ABSTRACT
Background: Patients with cancer represent a uniquely vulnerable population not only with higher susceptibility to COVID-19 but also at increased risk for death. However, detailed information on causes of death and the contribution of pre-existing health conditions to death yet is missing. Purpose(s): This study focuses on the implications of COVID-19 in the cardiovascular health of patients with cancer by assessing the relation between cancer and de novo acute heart failure (AHF) with in-hospital mortality. Method(s): The initial population consisted of 3968 patients included in the ISACS COVID-19 registry between March 2020 and February 2022. Of these, 546 patients with chronic HF were excluded, leaving a final population of 3422. Patients were divided in two groups according to the presence or absence of a cancer diagnosis at the time of hospitalization for COVID- 19. Primary outcomes were incidence of in-hospital mortality or AHF during hospitalization. Association between cancer and outcomes was estimated using multivariable logistic regression analyses. Subsidiary analysis was conducted to evaluate differences between patients with prior vs active cancer. Result(s): Of the 3422 patients included in the study, 468 patients had cancer (8.2% active, 5.5% past cancer). Cancer patients were older (68.9+/-13.4 vs 63.3+/-15.6, p-value <0.001) and more likely to be female (50.4% vs 39.1%, p-value <0.001). They presented more frequently with a history of chronic obstructive pulmonary disease (12.3% vs 7.6%, p-value = 0.001). When considering outcomes, cancer patients had a significantly higher incidence of in-hospital mortality (27.7% vs 19.2%;p-value <0.001). This despite the presence of a numerically higher mean PiO2/FiO2 (281+/-108.8 vs 267.05+/-122.5, p-value = 0.11) on admission and a lower rate of X-ray findings of interstitial pneumonia (60% vs 70.5%, p-value <0.001) than their non-oncological counterparts, as well as similar use of mechanical ventilation (30.6% vs 35.0%, p value=0.14). The association between cancer and death persisted when adjusting for demographic, laboratory findings and in-hospital treatment (OR: 1.46;95% CI: 1.11-1.94;p value=0.01). Cancer patients also had higher rates of AHF (9.6% vs 4.7%, p-value <0.001) during hospitalization. This association was independent from presence of cardiovascular risk factors or comorbidities (OR: 1.61;95% CI: 1.07-2.43;p value=0.02). When restricting the analysis to the cancer population, AHF appeared to be significantly associated with death (OR: 2.41;95% CI 1.18- 4.95;p-value = 0.01), but this correlation persisted only in patients affected by active cancer in age and sex adjusted analyses (OR: 4.27;95% CI: 1.51-12.07;p value=0.01 vs 1.20;95% CI: 0.38-3.76;p-value = 0.75). Conclusion(s): The incidence of AHF in cancer patients with COVID-19 is high. Patients with active cancer are also at high risk for mortality. This has implications for cardiac monitoring and chemotherapy administration during COVID-19.
ABSTRACT
Background and Aim: Cardiovascular manifestations are common (35-100%) in multisystem inflammatory syndrome in children (MIS-C), including ventricular dysfunction, shock, coronary artery dilation, pericardial effusion and conduction abnormalities. Our study aimed to analyse cardiovascular involvement in our patients with MIS-C treated in our hospital. Method(s): The retrospective cohort study included all patients with MIS-C treated from April 2020 to December 2021 in the Mother and Child Health Institute of Serbia. In every case, cardiovascular manifestations were analysed: ventricular dysfunction, coronary artery dilatation, pericardial effusion, shock and ECG changes. Result(s): The study included 77 patients, 45 boys and 32 girls, aver-age years of age 9.3 +/- 4.8. Elevated cardiac troponin I and pro-BNP were observed in 35.9% and 87.8% of patients, respectively. Myocardial dysfunction was observed in half of our patients (50.6%), with an average ejection fraction of 50.5 +/- 8.9%. Children older than 10 years had 4 times higher chances for myo-cardial dysfunction (OR 4.3, 95%CI 1.6-10.8;p = 0.003). Shock syndrome had 21.1% of children on admission, while 5.3% devel-oped shock during the in-hospital stay. Transient coronary artery (CA) dilatation was observed in 6.5% of patients;left CA in 3 pts (Z score +2,95 +/- 0.3), right CA in one patient (Z score +2), and in one LCA and RCA (RCA Z score 2.6). Transient CA dilatations were observed only in patients with KD-like clinical presentation (5/54 pts). Mild pericardial effusion with spontaneous resolution was detected in 28.6% of children, while one female adolescent had severe pericardial effusion with threatening cardiac tamponade. On the standard ECG, 53% of children had negative T wave in inferior or/and precordial leads averagely on day 2 (IQR 1-3 day);transient QTc prolongation was registered in 46% of patients, averagely on day 7 (IQR 5-9). Sinus bradycardia and coronary rhythm were registered in 42.1% of patients, while premature ven-tricular beats were observed in 2.7% of pts. left ventricle thrombus was detected in one patient with normal echocardiography find-ing. In this patient, increased activity of Factor VIII and XII was proven. Conclusion(s): Cardiac manifestations are common and potentially life-threatening in MIS-C and should be assessed for at presenta-tion and during the clinical course as indicated.
ABSTRACT
Background and Aim: Mixed shock in multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 is con-sequence of acute heart failure, inflammation-induced vasodilation and potential volume loss. Method(s): Retrospective analysis included 25 patients (7 girls) with MIS-C-related combined shock, treated in period from April 2020 to December 2021. Result(s): Mean age of patients was 12.6 +/- 4.0 years. Admission was 6.1 +/- 1.6 days after symptoms onset. Systemic inflammatory response was manifested with neutrophilia (10.7 +/- 4.2 x109/), lymphopenia (1.1 +/- 0.7 x109/L), elevated CRP (220.9 +/- 86.1 mg/L), ferritin (684.5 +/- 549.5 mug/L) and D-dimer (1528 +/- 1254 ng/mL). One third of patients had acute kidney injury with glomerular filtration rate of 64 +/- 22 mL/min/1.73 m2 and urea level of 16.0 +/- 8.4 mmol/L. All patients had acute heart failure with ejection fraction 47.2% +/- 7.7% and fractional shortening 23.6% +/- 4.9%, 92% of patients had NTproBNP gt;1500 pg/mL and 58% had elevated troponin I (1.34 +/- 1.47 ng/mL). Z-scores for end-diastolic left ventricle, interventricular septum and pos-terior wall diameters were 0.7 +/- 1.1, 1.7 +/- 1.3 and 0.6 +/- 0.7 respectively. All patients had mild/moderate mitral regurgitation, and 60% had mild pericardial effusion. Inotropes, administered during first 3.7 +/- 1.6 days, were divided in three groups: 1) dop-amine (n = 14), 2) dobutamine + dopamine (n = 5), 3) milrinone +/- dopamine (n = 6). Additional treatment included diuretics and captopril. Total fluid balance (including insensible loss of 300 mL/m2/day) through days 1-7 was +860 mL/m2, +128 mL/m2,-108 mL/m2,-36 mL/m2,-306 mL/m2,-335 ml/m2,-298 ml/m2 (total-95 ml/m2). Methylprednisolone/intravenous immuno-globulin and low-molecular-weight heparin/acetylsalicylic acid were administered and fever persisted 1.2 days averagely. Oxygen supplementation was needed in 71% of patients. Transitory bradycardia was noticed and there was no difference in heart rate between treatment groups. Profound hypotension was revealed on admission and correction differed regarding treat-ment (p lt;0.05) (Figure 1). All patient survived with clinical improvement (one had mechanical ventilation, and one had stroke). Conclusion(s): Mixed shock is the most severe manifestation of MIS-C, and treatment of heart failure should be combined with cau-tious fluid resuscitation.
ABSTRACT
Introduction: Acute myocarditis (AM) is an inflammatory disease of the myocardium. Myocardial injury in COVID-19 could appear as a result of the directvirus attacking, or viral-inducedmyocardial inflammationas a consequence of the aggressiveimmuneresponse.The aim of our study is a comparative analysis of the difference between children with AM before and during the SARS-CoV-2 pandemic. Methods: The retrospective analysis included all patients treated in our Institute with a diagnosisofAMfromJanuary2018toNovember 2020. Results: 24 patients were included in the study;in all patients (7/24) treated from April to November 2020, the infection was caused by SARS-CoV-2 (2 PCR, 5 serological tests of IgM antibodies). All patients with AM during the pandemic were older than 7 years. They were more likely to have abdominal pain (p=0.014), headache (p=0.003), cutaneous rash (p=0.003), conjunctivitis (p=0.003), while fulminant myocarditis was more commonly registered before the pandemic (p=0.04). A multisystem inflammatory syndrome in children associated with COVID-19 was present in 6 patients. Patients with AM in the pandemic had significantly lower values of troponin I (cTnI) (p=0.012), and platelets (p<0.001), but higher values of serum creatinine (p=0.013) and CRP (p=0.04) compared with patients before the pandemic. In the group of patients during the pandemic, a significant CRP reduction (p=0.007) was observed on the day of discharge compared to admission value. In the group of patients before the pandemic, cTnI values were significantly reduced (p=0.002). A significant recovery of systolic function was registered on the third in-hospital day in the group of patients presented during the pandemic (EF p=0.001;FS p=0.019);improvement was not observed in the group before COVID-19 pandemic. Adverse events were observed frequently in patients before the pandemic (p=0.04;3 died, and 4 dilated cardiomyopathy). Conclusions: In contrast to patients before the pandemic, in patients with AM during the COVID-19 pandemic, significantly higher values of inflammatory parameters, polymorphic clinical presentation as well as prompt recovery of LV function after applied therapy noticed in patients during SARS-CoV-2 pandemic underlie a possible new spectrum inflammatory disease with consequence viral-related myocardial inflammation with favorable prognosis.