Mechanical Circulatory Support in Patients With COVID-19 Presenting With Myocardial Infarction.

ST-segment elevation myocardial infarction (STEMI) complicating COVID-19 is associated with an increased risk of cardiogenic shock and mortality. However, little is known about the frequency of use and clinical impact of mechanical circulatory support (MCS) in these patients. We sought to define patterns of MCS utilization, patient characteristics, and outcomes in patients with COVID-19 with STEMI. The NACMI (North American COVID-19 Myocardial Infarction) is an ongoing prospective, observational registry of patients with COVID-19 positive (COVID-19+) with STEMI with a contemporary control group of persons under investigation who subsequently tested negative for COVID-19 (COVID-19-). We compared the baseline characteristics and in-hospital outcomes of COVID-19+ and patients with COVID-19- according to the use of MCS. The primary outcome was a composite of in-hospital mortality, stroke, recurrent MI, and repeat unplanned revascularization. A total of 1,379 patients (586 COVID-19+ and 793 COVID-19-) enrolled in the NACMI registry between January 2020 and November 2021 were included in this analysis; overall, MCS use was 12.3% (12.1% [n = 71] COVID-19+/MCS positive [MCS+] vs 12.4% [n = 98] COVID-19-/MCS+). Baseline characteristics were similar between the 2 groups. The use of percutaneous coronary intervention was similar between the groups (84% vs 78%; p = 0.404). Intra-aortic balloon pump was the most frequently used MCS device in both groups (53% in COVID-19+/MCS+ and 75% in COVID-19-/MCS+). The primary outcome was significantly higher in COVID-19+/MCS+ patients (60% vs 30%; p = 0.001) because of very high in-hospital mortality (59% vs 28%; p = 0.001). In conclusion, patients with COVID-19+ with STEMI requiring MCS have very high in-hospital mortality, likely related to the significantly higher pulmonary involvement compared with patients with COVID-19- with STEMI requiring MCS.

North American COVID-19 Myocardial Infarction (NACMI) Risk Score for Prediction of In-Hospital Mortality.

Background: In-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI. Methods: Baseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient. Results: In-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 â€‹years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P â€‹< â€‹.001), and the model demonstrated good discriminative power (c-statistic â€‹= â€‹0.81) and calibration (Hosmer-Lemeshow, P â€‹= â€‹.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high-risk score categories, respectively). Conclusions: The risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.

Trends in Clinical Presentation, Management, and Outcomes of STEMI in Patients With COVID-19.

BACKGROUND: We previously reported high in-hospital mortality for ST-segment elevation myocardial infarction (STEMI) patients with COVID-19 treated in the early phase of the pandemic. OBJECTIVES: The purpose of this study was to describe trends of COVID-19 patients with STEMI during the course of the pandemic. METHODS: The NACMI (North American COVID-19 STEMI) registry is a prospective, investigator-initiated, multicenter, observational registry of hospitalized STEMI patients with confirmed or suspected COVID-19 infection in North America. We compared trends in clinical characteristics, management, and outcomes of patients treated in the first year of the pandemic (January 2020 to December 2020) vs those treated in the second year (January 2021 to December 2021). RESULTS: A total of 586 COVID-19-positive patients with STEMI were included in the present analysis; 227 treated in Y2020 and 359 treated in Y2021. Patients' characteristics changed over time. Relative to Y2020, the proportion of Caucasian patients was higher (58% vs 39%; P < 0.001), patients presented more frequently with typical ischemic symptoms (59% vs 51%; P = 0.04), and patients were less likely to have shock pre-PCI (13% vs 18%; P = 0.07) or pulmonary manifestations (33% vs. 47%; P = 0.001) in Y2021. In-hospital mortality decreased from 33% (Y2020) to 23% (Y2021) (P = 0.008). In Y2021, none of the 22 vaccinated patients expired in hospital, whereas in-hospital death was recorded in 37 (22%) unvaccinated patients (P = 0.009). CONCLUSIONS: Significant changes have occurred in the clinical characteristics and outcomes of STEMI patients with COVID-19 infection during the course of the pandemic.

Potential Role of the Moderna COVID-19 Vaccine in Enoxaparin's Effects on Liver Functions.

Enoxaparin is commonly used for prophylaxis as an anticoagulant in hospital settings. Although enoxaparin has been known to cause many minor adverse reactions, hepatocellular injury is one of the rare side effects which can impact clinical course, marked by an asymptomatic rise in liver function panel tests. In this paper, we not only delineate the relationship between enoxaparin-induced hepatocellular injury but also associate it with fevers that have not been previously documented. Furthermore, we posit the Moderna COVID19 vaccine as a potential contributor to this outcome. We hypothesize that the link between enoxaparin and hepatic injury is possibly due to the inflammatory state, which may be augmented by the vaccine.

Left Ventricular Global Longitudinal Strain in Patients With COVID-19 Infection.

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, is an ongoing pandemic that has affected millions globally. Many infected patients have been noted to have cardiovascular damage. Prior to the development of clinical symptoms, the use of transthoracic echocardiography, specifically with measurements of left ventricular global longitudinal strain (LVGLS), may provide an additional prognostic marker for patients infected with COVID-19. We sought to determine whether patients with COVID-19 and reduced LVGLS have an increased risk for mortality. The mean LVGLS was determined to be significantly lower in the non-survivors compared to the survivors (-11.6 ± 1.8 vs -15.4 ± 0.74, p<0.05). It should be noted, however, that even those that survived were found to have reduced LVGLS (<-18.5%). A multivariate logistic regression analysis was also performed that demonstrated a relationship between reduced LVGLS and an increased risk for mortality. Overall, our data indicate that COVID-19 patients may have subclinical left ventricular dysfunction, and that critically ill patients may have a greater decline in cardiac dysfunction.

Paradigm Shifts in Cardiac Care: Lessons Learned From COVID-19 at a Large New York Health System.

The coronavirus disease-2019 (COVID-19) pandemic has overwhelmed healthcare systems around the world, resulting in morbidity, mortality, and a dramatic economic downturn In the United States. Urgent responses to the pandemic halted routine hospital workflow in an effort to increase hospital capacity, maintain staffing, and ration protective gear. Most notably, New York saw the largest surge of COVID-19 cases nationwide. Healthcare personnel and physician leaders at Northwell Health, the largest healthcare system in New York, have worked together to successfully implement operational changes resulting in a paradigm shift in cardiac care delivery. In this manuscript, we detail specific protocol adjustments made in our cardiology department, cardiology service line, and healthcare system in the face of the COVID-19 pandemic. We discuss the sustainability of this shift moving forward and the opportunity to optimize care for cardiovascular patients in the post COVID-19 era.

Pulmonary Embolism in Patients Hospitalized With COVID-19 (From a New York Health System).

Pulmonary embolisms (PEs) in coronavirus disease 2019 (COVID-19) have increasingly been reported in observational studies. However, limited information describing their clinical characteristics and outcomes exists. Our study aims to describe clinical features and risk stratification strategies of hospitalized COVID-19 patients with PE. We retrospectively analyzed 101 hospitalized patients with COVID-19 infection and acute PE. Clinical outcomes measured were intensive care unit admission, mechanical ventilation, bleeding and transfusion events, acute kidney injury (AKI) and mortality. Pulmonary severity index (PESI) scores were used for risk stratification. The most common comorbidities were hypertension (50%), obesity (27%) and hyperlipidemia (32%) among this cohort. Baseline D-dimer abnormalities (4,647.0 ± 8,281.8) were noted on admission with a 3-fold increase at the time of PE diagnosis (13,288.4 ± 14,917.9; p <0.05). Five (5%) patients required systemic thrombolysis and 12 (12%) patients experienced moderate to severe bleeding. Thirty-one (31%) patients developed AKI and 1 (1%) patient required renal replacement therapy. Twenty-three (23%) patients were admitted to intensive care unit, of which 20 (20%) patients received mechanical ventilation. The mortality rate was 20%. Most patients (65%) had Intermediate to high risk PESI scores (>85), which portended a worse prognosis with higher mortality rate and length of stay. In conclusion, this study provides characteristics and early outcomes for hospitalized patients with COVID-19 and acute pulmonary embolism. PESI scores were utilized for risk stratifying clinical outcomes. Our results should serve to alert the medical community to heighted vigilance of this VTE complication associated with COVID-19 infection.