Endothelial dysfunction in the post-COVID-19 period: A meta-analysis

Background: Coronavirus disease (COVID)-19 is an entity characterized by a cytokine storm and profound endotheliitis. Although several reports have pointed to the presence of endothelial dysfunction in the acute phase, data is accumulating regarding a possible prolonged adverse effect of COVID-19 on endothelial function. Purpose(s): This systematic review and meta-analysis aims to evaluate the degree of endothelial impairment, assessed by flow-mediated dilation (FMD) of the brachial artery, in individuals recovering from COVID-19. Method(s): We conducted a systematic literature search for studies assessing FMD between in patients post-COVID-19 and controls. Exclusion criteria consisted of the absence of a control group, measurement of FMD only during the acute phase of the disease, and not reporting FMD in % change. Effect sizes were pooled via random-effect model and the results are expressed as uncorrected standardized mean difference (SMD), using the Cohen's d as the effect size metric, with 95% confidence intervals (CI). Between-study heterogeneity was assessed through the calculation of I2. Subgroup analysis according to follow-up duration and the presence of cardiovascular risk factor-matched controls was also carried out. Result(s): Database search identified 51 studies. Following the application of the exclusion criteria, 7 studies were included in the meta-analysis (post-COVID-19: 342 subjects, Control: 273 subjects). Compared to controls, patients post-COVID-19 had significantly lower FMD% values (SMD: -1.06, 95% CI: -1.74 to -0.38, p<0.01, I2: 86%) (Figure 1). Results remained unaffected after exclusion of any single study using the leave-oneout method. Subgroup analysis revealed no significant differences in FMD between post-COVID-19 patients and controls according to follow-up duration or the presence of cardiovascular risk factor-matched control group. Conclusion(s): Flow-mediated dilation of the brachial artery, indicative of endothelial dysfunction, was significantly reduced in post-COVID-19 subjects compared to non-infected controls. This finding may be an alarming sign towards a higher risk of incident cardiovascular events. (Figure Presented) .

Time-related aortic inflammatory response, as assessed with 18F-FDG PET/CT, in patients hospitalized with severely or critical COVID-19

Aim: Arterial involvement has been implicated in the coronavirus disease of 2019 (COVID-19). Fluorine 18-fluorodeoxyglucose positron emission tomography/ computed tomography (18F-FDG PET/CT) imaging is a valuable tool for the assessment of aortic inflammation and is a predictor of outcome. We sought to prospectively assess the presence of aortic inflammation and its time-dependent trend in patients with COVID-19. Method(s): Between November 2020 and May 2021, in this pilot, casecontrol study, we recruited 20 patients with severe or critical COVID-19 (mean age of 59+/-12 years), while 10 age and sex-matched individuals served as the control group. Aortic inflammation was assessed by measuring 18F-FDG uptake in PET/CT performed 20-120 days post-admission. Global aortic target to background ratio (GLA-TBR) was calculated as the sum of TBRs of ascending and descending aorta, aortic arch, and abdominal aorta divided by 4. Index aortic segment TBR (IAS-TBR) was designated as the aortic segment with the highest TBR. Result(s): There was no significant difference in aortic 18F-FDG PET/CT uptake between patients and controls (GLA-TBR: 1.46 [1.40-1.57] vs. 1.43 [1.32-1.70], respectively, p=0.422 and IAS-TBR: 1.60 [1.50-1.67] vs. 1.50 [1.42-1.61], respectively, p=0.155). There was a moderate correlation between aortic TBR values (both GLA and IAS) and time distance from admission to 18F-FDG PET-CT scan (Spearman's rho=-0.528, p=0.017 and Spearman's rho=-0.480, p=0.032, respectively), Figure 1. Patients who were scanned less than or equal to 60 days from admission (n=11) had significantly higher GLA-TBR values compared to patients that were examined more than 60 days post-admission (GLA-TBR: 1.53 [1.42-1.60] vs. 1.40 [1.33-1.45], respectively, p=0.016 and IAS-TBR: 1.64 [1.51-1.74] vs. 1.52 [1.46-1.60], respectively, p=0.038). There was a significant difference in IAS-TBR between patients scanned <=60 days and controls (1.64 [1.51-1.74] vs. 1.50 [1.41-1.61], p=0.036), Figure 2. Conclusion(s): This is the first study suggesting that aortic inflammation, as assessed by 18F-FDG PET/CT imaging, is increased in the early post-COVID phase in patients with severe or critical COVID-19 and largely resolves over time. Our findings may have important implications for the understanding of the course of the disease and for improving our preventive and therapeutic strategies.

THE EFFECT OF E HEALTH ESH APPLICATION ON BP MANAGEMENT PRELIMINARY RESULTS

Objective: Main issues in the treatment of hypertension are the low level of blood pressure (BP) control and the economic burden for health care systems. Mobile application with telemonitoring of BP could contribute to better control and lower costs by reducing office visits. This could be useful nowadays with difficult access to health system due to covid-19. The purpose of this study was to investigate if an innovative management strategy of hypertension, such as the use of ESH care application for smartphones combined with a dedicated platform, could improve hypertension control and replace frequent office visits. Design and method: 30 uncontrolled hypertensive patients, treated or untreated [mean age 53 ± 9 years, mean office BP (OBP) 146.3 ± 6.2 / 92.5 ± 9 mmHg, 53% men, 33% smokers, 23% with hypercholesterolemia] were randomized to the application assisted strategy (AAS) (17 patients), where a mobile phone application was offered to communicate home BP measurements (HBPm), or to regular office visits (13 patients). Patients BP measurements (HBPm for AAS and OBP for standard care group) were evaluated in 1 and 3 months with treatment titration if uncontrolled. In all patients OBP and ambulatory BP measurement (ABPM) were evaluated in 6 months. Results: In both groups the reduction in OBP and ABPM was significant in 6 months. In the AAS group the reduction in systolic/diastolic OBP and 24 h systolic/ diastolic BP in 6 months was -26.5 ± 5.6 / -19.4 ± 8.2 mmHg (p < 0,001) and -19.6 ± 7.7 / -13.8 ± 4.8 mmHg (p < 0.001), respectively. In the standard care group, the reduction in systolic/diastolic OBP and 24 h systolic/diastolic BP in 6 months was -22.6 ± 9.7 / -9.6 ± 11 mmHg (p < 0.005) and -18.4 ± 6.0 / - 8.8 ± 4.4 mmHg (p < 0.001). In AAS group compared to standard care group there was a greater reduction in 24 h diastolic BP (-13.8 ± 4.8 mmHg vs -8.8 ± 4.4 mmHg, p = 0.016) and in diastolic OBP (-19.4 ± 8.2 mmHg vs -9.6 ± 11.0 mmHg, p = 0.04). Conclusions: The present results indicate that the monitoring of patients through a mobile health tool could be useful in hypertension management as it is correlated with better BP control compared to office visits. The trial is still enrolling patients.

THE EFFECT OF COMMON SURGICAL MASKS ON UNATTENDED BLOOD PRESSURE CHANGES IN DRUG TREATED HYPERTENSIVE PATIENTS

Objective: While there are several studies that have focused on the role of face masks in preventing airborne transmission of SARS-CoV-2, few data are available on their effects on physiological measures, and no study has examined their effects on blood pressure (BP). The purpose of our study was to investigate the effect of surgical masks on BP in drug-treated hypertensive patients who had a routine follow-up visit to a university hospital outpatient hypertension clinic. Design and method: The study included already treated hypertensive patients aged > 18 years, while the exclusion criteria were atrial fibrillation or any other arrhythmia affecting the BP measurement, an arm circumference > 42 cm, mental disorders, Parkinson disease, pregnancy, intolerance to the BP measurement method, or unwillingness to participate. A new surgical mask was provided to all participants to replace the face mask that was already in use. After the routine mask-on office BP measurement, patients were left alone and randomized to automated office BP measurement, with measurements taken after first wearing a mask for 10 min, then without wearing the mask for 10 min, and vice versa. Results: A total number of 265 patients were included in the study. Among the participants, 115 were women (43.4%), the mean age was 62 ± 12 years, and the mean office BP was 134 ± 15 / 81 ± 12 mmHg. There was no significant difference between mask-on unattended systolic BP (133 ± 15 mmHg) and mask-off unattended systolic BP (132 ± 15 mmHg) (P = 0.13) or between mask-on unattended diastolic BP (77 ± 13 mmHg) and mask-off unattended diastolic BP (76 ± 13 mmHg) (P = 0.32). Moreover, there was no difference in the heart rate (mask-on first, 69 ± 11 bpm;mask-off first, 69 ± 11 bpm, P = 0.7). Conclusions: Common surgical masks do not affect systolic/diastolic BP levels during unattended BP measurements in treated hypertensive patients.

Wearable blood pressure measurement devices and new approaches in hypertension management: the digital era.

Out-of-office blood pressure (BP) measurement is considered an integral component of the diagnostic algorithm and management of hypertension. In the era of digitalization, a great deal of wearable BP measuring devices has been developed. These digital blood pressure monitors allow frequent BP measurements with minimal annoyance to the patient while they do promise radical changes regarding the diagnostic accuracy, as the importance of making an accurate diagnosis of hypertension has become evident. By increasing the number of BP measurements in different conditions, these monitors allow accurate identification of different clinical phenotypes, such as masked hypertension and pathological BP variability, that seem to have a negative impact on cardiovascular prognosis. Frequent measurements of BP and the incorporation of new features in BP variability, both enable well-rounded interpretation of BP data in the context of real-life settings. This article is a review of all different technologies and wearable BP monitoring devices.

Acute effects of COVID-19 vaccination on inflammatory, macrovasular and microvascular biomarkers

Purpose: To fight the COVID-19 pandemic, messenger RNA (mRNA) vaccines were the first to be adopted by vaccination programs worldwide. We sought to investigate the short-term effect of mRNA vaccine administration on endothelial function and arterial stiffness. Methods: Thirty-two participants (mean age 37±8 years, 20 men) that received the BNT162b2 mRNA COVID-19 vaccine were studied in 3 sessions in a sequence-randomized, sham-controlled, assessor-blinded, cross-over design. Primary outcome was endothelial function assessed by brachial artery flow-mediated dilatation (FMD), and secondary outcomes were aortic stiffness, evaluated with carotid-femoral pulse wave velocity (PWV), microvascular function that was estimated with hyperemic mean blood flow velocity (HMBFV) of the brachial artery, and inflammation measured by high-sensitivity C-reactive protein (hsCRP) and interleukins (hsIL-6 and hsIL-1b) in blood samples. The outcomes were assessed prior to, and at 8h, 24h post the 1st dose of vaccination, and 8h, 24h and 48h post the 2nd. Results: There was an increase in hsCRP that was apparent at 24h after both the 1st dose (−0.60 [95% Confidence intervals [CI]: −1.60 to −0.20], p=0.013) and the 2nd dose (max median difference at 48h −6.60 [95% CI: −9.80 to −3.40], p<0.001) compared to sham. Similarly, interleukins also increased. The vaccine did not change PWV. FMD remained unchanged during the 1st dose but decreased significantly by 1.5% (95% CI: 0.1% to 2.9%, p=0.037) at 24h post the 2nd dose (Figure). FMD values returned towards baseline at 48h. HMBFV remained unchanged during the 1st dose but at 48h post the 2nd dose was numerically lower than the sham procedure but the difference between the 2 sessions was not statistically significant (max mean difference at 48h 8.6 [95% CI: −0.6 to 17.8], p=0.067). Conclusions: Our study shows that the mRNA vaccine causes a prominent increase in inflammatory markers, especially after the 2nd dose and a transient deterioration of endothelial function at 24h that returns towards baseline at 48h. These results confirm the short-term cardiovascular safety of the vaccine. Funding Acknowledgement: Type of funding sources: None.Figure 1

BLOOD PRESSURE MANAGEMENT WITH THE ESH CARE APP - PRELIMINARY RESULTS

Objective: Main issues in the treatment of hypertension are the low level of blood pressure (BP) control and the economic burden for health care systems. Mobile application with telemonitoring of BP could contribute to better control and lower costs by reducing office visits. This could be useful nowadays with difficult access to health system due to covid-19. The purpose of this study was to investigate if an innovative management strategy of hypertension, such as the use of ESH care application for smartphones combined with a dedicated platform, could improve hypertension control and replace frequent office visits. Design and method: 30 uncontrolled hypertensive patients, treated or untreated [mean age 53 ± 9 years, mean office BP (OBP) 146.3 ± 6.2 / 92.5 ± 9 mmHg, 53% men, 33% smokers, 23% with hypercholesterolemia] were randomized to the application assisted strategy (AAS) (17 patients), where a mobile phone application was offered to communicate home BP measurements (HBPm), or to regular office visits (13 patients). Patients' BP measurements (HBPm for AAS and OBP for standard care group) were evaluated in 1 and 3 months with treatment titration if uncontrolled. In all patients OBP and ambulatory BP measurement (ABPM) were evaluated in 6 months. Results: In both groups the reduction in OBP and ABPM was significant in 6 months. In the AAS group the reduction in systolic/diastolic OBP and 24 h systolic/ diastolic BP in 6 months was -26.5 ± 5.6 / -19.4 ± 8.2 mmHg (p < 0,001) and -19.6 ± 7.7 / -13.8 ± 4.8 mmHg (p < 0.001), respectively. In the standard care group, the reduction in systolic/diastolic OBP and 24 h systolic/diastolic BP in 6 months was -22.6 ± 9.7 / -9.6 ± 11 mmHg (p < 0.005) and -18.4 ± 6.0 / - 8.8 ± 4.4 mmHg (p < 0.001). In AAS group compared to standard care group there was a greater reduction in 24 h diastolic BP (-13.8 ± 4.8 mmHg vs -8.8 ± 4.4 mmHg, p = 0.016) and in diastolic OBP (-19.4 ± 8.2 mmHg vs -9.6 ± 11.0 mmHg, p = 0.04) Conclusions: The present results indicate that the monitoring of patients through a mobile health tool could be useful in hypertension management as it is correlated with better BP control compared to office visits. The trial is still enrolling patients.

SURGICAL MASKS AND UNATTENDED BLOOD PRESSURE CHANGES IN TREATED HYPERTENSIVE PATIENTS

Objective: Although the effect of face masks on preventing airborne transmission of SARS-CoV-2 is well studied, few data are available on their effects on physiological measures and no study has evaluated their effect on blood pressure (BP). The purpose of our study was to investigate the effect of surgical masks on BP in drug-treated hypertensive patients who had a routine follow-up visit to a university hospital outpatient hypertension clinic. Design and method: The study included already treated hypertensive patients aged > 18 years, while the exclusion criteria were atrial fibrillation or any other arrhythmia affecting the BP measurement, an arm circumference > 42 cm, mental disorders, Parkinson's disease, pregnancy, intolerance to the BP measurement method, or unwillingness to participate. Following the routine mask-on office BP measurement, patients were left alone and randomized to automated office BP measurement, with measurements taken after first wearing a mask for 10 min, then without wearing the mask for 10 min, and vice versa. Results: A total number of 265 patients were included in the study. Among the participants, 115 were women (43.4%), the mean age was 62 ± 12 years, and the mean office BP was 134 ± 15/81 ± 12 mmHg. There was no significant difference between mask-on unattended systolic BP (133 ± 15 mmHg) and mask-off unattended systolic BP (132 ± 15 mmHg) (P = 0.13) or between mask-on unattended diastolic BP (77 ± 13 mmHg) and mask-off unattended diastolic BP (76 ± 13 mmHg) (P = 0.32). Moreover, there was no difference in the heart rate (mask-on, 69 ± 11 bpm;mask-off, 69 ± 11 bpm, P = 0.7). Conclusions: The results of our study indicate that common surgical masks do not affect systolic/diastolic BP levels during unattended BP measurements.

IMPACT OF HYPERTENSION AS AN ADDITIONAL RISK FACTOR IN CARDIORESPIRATORY STATUS OF POST SARS-COV-2 INFECTED SUBJECTS

Objective: Few data have been published regarding the holistic approach of post- Covid patients, examining physical health. The purpose of our study was to examine the impact of arterial hypertension in the cardiopulmonary status of post-covid patients 3 months after the first day of infection. Design and method: All participants who recovered Covid-19 infection underwent cardiorespiratory exercise using either Bruce or modified Bruce protocol where all parameters were evaluated and transthoracic echocardiogram. The population was separated into two groups based on history of hypertension. Group I (n = 29) included hypertensive subjects and Group II (n = 75) included normotensive subjects. Results: A total of 104 patients were assessed 3 months after the onset of COVID- 19 symptoms. We recorded a mean age of 49 ± 15 years, 50.5% of them were males, 8.7% had a history of coronary heart disease. Hypertensives had higher BMI (29.24 ± 24 vs 26.64 kg/m2, p < 0.01) and BSA (2.09 ± 0.25 vs. 1.95 ± 0.58, p = 0.001). They were hospitalized in higher percentage comparing to normotensives (72.4% vs. 41.3%, p < 0.01). Left atrial diameter (41 ± 6 vs. 35 ± 5.5 mm, p < 0.001) was significantly larger in hypertensives. Furthermore, A wave (79 ± 21 vs. 58 ± 18 cm/s, p < 0.001) and ratios of E/A (1.01 ± 0.42 vs. 1.28 ± 0.44, p < 0.01) and E/E' (7.3 ± 3.7 vs. 5.9 ± 4.3, p < 0.01) differed between two groups. Finally, LVEF (%) was significantly impaired in hypertensive comparing to normotesive subjects (53 ± 13% vs. 59 ± 7%). This finding was depicted in lower maximum oxygen consumption (VO2 22 ± 4.5 vs.28 ± 8 ml/kg/min, p < 0.001), metabolic equivalents (METS) at peak, 9.1 ± 3 vs. 14 ± 20, p < 0.001), maximum heart rate (maxHR 147 ± 17 vs. 165 ± 21 bpm, p < 0.001) and HR1st minute recovery (123 ± 28 vs. 138 ± 21 bpm, p: 0.02) comparing to normotensive. Systolic blood pressure (SBP, 180 ± 29 vs. 165 ± 25mmHg, p: 0.02) during the 1st minute of recovery was higher in hypertensives. Finally, the duration of exercise was significantly lower in patients with hypertension (7.3 ± 2.7 vs. 9 ± 4 min, p:0.02) Conclusions: the current study highlighted the negative impact of hypertension in the ability to exercise. Regardless of the disease severity, post-covid patients need a comprehensive approach for rehabilitation including the modification of risk factors like hypertension and obesity.

CARDIOPULMONARY EXERCISE TEST AND ECHOCARDIOGAPHIC FINDINGS IN HOSPITALISED POST SARS-COV-2 PATIENTS: THE EFFECT OF ARTERIAL HYPERTENSION

Objective: There is little data concerning the impact of arterial hypertension (HTN) on the cardiopulmonary status and right ventricle (RV) function of patients with SARS-Cov-2 infection. The purpose of our study was to investigate whether HTN affects the functional status of hospitalized for SARS-Cov-2 patients, using cardiopulmonary test and echocardiographic parameters, 3 months after the first day of infection. Design and method: Subjects who were hospitalized and survived Covid-19 infection were divided into two groups according to history of HTN. All subjects underwent cardiorespiratory exercise using Bruce or modified Bruce protocol evaluating all parameters. Echocardiographic findings including right ventricle strain were analyzed using an offline program. Results: A total population of 52 hospitalized Sars-Cov-2 patients with a mean age of 57 ± 11.5 years were evaluated 3 months after the symptoms onset. Males amounted to 51.9 %. History of coronary artery disease was recorded in 15.4% of them. In hypertensive subjects, age (63 ± 8 vs. 52 ± 11 years, p < 0.001), BMI (29.9 ± 4.6 vs. 27.1 ± 5.8 kg/m2, p:0.03) and BSA (2.1 ± 0.25 vs. 2 ± 0.9 m2, p:0.04) were significantly higher. When analyzing cardiopulmonary test parameters, only maximum systolic blood pressure ((SBP, mmHg), 190 ± 21 vs.171 ± 26, p: 0.02) at peak and during the 1st minute of recovery (180 ± 23 vs. 157 ± 27 mmHg, p: 0.005) were higher comparing to normotensive subjects. Furthermore, diameter of left atrium ((LA, mm), 42 ± 6 vs.38 ± 6 p: 0.009), left ventricle ejection fraction ((LVEF,%), 48 ± 11 vs. 57 ± 6, p:0.004) and the absolute mean value of right ventricle strain ((RVLS, %), 9.1 ± 4 vs. 12.7 ± 5.4, p:0.04) differed significantly between two groups. Using linear regression analysis adjusted for age, gender, HTN, coronary heart disease and LVEF, HTN Conclusions: Our study highlighted negative impact of HTN both in right and left ventricle functionality, implying HTN as a negative independent predictive factor for right ventricle strain in patients hospitalized for SARS-Cov-2.

THE EFFECT OF COVID-19 VACCINE ON ARTERIAL FUNCTION

Objective: To fight the COVID-19 pandemic, messenger RNA (mRNA) vaccines were the first to be adopted by vaccination programs worldwide. We sought to investigate the short-term effect of mRNA vaccine administration on endothelial function and arterial stiffness. Design and method: Thirty-two participants (mean age 37 ± 8 years, 20 men) that received the BNT162b2 mRNA COVID-19 vaccine were studied in 3 sessions in a sequence-randomized, sham-controlled, assessor-blinded, cross-over design. The primary outcome was endothelial function assessed by brachial artery flow-mediated dilatation (FMD), and secondary outcomes were aortic stiffness, evaluated with carotid-femoral pulse wave velocity (PWV) and augmentation index (AIx@75), and inflammation measured by high-sensitivity C-reactive protein (hsCRP) in blood samples. The outcomes were assessed prior to, and at 8 h, 24 h post the 1st dose of vaccination, and 8 h, 24 h, and 48 h post the 2nd. Results: There was an increase in hsCRP that was apparent at 24 h after both the 1st dose (-0.60 [95% Confidence intervals [CI]: -1.60 to -0.20], p = 0.013) and the 2nd dose (max median difference at 48 h -6.60 [95% CI: -9.80 to -3.40], p < 0.001) compared to sham. The vaccine did not change PWV or AIx@75. FMD remained unchanged during the 1st dose but decreased significantly by 1.5% (95% CI: 0.1% to 2.9%, p = 0.037) at 24 h post the 2nd dose. FMD values returned towards baseline at 48 h. Conclusions: Our study shows that the mRNA vaccine causes a prominent increase in inflammatory markers, especially after the 2nd dose, and a transient deterioration of endothelial function at 24 h that returns towards baseline at 48 h. These results confirm the short-term cardiovascular safety of the vaccine.

COVID-19 ASSOCIATED REDUCTION IN HYPERTENSION-RELATED DIAGNOSTIC AND THERAPEUTIC PROCEDURES IN EXCELLENCE CENTERS OF THE EUROPEAN SOCIETY OF HYPERTENSION

Objective: The Covid-19 pandemic necessitated a decrease in non-Covid-19 related diagnostic and therapeutic procedures in many countries. We explored the impact on hypertension care in the Excellence Center (EC) network of the European Society of Hypertension. Design and method: We conducted an electronic survey regarding 6 key procedures in hypertension care among our ECs. Results: Overall, 54 ECs from 18 European and 3 non-European countries participated. From 2019 to 2020, there was a significant decrease in the median number per center of ambulatory blood pressure monitorings (ABPMs;544 vs 289), duplex ultrasound investigations of renal arteries (DUS RA;88.5 vs 55), computed tomographic investigations of renal arteries (CT RA;66 vs 19.5), percutaneous renal artery angioplasties (PTA RA;5 vs 1), laboratory tests for catecholamines (2019: 116 vs 67.5) and for ennin/aldosterone (146 vs 83.5). All comparisons were statistically significant with p < 0.001, respectively (Figure). While the reduction in all diagnostic and therapeutic procedures was observed in all 3-months period comparisons between 2019 and 2020, the most profound decrease occurred from April to June 2020, which was the period of the first wave and the first lockdown in most countries. In this period, as compared to 2019, the median reduction in 2020 was 50.7% (ABPM), 47.1% (DUS RA), 50% (CT RA), 57.1% (PTA RA), 46.9% (catecholamines) and 41% ( ennin/aldosterone), respectively. Based on Friedman test, overall differences in reduction between 3 months time intervals were statistically highly significant. Conclusions: Diagnostic and therapeutic procedures related to hypertension were dramatically reduced during the first year of the Covid-19 pandemic, with the largest reduction during the first lockdown. The long-term consequences regarding blood pressure control and, ultimately, cardiovascular events remain to be investigated.

Deformation analysis in post-hospitalised patients with moderate SARS-CoV-2 infection

Background: SARS-CoV-2 infection is associated with multiple cardiac manifestations (1,2). Global longitudinal strain (GLS) by speckle tracking echocardiography (STE) is a novel transthoracic echocardiography (TTE) measure of myocardial deformation, which could early recognize subclinical cardiac injury in COVID-19 patients (3,4). Purpose: We aimed to explore GLS profiles in post-hospitalized COVID-19 patients to identify features of eventual subclinical cardiac injury and to investigate the possible correlation with the severity of infection. Methods: We enrolled 33 patients (mean age 59.2 ± 13, 64% men) with positive SARS-CoV-2 RT-PCR, hospitalized for moderate COVID-19 disease, with no admission to intensive care unit. Patients were submitted to TTE 1-2 months after discharge. Images were anonymised and analysed offline by two accredited cardiologists. Clinical parameters and laboratory findings from hospitalization were also collected. Acute myocardial infarction and pulmonary embolism were exclusion criteria. Results: Mean duration of hospitalization was 12.9 ± 8.0 days. Study population had normal systolic function with a mean LV ejection fraction 58.6% (±3.6) while the majority of patients had relative low values of LV global longitudinal strain, mean 15.2% (±2.3). Arterial hypertension was present in 51.5% of patients and a history of previous myocardial infarction was referred in 6.1% of the population. Only 24.2% of patients had elevated troponin levels during the previous in-hospital period (mean maximal value of hs-troponin was 18.1 ±16.6 pg/mL) whereas 81.8% had abnormal D-Dimers values (mean 2424 μg /L, range ±2825) and 93.1% had high hs-CRP values (138.2 ±92.0 mg/L) . Duration of hospitalization had strong significant correlation with D-Dimers (rho: 0.708, p: <0.001) and hs CRP (rho:0383, p:0.028) and marginal association with troponin ( rho: 0.335, p:0.056). Moreover, global longitudinal strain showed significant association with duration of hospitalization (rho:-0.545, p: 0.007). Traditional systolic indices as LVEF and the various diastolic parameters showed no significant association with severity of disease reflected by the duration of hospitalization and the other clinical and laboratory biomarkers. Conclusion: Cardiac manifestations of SARS-CoV-2 infections could be present in mild to moderate disease and seems to associate with the severity of infection. The novel echocardiographic parameters such as GLS could add valuable information and identify possible subclinical cardiac injury often unrecognized by traditional TTE examination.

Dobutamine stress echocardiography during covid-19 pandemic: impact on volume and positivity rates in a tertiary hospital

Introduction: The emergence of coronavirus 2019 infection (covid-19) was accompanied by severe social and economic restrictions and applied significant pressure to the healthcare systems. The first pandemic wave started in March to May 2020 and was characterized by the peak of confinement measures and lockdown application. The second wave started in September and peaked in November to December 2020 and was characterized by improved healthcare organization but significant burden for the hospitals and intensive care units. Dobutamine stress echocardiography (DSE) is used for evaluation of ischemia in patients with known or suspected coronary artery disease. Purpose: To compare DSE volume and positivity rates between 2019 and 2020 time periods in a department of a public tertiary hospital. Methods: We retrospectively analysed DSE studies performed in our department in 2020 including the peak of covid-19 restrictions and compared the data to the 2019. Results: Volume of DSE studies decreased from 1516 in 2019 to 996 in 2020 (-34.3%). The study volume reduction was greater in April (-93.7%) and May (-54.5%) when the covid-19 restrictions were at the peak. Great decreases were also recorded in November (-46.8%) and December (-53.5%) when the second wave of covid-19 disease emerged. Conversely, small increases were recorded in September (7.1%) and October (10.6%) (figure 1). Regarding positivity rates, a statistically non-significant increase was recorded (33.6% vs 34.2% in 2019 and 2020 respectively, p = 0.73). Interestingly a statistically significant increase in positivity levels was recorded during the period March to May 2020 compared to the same period of 2019 (44.7% vs 36.9%, p = 0.029). On the contrary, positivity rates were decreased at the period September to December (27.1% vs 34.2%, p = 0.019) (figure 2). Conclusions: Volume of DSE studies was significantly reduced in 2020 when compared to 2019 during respective peaks of the pandemic and the accompanying restriction measures. Positivity rates were higher during the first pandemic wave, possibly due to decreased hospital attendance of mildly symptomatic patients in combination with stricter admission criteria at the emergency department. Lower positivity rates during the second pandemic wave possibly reflect an adjustment of both healthcare systems and patients to the new conditions imposed by the covid-19 pandemic.

The impact of SARS-COV-2 on stroke epidemiology and care: A meta-analysis

Background: Emerging data indicates an increased risk for cerebrovascular events with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and highlights the potential impact of coronavirus disease (COVID-19) on the management and outcomes of acute stroke. We conducted a systematic review and meta-analysis to evaluate the aforementioned considerations. Methods: We performed a meta-analysis of observational cohort studies reporting on the occurrence and/or outcomes of patients with cerebrovascular events in association with their SARSCoV- 2 infection status. We used a random-effects model. Summary estimates were reported as odds ratios (ORs) and corresponding 95% confidence intervals (95%CI). Results: We identified 16 cohort studies including 44,004 patients. Among patients with SARS-CoV- 2, 1.3% (95%CI: 0.9-1.8%;I =88%) were hospitalized for cerebrovascular events, 1.2% (95%CI: 0.8-1.5%;I =85%) for ischemic stroke, and 0.2% (95%CI: 0.1-0.4%;I =69%) for hemorrhagic stroke. Compared to non-infected contemporary or historical controls, patients with SARS-CoV-2 infection had increased odds of ischemic stroke (OR=3.58, 95%CI: 1.43-8.92;I =43%) and cryptogenic stroke (OR=3.98, 95%CI: 1.62-9.77;I =0%). Odds for in-hospital mortality were higher among SARS-CoV-2 stroke patients compared to non-infected contemporary or historical stroke patients (OR=5.60, 95%CI: 3.19-9.80;I =45%). SARS-CoV-2 infection status was not associated to the likelihood of receiving intravenous thrombolysis (OR=1.42, 95%CI: 0.65-3.10;I =0%) or endovascular thrombectomy (OR=0.78, 95%CI: 0.35-1.74;I =0%) among hospitalized ischemic stroke patients during the COVID-19 pandemic. Diabetes mellitus was found to be more prevalent among SARS-CoV-2 stroke patients compared to non-infected contemporary or historical controls(OR=1.39, 95%CI: 1.04-1.86;I =0%). Conclusion: SARS-CoV-2 appears to be associated with an increased risk of ischemic stroke,particularly the cryptogenic subtype. SARS-CoV-2 infection in stroke substantially increases themortality risk.