Post-Acute Sequelae of COVID-19: The Potential Role of Exercise Therapy in Treating Patients and Athletes Returning to Play.

Post-acute sequelae of coronavirus disease 19 (COVID-19) (PASC) describe a wide range of symptoms and signs involving multiple organ systems occurring after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, representing a growing health problem also in the world of sport and the athletic population. Patients with PASC have new, returning, or persisting symptoms four or more weeks after the infection. Among the most frequent symptoms, patients complain of fatigue, dyspnea, exercise intolerance, and reduced functional capacity that interfere with everyday life activity. The role of exercise programs in PASC patients will be identified, and upcoming studies will establish the magnitude of their benefits. However, the benefits of exercise to counteract these symptoms are well known, and an improvement in cardiopulmonary fitness, functional status, deconditioning, and quality of life can be obtained in these patients, as demonstrated in similar settings. Based on this background, this review aims to summarise the current evidence about the PASC syndrome and the benefit of exercise in these patients and to provide a practical guide for the exercise prescription in PASC patients to help them to resume their functional status, exercise tolerance, prior activity levels, and quality of life, also considering the athletic population and their return to play and sports competitions.

Advances in Molecular Biomarkers in Cardiology.

Cardiovascular diseases (CVD) represent the leading cause of death in the world despite innovations in therapies and advances in the general management of patients [...].

Case Report: Two Case Reports of Acute Myopericarditis After mRNA COVID-19 Vaccine.

Background: Cases of myocarditis and myopericarditis after mRNA COVID-19 vaccines have been reported, especially after the second dose and in young males. Their course is generally benign, with symptoms onset after 24-72 h from the dose. Case Summary: We report two cases of myopericarditis after the second dose of the mRNA-1273 COVID-19 vaccine in two young males. Both the patients were administered the mRNA-1273 COVID-19 vaccine from the same batch on the same day and experienced fever on the same day of the vaccine, and symptoms consisted of myopericarditis 3 days after the dose. Discussion: Myopericarditis is usually considered an uncommon adverse reaction after various vaccinations, reported also after the mRNA COVID-19 vaccine. Several explanations have been proposed, including an abnormal activation of the immune system leading to a pro-inflammatory cascade responsible for myocarditis development. Both patients experienced the same temporal onset as well as the same symptoms, it is also useful to underscore that both vaccines belonged to the same batch of vaccines. However, despite these cases, vaccination against COVID-19 far outweighs the risk linked to COVID-19 infection and remains the best option to overcome this disease.

TIMES TO ACT. Italian-Spanish-Polish-Uzbek Expert Forum Position Paper 2022. Dyslipidemia and arterial hypertension: The two most important and modifiable risk factors in clinical practice.

Hypertension and lipid disorders are two of the main cardiovascular risk factors. Both risk factors - if detected early enough - can be controlled and treated with modern, effective drugs, devoid of significant side effects, available in four countries as different as Italy, Spain, Poland, and Uzbekistan. The aim herein, was to develop this TIMES TO ACT consensus to raise the awareness of the available options of the modern and intensified dyslipidemia and arterial hypertension treatments. The subsequent paragraphs involves consensus and discussion of the deleterious effects of COVID-19 in the cardiovascular field, the high prevalence of hypertension and lipid disorders in our countries and the most important reasons for poor control of these two factors. Subsequently proposed, are currently the most efficient and safe therapeutic options in treating dyslipidemia and arterial hypertension, focusing on the benefits of single-pill combination (SPCs) in both conditions. An accelerated algorithm is proposed to start the treatment with a PCSK9 inhibitor, if the target low-density-lipoprotein values have not been reached. As most patients with hypertension and lipid disorders present with multiple comorbidities, discussed are the possibilities of using new SPCs, combining modern drugs from different therapeutic groups, which mode of action does not confirm the "class effect". We believe our consensus strongly advocates the need to search for patients with cardiovascular risk factors and intensify their lipid-lowering and antihypertensive treatment based on SPCs will improve the control of these two basic cardiovascular risk factors in Italy, Spain, Poland and Uzbekistan.

Case Report: Two Case Reports of Acute Myopericarditis After mRNA COVID-19 Vaccine

Background Cases of myocarditis and myopericarditis after mRNA COVID-19 vaccines have been reported, especially after the second dose and in young males. Their course is generally benign, with symptoms onset after 24–72 h from the dose. Case Summary We report two cases of myopericarditis after the second dose of the mRNA-1273 COVID-19 vaccine in two young males. Both the patients were administered the mRNA-1273 COVID-19 vaccine from the same batch on the same day and experienced fever on the same day of the vaccine, and symptoms consisted of myopericarditis 3 days after the dose. Discussion Myopericarditis is usually considered an uncommon adverse reaction after various vaccinations, reported also after the mRNA COVID-19 vaccine. Several explanations have been proposed, including an abnormal activation of the immune system leading to a pro-inflammatory cascade responsible for myocarditis development. Both patients experienced the same temporal onset as well as the same symptoms, it is also useful to underscore that both vaccines belonged to the same batch of vaccines. However, despite these cases, vaccination against COVID-19 far outweighs the risk linked to COVID-19 infection and remains the best option to overcome this disease.

EACVI survey on burnout amongst cardiac imaging specialists during the 2019 coronavirus disease pandemic.

AIMS: The European Association of Cardiovascular Imaging Scientific Initiatives Committee conducted a global survey to evaluate the impact of the 2019 coronavirus disease (COVID-19) pandemic on the mental well-being of cardiac imaging specialists. METHODS AND RESULTS: In a prospective international survey performed between 23 July 2021 and 31 August 2021, we assessed the mental well-being of cardiac imaging specialists ∼18 months into the COVID-19 pandemic. One-hundred-and-twenty-five cardiac imaging specialists from 34 countries responded to the survey. More than half described feeling anxious during the pandemic, 34% felt melancholic, 27% felt fearful, and 23% respondents felt lonely. A quarter of respondents had increased their alcohol intake and more than half reported difficulties in sleeping. Two-thirds of respondents described worsening features of burnout during the past 18 months, 44% considered quitting their job. One in twenty respondents had experienced suicidal ideation during the pandemic. Despite these important issues, the majority of participants (57%) reported having no access to any formal mental health support at work. CONCLUSION: The survey has highlighted important issues regarding the mental well-being of cardiac imaging specialists during the COVID-19 pandemic. This is a major issue in our sub-specialty, which requires urgent action and prioritization so that we can improve the mental health of cardiovascular imaging specialists.

COVID-19 Severity and Cardiovascular Disease: An Inseparable Link.

The COVID-19 pandemic is a global health issue that has so far affected over 250 million people worldwide [...].

Acute myopericarditis after mRNA COVID-19 vaccine

Aims Cases of myocarditis and myopericarditis after mRNA COVID-19 vaccines have been reported, especially after the second dose and in young males. Their course is generally benign, with symptoms onset after 24–72 h from the dose. Methods and results We report two cases of myopericarditis after the second dose of the mRNA-1273 COVID-19 vaccine in two young males, 20-years old and 21-years old. Both the patients were administered the vaccine on the same day. They both experienced fever on the same day of the vaccine and symptoms consistent with myopericarditis three days after the dose, which was confirmed by cardiac magnetic resonance. Figure 1 summarizes the main non-invasive findings that suggested and confirmed the diagnosis of acute myopericarditis. The disease course was benign in both patients, and only one patient presented rare ventricular arrhythmias on the admission day. They were both discharged on the 9th day of the in-hospital stay. Conclusions Myopericarditis is usually considered an uncommon adverse reaction after various vaccinations, reported also after the mRNA COVID-19 vaccine. Several explanations have been proposed, including an abnormal activation of the immune system leading to a pro-inflammatory cascade responsible for myocarditis development. The temporal aspect of these case reports is rather peculiar and it is useful to underscore that both vaccines belonged to the same batch of vaccines. However, despite these cases, vaccination against COVID-19 far outweighs the risk linked to COVID-19 infection and remains the best option to overcome this disease. 403 Figure

Biomarkers Predict In-Hospital Major Adverse Cardiac Events in COVID-19 Patients: A Multicenter International Study.

BACKGROUND: The COVID-19 pandemic carries a high burden of morbidity and mortality worldwide. We aimed to identify possible predictors of in-hospital major cardiovascular (CV) events in COVID-19. METHODS: We retrospectively included patients hospitalized for COVID-19 from 10 centers. Clinical, biochemical, electrocardiographic, and imaging data at admission and medications were collected. Primary endpoint was a composite of in-hospital CV death, acute heart failure (AHF), acute myocarditis, arrhythmias, acute coronary syndromes (ACS), cardiocirculatory arrest, and pulmonary embolism (PE). RESULTS: Of the 748 patients included, 141(19%) reached the set endpoint: 49 (7%) CV death, 15 (2%) acute myocarditis, 32 (4%) sustained-supraventricular or ventricular arrhythmias, 14 (2%) cardiocirculatory arrest, 8 (1%) ACS, 41 (5%) AHF, and 39 (5%) PE. Patients with CV events had higher age, body temperature, creatinine, high-sensitivity troponin, white blood cells, and platelet counts at admission and were more likely to have systemic hypertension, renal failure (creatinine ≥ 1.25 mg/dL), chronic obstructive pulmonary disease, atrial fibrillation, and cardiomyopathy. On univariate and multivariate analysis, troponin and renal failure were associated with the composite endpoint. Kaplan-Meier analysis showed a clear divergence of in-hospital composite event-free survival stratified according to median troponin value and the presence of renal failure (Log rank p < 0.001). CONCLUSIONS: Our findings, derived from a multicenter data collection study, suggest the routine use of biomarkers, such as cardiac troponin and serum creatinine, for in-hospital prediction of CV events in patients with COVID-19.

SARS-CoV-2 infection and return to play in junior competitive athletes: is systematic cardiac screening needed?

BACKGROUND: SARS-CoV-2 infection might be associated with cardiac complications in low-risk populations, such as in competitive athletes. However, data obtained in adults cannot be directly transferred to preadolescents and adolescents who are less susceptible to adverse clinical outcomes and are often asymptomatic. OBJECTIVES: We conducted this prospective multicentre study to describe the incidence of cardiovascular complications following SARS-CoV-2 infection in a large cohort of junior athletes and to examine the effectiveness of a screening protocol for a safe return to play. METHODS: Junior competitive athletes suffering from asymptomatic or mildly symptomatic SARS-CoV-2 infection underwent cardiac screening, including physical examination, 12-lead resting ECG, echocardiogram and exercise ECG testing. Further investigations were performed in cases of abnormal findings. RESULTS: A total of 571 competitive junior athletes (14.3±2.5 years) were evaluated. About half of the population (50.3%) was mildly symptomatic during SARS-CoV-2 infection, and the average duration of symptoms was 4±1 days. Pericardial involvement was found in 3.2% of junior athletes: small pericardial effusion (2.6%), moderate pericardial effusion (0.2%) and pericarditis (0.4%). No relevant arrhythmias or myocardial inflammation was found in subjects with pericardial involvement. Athletes with pericarditis or moderate pericardial effusion were temporarily disqualified, and a gradual return to play was achieved after complete clinical resolution. CONCLUSIONS: The prevalence of cardiac involvement was low in junior athletes after asymptomatic or mild SARS-CoV-2 infection. A screening strategy primarily driven by cardiac symptoms should detect cardiac involvement from SARS-CoV-2 infection in most junior athletes. Systematic echocardiographic screening is not recommended in junior athletes.

Obesity Strongly Predicts COVID-19-Related Major Clinical Adverse Events in Coptic Clergy.

BACKGROUND AND AIMS: The Coptic clergy, due to their specific work involving interaction with many people, could be subjected to increased risk of infection from COVID-19. The aim of this study, a sub-study of the COVID-19-CVD international study of the impact of the pandemic on the cardiovascular system, was to assess the prevalence of COVID-19 among Coptic priests and to identify predictors of clinical adverse events. METHODS: Participants were geographically divided into three groups: Group-I: Europe and USA, Group II: Northern Egypt, and Group III: Southern Egypt. Participants' demographic indices, cardiovascular risk factors, possible source of infection, number of liturgies, infection management, and major adverse events (MAEs), comprising death, or mechanical ventilation, were assessed. RESULTS: Out of the 1570 clergy serving in 25 dioceses, 255 (16.2%) were infected. Their mean age was 49.5 ± 12 years and mean weekly number of liturgies was 3.44 ± 1.0. The overall prevalence rate was 16.2% and did not differ between Egypt as a whole and overseas (p = 0.23). Disease prevalence was higher in Northern Egypt clergy compared with Europe and USA combined (18.4% vs. 12.1%, p = 0.03) and tended to be higher than in Southern Egypt (18.4% vs. 13.6%, p = 0.09). Ten priests (3.92%) died of COVID-19-related complications, and 26 (10.2) suffered a MAE. The clergy from Southern Egypt were more obese, but the remaining risk factors were less prevalent compared with those in Europe and USA (p = 0.01). In multivariate analysis, obesity (OR = 4.180; 2.479 to 12.15; p = 0.01), age (OR = 1.055; 0.024 to 1.141; p = 0.02), and systemic hypertension (OR = 1.931; 1.169 to 2.004; p = 0.007) predicted MAEs. Obesity was the most powerful independent predictor of MAE in Southern Egypt and systemic hypertension in Northern Egypt (p < 0.05 for both). CONCLUSION: Obesity is very prevalent among Coptic clergy and seems to be the most powerful independent predictor of major COVID-19-related adverse events. Coptic clergy should be encouraged to follow the WHO recommendations for cardiovascular disease and COVID-19 prevention.

A prospective study on the consequences of SARS-CoV-2 infection on the heart of young adult competitive athletes: Implications for a safe return-to-play.

OBJECTIVES: The COVID-19 pandemic has shocked the sports world because of the suspension of competitions and the spread of SARS-CoV-2 among athletes. After SARS-CoV-2 infection, cardio-pulmonary complications can occur and, before the resumption of sports competitions, a screening has been recommended. However, few data are available and discrepancies exist in the screening modalities. We conducted this prospective study to investigate the incidence of cardiovascular consequences following SARS-CoV-2 infection in young adult competitive athletes and the appropriate screening strategies for a safe return-to-play. METHODS: Ninety competitive athletes (24 ± 10 years) after asymptomatic or mildly symptomatic SARS-CoV-2 infection were screened by physical examination, blood testing, spirometry, 12­lead resting ECG, 24-h ambulatory ECG monitoring, echocardiogram, and cardiopulmonary exercise testing (CPET). RESULTS: Sixty-four athletes (71.1%) were male, and most (76.7%) were mildly symptomatic. After SARS-CoV-2 infection, spirometry and resting ECG were normal in all athletes. Ambulatory ECG monitoring demonstrated <50/24 h supraventricular and ventricular premature beats in 53.3% and 52.2% of athletes, respectively, in the absence of malignant arrhythmias. CPET did not demonstrate cardiopulmonary limitations. Echocardiography showed pericardial effusion in 3 athletes (all females) with symptomatic SARS-CoV-2 infection (3.3%; 4.4% in the symptomatic group) with a definitive diagnosis of myopericarditis in 1 athlete (1.1%) and pericarditis in 2 athletes (2.2%). CONCLUSIONS: Cardiac consequences of SARS-CoV-2 infection were found in 3.3% of competitive athletes. An appropriate screening primarily based on the detection of uncommon arrhythmias and cardiac symptoms should be recommended in competitive athletes after SARS-CoV-2 infection to detect a cardiac involvement and guarantee a safe return-to-play.

Combined Cardiac Risk Factors Predict COVID-19 Related Mortality and the Need for Mechanical Ventilation in Coptic Clergy.

BACKGROUND AND AIMS: The clinical adverse events of COVID-19 among clergy worldwide have been found to be higher than among ordinary communities, probably because of the nature of their work. The aim of this study was to assess the impact of cardiac risk factors on COVID-19-related mortality and the need for mechanical ventilation in Coptic clergy. METHODS: Of 1570 Coptic clergy participating in the COVID-19-Clergy study, serving in Egypt, USA and Europe, 213 had the infection and were included in this analysis. Based on the presence of systemic arterial hypertension (AH), participants were divided into two groups: Group-I, clergy with AH (n = 77) and Group-II, without AH (n = 136). Participants' demographic indices, cardiovascular risk factors, COVID-19 management details and related mortality were assessed. RESULTS: Clergy with AH were older (p < 0.001), more obese (p = 0.04), had frequent type 2 diabetes (DM) (p = 0.001), dyslipidemia (p = 0.001) and coronary heart disease (CHD) (p = 0.04) compared to those without AH. COVID-19 treatment at home, hospital or in intensive care did not differ between the patient groups (p > 0.05 for all). Clergy serving in Northern and Southern Egypt had a higher mortality rate compared to those from Europe and the USA combined (5.22%, 6.38%, 0%; p = 0.001). The impact of AH on mortality was significant only in Southern Egypt (10% vs. 3.7%; p = 0.01) but not in Northern Egypt (4.88% vs. 5.81%; p = 0.43). In multivariate analysis, CHD OR 1.607 ((0.982 to 3.051); p = 0.02) and obesity, OR 3.403 ((1.902 to 4.694); p = 0.04) predicted COVID-19 related mortality. A model combining cardiac risk factors (systolic blood pressure (SBP) ≥ 160 mmHg, DM, obesity and history of CHD) was the most powerful independent predictor of COVID-19-related mortality, OR 3.991 ((1.919 to 6.844); p = 0.002). Almost the same model also proved the best independent multivariate predictor of mechanical ventilation OR 1.501 ((0.809 to 6.108); p = 0.001). CONCLUSION: In Coptic clergy, the cumulative impact of risk factors was the most powerful predictor of mortality and the need for mechanical ventilation.

Reduction of Emergency Calls and Hospitalizations for Cardiac Causes: Effects of Covid-19 Pandemic and Lockdown in Tuscany Region.

Introduction: Containment measures were established to flatten the curve of COVID-19 contagion in order to avoid a crash of the healthcare system. However, these measures influenced the rate of hospitalization of cardiac patients. In this study, we aimed to analyse the impact of COVID-19 and the effects of lockdown measures on hospital admissions and alerts of emergency medical system (EMS) for cardiac causes in the Tuscany region. Methods: An observational, retrospective analysis from Italian Tuscany region was conducted. We evaluated consecutive patients contacting EMS or admitted to the 39 Emergency Departments (EDs) in Tuscany for cardiac causes in the first trimester of 2020. Data were compared with the same period in 2018/19. Results: The alerts of EMS for cardiac causes significantly decrease in 2020 and the highest difference between 2018/19 and 2020 was found immediately after national lockdown (Δ = -47.4%, p < 0.001). The number of admissions for chest pain in the EDs also decreased, with a maximum difference of -67.6% (p < 0.001) vs. 2018/19. The number of hospital accesses for acute coronary syndromes, atrial fibrillation, and heart failure in the EDs significantly decreased in 2020 as compared to 2018/19 (maximum Δ = -58.9%, p < 0.001; maximum Δ = -63.0%, p < 0.001; maximum Δ = -72.7%, p < 0.001, respectively). Conclusions: A significant decrease in the contacts to EMS for cardiac causes and in cardiac diagnoses was observed during the first trimester of 2020. Fear of contagion has likely played a relevant role. The lesson learnt from first wave of COVID-19 pandemic suggests that appropriate public information strategies and re-education of people are essential.

COVID-19 and Acute Coronary Syndromes: Current Data and Future Implications.

Coronavirus disease-2019 (COVID-19) pandemic is a global healthcare burden, characterized by high mortality and morbidity rates all over the world. During the outbreak period, the topic of acute coronary syndromes (ACS) has raised several clinical issues, due to the risks of COVID-19 induced myocardial injury and to the uncertainties about the management of these cardiologic emergency conditions, which should be organized optimizing the diagnostic and therapeutic resources and ensuring the maximum protection to healthcare personnel and hospital environment. COVID-19 status should be assessed as soon as possible. Moreover, considerably lower rates of hospitalization for ACS have been reported all over the world, due to patients' hesitations to refer to hospital and to missed diagnosis. As a result, short- and long-term complications of myocardial infarction are expected in the near future; therefore, great efforts of healthcare providers will be required to limit the effects of this issue. In the present review we discuss the impact of COVID-19 pandemic on ACS diagnosis and management, with possible incoming consequences, providing an overview of the available evidence and suggesting future changes in social and clinical approach to ACS.

COVID-19 and the burning issue of drug interaction: never forget the ECG.

The coronavirus disease of 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), has been rapidly escalating, becoming a relevant threat to global health. Being a recent virus outbreak, there are still no available therapeutic regimens that have been approved in large randomised trials and so patients are currently being treated with multiple drugs. This raises concerns regarding drug interaction and their implication in arrhythmic burden. In fact, two of the actually used drugs against SARS-CoV2, such as chloroquine and the combination lopinavir/ritonavir, might determine a QT (the time from the start of the Q wave to the end of the T wave) interval prolongation and they show several interactions with antiarrhythmic drugs and antipsychotic medications, making them prone to an increased risk of developing arrhythmias. This brief review focuses the attention on the most relevant drug interactions involving the currently used COVID-19 medications and their possible association with cardiac rhythm disorders, taking into account also pre-existing condition and precipitating factors that might additionally increase this risk. Furthermore, based on the available evidence and based on the knowledge of drug interaction, we propose a quick and simple algorithm that might help both cardiologists and non-cardiologists in the management of the arrhythmic risk before and during the treatment with the specific drugs used against SARS-CoV2.

COVID-19 in patients with heart failure: the new and the old epidemic.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has spread in nearly 200 countries in less than 4 months since its first identification; accordingly, the coronavirus disease 2019 (COVID 2019) has affirmed itself as a clinical challenge. The prevalence of pre-existing cardiovascular diseases in patients with COVID19 is high and this dreadful combination dictates poor prognosis along with the higher risk of intensive care mortality. In the setting of chronic heart failure, SARS-CoV-2 can be responsible for myocardial injury and acute decompensation through various mechanisms. Given the clinical and epidemiological complexity of COVID-19, patiens with heart failure may require particular care since the viral infection has been identified, considering an adequate re-evaluation of medical therapy and a careful monitoring during ventilation.

Safe performance of echocardiography during the COVID-19 pandemic: a practical guide.

Coronavirus disease-2019 (COVID-19) outbreak has become a worldwide healthcare emergency, with continuously growing number of infected subjects. Considering the easy virus spread through respiratory droplets produced with cough, sneezes or spit or through close contact with infected people or surfaces, healthcare workers are further exposed to COVID-19. Particularly, echocardiography remains an essential diagnostic service which, due to the close contact with patients during the exam, provides echocardiographers high-risk of contagion. Therefore, the common modalities of performing echocardiography should be improved in this scenario, avoiding performing unnecessary exams, using the appropriate personal protective equipment depending on patients' status and location, optimizing time-effectiveness of the echocardiographic study and accurately sanitizing the environment and devices after each exam. This paper aims to provide a simple guide for the clinicians to balance between providing the best care to each patient and protecting themselves and other patients from the spread of the virus. It also proposes the use of the mnemonic PREVENT to resume the crucial indications to be followed for the execution of appropriate echocardiographic examination during the COVID-19 pandemic.

Usefulness of echocardiography to detect cardiac involvement in COVID-19 patients.

Coronavirus disease 2019 (COVID-19) outbreak is a current global healthcare burden, leading to the life-threatening severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, evidence showed that, even if the prevalence of COVID-19 damage consists in pulmonary lesions and symptoms, it could also affect other organs, such as heart, liver, and spleen. Particularly, some infected patients refer to the emergency department for cardiovascular symptoms, and around 10% of COVID-19 victims had finally developed heart injury. Therefore, the use of echocardiography, according to the safety local protocols and ensuring the use of personal protective equipment, could be useful firstly to discriminate between primary cardiac disease or COVID-19-related myocardial damage, and then for assessing and monitoring COVID-19 cardiovascular complications: acute myocarditis and arrhythmias, acute heart failure, sepsis-induced myocardial impairment, and right ventricular failure derived from treatment with high-pressure mechanical ventilation. The present review aims to enlighten the applications of transthoracic echocardiography for the diagnostic and therapeutic management of myocardial damage in COVID-19 patients.