with rheumatic diseases (RDs) and 30 healthy subjects receiving the Pfizer-BioNTech vaccine (0.3 ml i.m. in two doses 21 days apart, time 0 and 3 weeks). Results: As of 30 January 2021, 57 subjects (27 patients and 30 healthy subjects) were interviewed. The epidemiological and clinical features of the 27 patients are reported in Table 1. Among the whole population, 35 subjects (16 patients and 19 healthy subjects) complained of an adverse event after the first vaccine dose, with symptom onset occurring within 1 day of vaccination. All adverse events (100%) were classified as nonserious and included: injection site pain (17), fatigue (5), headache (16), fever (3), tachycardia (2), and paresthesia (2). After 21 days, 6 patients and 11 healthy subjects received the second vaccine dose. Fifteen (5 patients and 10 healthy subjects) of them (88%) reported adverse events, again categorized as nonserious. Specifically, injection site pain (7), fatigue (10), headache (10), fever (10), paresthesia (1), cutaneous vasculitis (1), itchy and scratchy throat (1), diarrhea (4), lymph node enlargement (1) were recorded. No differences were noted between patients with RDs and healthy subjects in terms of adverse events. Conclusion: This preliminary study shows that the Pfizer-BioNTech COVID-19 vaccine is as safe in patients with RDs as in healthy subjects. Whether patients with RDs will develop protective titers of anti-SARS-CoV-2 antibodies as compared to healthy subjects will be evaluated in further, ongoing studies.

Telemedicine in rheumatology at time of COVID pandemic

Background: The outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has imposed considerable restrictions on people's mobility in order to limit infection transmission. Before the COVID -19 pandemic tele-rheumatology was proposed to patients living in remote areas. Currently, the use of telemedicine has increased significantly. We report on the implementation of a telemedicine program for the evaluation and treatment of patients with rheumatic diseases (1). Objectives: The aim of the study is to evaluate telemedicine as a viable approach for routine follow-up and management of rheumatic disease. Methods: Sixty-six patients were evaluated online by the remote rheumatologist in four weeks. The population of rheumatology patients was evaluated using a IARPLUS platform Information collected included demographic information consisting of age, gender, and primary rheumatologic diagnosis. Results: The average age of patients who were seen was 54 years and 85% of patients were women. The most common disorders included rheumatoid arthritis (22, 33%), axial spondyloarthropathies (7, 11%), and psoriatic arthritis (15,23%), systemic sclerosis (13, 20%), lupus (6, 9%), UCTD (2,3%), Sjogren and fibromyalgia (1, 1.5%). Results: All patients were given recommendations on COVID-19 vaccine administration. Therapy was remodeled in 13 patients (in particular in 5 patients with anemia intravenous iron infusion was scheduled;1 started immunosuppressant therapy for proteinuria, 4 increased methotrexate for disease activity, 2 discontinued Methotrexate for adverse events (hypertransaminasemia), 1 suspended OH-chloroquine due to retinal accumulation;2 biologic-naive patients, after a three-month of waiting due to inability to come to the hospital, started the biologic drug;22 patients received a renewal of the therapeutic plan;25 patients had a regular six-month follow up;2 ticket exemption for illness;13 consultations and/ or laboratory tests (1 pneumological consultation, 1 ophthalmological consultation, 1 request for sacro-iliac MRI, 3 nailfold videocapillaroscopies, 3 FKT, 1 musculotendinous ultrasound, 1 antibodies for celiac disease, 2 antibodies anti Sars-CoV-2). Conclusion: Telemedicine is becoming more prevalent. We report the successful use of this service in evaluation and management of rheumatic diseases in a period with limited access to rheumatologic care. We have shown that patients can be seen, evaluated, and successfully treated with a variety of medications, including biologic agents, and evaluated for both chronic inflammatory arthropaties and connective tissue diseases.

Clinical application of lung ultrasound score on COVID-19 setting: a regional experience in Southern Italy.

OBJECTIVE: We aimed to assess the correlation between LUS Soldati proposed score and clinical presentation, course of disease and the possible need of ventilation support/intensive care. PATIENTS AND METHODS: All consecutive patients with laboratory confirmed SARS-CoV-2 infection and hospitalized in two COVID Centers were enrolled. All patients performed blood gas analysis and lung ultrasound (LUS) at admission. The LUS acquisition was based on standard sequence of 14 peculiar anatomic landmarks with a score between 0-3 based on impairment of LUS picture. Total score was computed with their sum with a total score ranging 0 to 42, according to Soldati LUS score. We evaluated the course of hospitalization until either discharge or death, the ventilatory support and the transition in intensive care if needed. RESULTS: One hundred and fifty-six patients were included in the final analysis. Most of patients presented moderate-to-severe respiratory failure (FiO2 <20%, PaO2 <60 mmHg) and consequent recommendation to invasive mechanic ventilation (CPAP/NIV/OTI). The median ultrasound thoracic score was 28 (IQR 18-36) and most of patients could be ascertained either in a score 2 (40%) or score 3 pictures (24.4%). The bivariate correlation analysis displayed statistically significant and high positive correlations between the LUS score and the following parameters: ventilation (rho=0.481, p<0.001), lactates (rho=0.464, p<0.001), dyspnea (rho=0.398, p=0.001) mortality (rho=0.410, p=0.001). Conversely, P/F (rho= -0.663, p<0.001), pH (rho = -0.363, p=0.003) and pO2 (rho = -0.400 p=0.001) displayed significant negative correlations. CONCLUSIONS: LUS score improve the workflow and provide an optimal management both in early diagnosis and prognosis of COVID-19 related lung pathology.