ABSTRACT
Background: Several reports have described the negative prognostic impact of ageing in patients with ST-Elevation Myocardial Infarction (STEMI) undergoing primary angioplasty. During the COVID-19 pandemic, increased mortality was observed in patients admitted for STEMI. However, there are no data on the impact of ageing on the outcome of this high-risk patients during the pandemic. Objective(s): The ISACS-STEMI COVID-19 is a large-scale retrospective multicenter registry involving primary PCI centers from Europe, Latin America, South-East Asia and North-Africa, including patients treated from 11920 of March until June 30, 2019 and 2020). Primary study endpoint of this analysis was in-hospital mortality. Secondary endpoints was 30-day mortality. Result(s): Our population is represented by 16083 STEMI patients undergoing mechanical reperfusion, who were divided according to age (< 55 years, n = 4179 (25,98%);55-65 years, n = 4814 (29,93%);65-75 years, n = 4016 (24,97%);75-65 years, n = 2226 (13,84%);>85 years, n = 821 (5,10%). Ageing was linearly and independently associated with in-hospital (figure 1) and 30-day mortality (adjusted p < 0.0001). The COVID pandemic had a significant impact on in-hospital and 30-day mortality (adjusted p < 0.001), that was linearly related to age, particularly for inhospital mortality (Figure 1). Conclusion(s): Our study showed that among STEMI patients undergoing primary angioplasty, age was linearly associated to mortality in both precovid and covid era. The COVID-19 pandemic had a significant impact on mortality, especially in more advanced age.
ABSTRACT
Acute coronary syndromes (ACS) may complicate the clinical course of patients with Coronavirus Disease 2019 (COVID-19). It is still unclear whether this condition is a direct consequence of the primary disease. However, several mechanisms including direct cellular damage, endothelial dysfunction, in-situ thrombosis, systemic inflammatory response, and oxygen supply-demand imbalance have been described in patients with COVID-19. The onset of a pro-thrombotic state may also be facilitated by the endothelial dysfunction secondary to the systemic inflammatory response and to the direct viral cell damage. Moreover, dysfunctional endothelial cells may enhance vasospasm and platelet aggregation.The combination of these factors promotes atherosclerotic plaque instability, thrombosis and, consequently, type 1 myocardial infarction.Furthermore, severe hypoxia due to extensive pulmonary involvement, in association with other conditions described in COVID-19 such as sepsis, tachyarrhythmias, anemia, hypotension, and shock, may lead to mismatch between oxygen supply and demand, and cause type 2 myocardial infarction.A deeper understanding of the potential pathophysiological mechanisms underlying ACS in patients with COVID-19 could help the therapeutic management of these very high-risk patients.
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Background: Despite several pharmacological advances, the morbidity and mortality in heart failure (HF) remain high, posing a problem for both patients and the National Health System. The natural history of this disease alternates phases of stability and phases of exacerbation, with a progressive decline in the patient's functional capacity and quality of life;this has led to the development of remote monitoring systems. These devices are emerging as an important tool for the effective HF management, even during the COVID-19 pandemic. Methods: We enrolled 6 patients with end-stage HF, who received the combined CardioMEMS / Levosimendan strategy to reduce the number of hospitalizations and optimize both tailored adjustment of home therapy and infusions of Levosimendan. Specifically, CardioMEMS is a wireless sensor that can be implanted in the pulmonary artery, where it detects cardiac filling pressures, an objective measure of the patient's hemodynamic congestion;these pressures increase two weeks before the onset of symptomatic congestion. Results: The 6 patients (72.25±4.60 years;33.33% female) who received the device did not have any complications related to the procedure. Patients were monitored daily by CardioMEMS;if the cardiologist detected a tendency for pulmonary artery diastolic pressure (PAPd) to rise, patients were contacted for home therapeutic changes. If no further changes were possible, the patient was hospitalized for the infusion of Levosimendan. In particular, following the implantation of CardioMEMS, a significant reduction in HF unscheduled hospital admissions was recorded (hospitalizations / month: pre-CardioMEMS 0.657±0.303 vs post-CardioMEMS 0.029±0.021, p 0.0313) (Figure 1). In addition, lower pulmonary arterial pressures were recorded at 6-months FU on CardioMEMS monitoring (pre vs post: PAPs: 51.25±2.56 vs 42.75±2.46 mmHg, p 0.0168;PAPd: 26.25±0.85 vs 20.25±0.85 mmHg, p 0.0034), a reduction in the echocardiographic E/e' ratio (20.86±1.77 vs 14.13±2.02, p 0.0057), an improvement in the quality of life (EQ5D 75.17±2.06 vs 108.60±8.70, p 0.0078) and a reduction in IL-6 levels (p 0.0211). Conclusions: In this study we present the first experience of serial infusions of Levosimendan guided by CardioMEMS. Our results support the usefulness of this device in remote management of the HF patient, especially during this pandemic.
ABSTRACT
Aims: Pulmonary involvement in Coronavirus 19 disease (COVID-19) may affect right ventricular (RV) function and pulmonary pressures resulting in further deterioration of patient clinical status. However, the prognostic value of echocardiographic parameters including tricuspid annular plane systolic excursion (TAPSE), systolic pulmonary artery pressure (PASP), and TAPSE/PASP ratio has been poorly investigated in this clinical setting. Methods and results: This is a multicentre Italian study including patients admitted for severe COVID-19 in seven Italian Hospitals. Transthoracic echocardiography (TTE) was performed within 48 h from admission in all cases. In-hospital mortality and pulmonary embolism (PE) were identified as the primary and secondary outcome measures, respectively. Of 1401 patients with severe COVID-19, 227 (16.1%) subjects underwent TTE within 48 h from admission and were included in this study. The mean age was 68±13 years and 62.6% of patients were male. Intensive care unit (ICU) admission was reported in 73 patients (32.2%);ICU patients showed lower left ventricular ejection fraction (LVEF), lower TAPSE, and higher LV end systolic volume and PASP values than non-ICU patients. Also, ICU patients showed higher incidence of acute respiratory distress syndrome (82.2% vs. 30.5%;P<0.001), acute cardiac injury (46.6% vs. 22.7%;P<0.001), acute heart failure (34.2% vs. 9.1%;P<0.001), and death (63.9% vs. 14.3%;P<0.001) compared with non-ICU patients. By stratifying the study population into tertiles according to TAPSE, PASP, and TAPSE/PASP values, patients in the lower TAPSE and TAPSE/PASP ratio tertiles, and those in the higher PASP tertile, showed a significantly higher incidence of death during the hospitalization. At univariable logistic regression analysis, TAPSE, PASP, and TAPSE/PASP were significantly associated with a higher risk of death and PE, both in patients admitted or not to ICU. After propensity score weighting adjustment for multiple baseline potential confounders and further multivariable adjustment for LVEF value, the regression analysis showed that TAPSE, PASP and TAPSE/PASP were independently associated with risk of death (TAPSE: OR: 0.85, CI: 0.74-0.97, P=0.017;PASP: OR: 1.08, CI: 1.03-1.13, P=0.002;TAPSE/PASP: OR: 0.02, CI: 0.02 × 10-1-0.20, P<0.001) and with the risk of PE (TAPSE: OR: 0.70, CI: 0.60-0.82, P<0.001;PASP: OR: 1.10, CI: 1.05-1.14, P<0.001;TAPSE/PASP: OR: 0.02 × 10-1, CI: 0.01 × 10-2- 0.04, P<0.001) during the hospitalization. The risk death according to TAPSE, PASP, and TAPSE/PASP ratio tertiles was estimated considering discharge alive as competing risk (Figure). The lowest TAPSE and TAPSE/PASP tertiles, and the highest PASP tertile, were significantly associated with poorer survival during the hosptialization (P<0.001). Conclusions: Echocardiographic evidence of RV systolic dysfunction, increased PASP and a poor RV-arterial coupling assessed by TAPSE/PAPS ratio may help to identify COVID-19 patients at higher risk of mortality and PE during the hospitalization.
ABSTRACT
Adequate preventive specific and unspecific and therapeutic procedures are urgently required for the new incoming generation of viruses;some strategies approached the infections with chemotherapies adopted from previous antiviral programs or with off label drugs. The optimal goal would be to practice a widespread treatment safe, effective, sustainable, cheap as much as possible. The enhancement of innate immunity defenses and the support of the trained immunity are very helpful aside of the incoming vaccines. Innate immunity is the most ancient ready and quick defense against pathogens of al the living species: it commits phagocytic cells to directly get rid of the infectious agents, while the trained immunity is expressed by the adaptive immunity a late evolutionary phase (2 million years after the innate one): the antibodies producing immunological memory is usually tailored against specific antigens but can be expanded eliciting an immune response against other infecting noxa. This paper deals with the clinical history and revival of C. parvum, a killed commensal bacterium located in the sebaceous glands with strong unspecific antitumoral and antiviral innate immunity enhancing properties that can profitably be updated in hazardous infectious emergencies.
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Background: 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. Methods: 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. Results: 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. Conclusions: This meta-analysis suggests that older age and diabetes are associated with higher risk of in-hospital mortality in patients infected by SARS-CoV-2. Conversely, male sex, hypertension, and smoking did not independently correlate with fatal outcome.