ABSTRACT
Introduction The 2019 coronavirus pandemic has taken a toll on our society. Although most patients report minimal symptoms, a small proportion of patients have reported significant respiratory symptoms that led to admission to the inpatient medical ward or even the intensive care unit. Complications and long-term sequela of COVID-19 are still being reported and studied. The presence of cardiomyopathy, whether established or new-onset and its effect on inpatient mortality, admission to the intensive care unit or length of stay hasn't been studied. Methods All inpatient hospitalizations in our database between March 1, 2020, and April 30, 2020, due to COVID-19 were reviewed. Patients who had at least a limited echocardiogram during this time were included in the study if they were above the age of 18. Patients were then assigned to three groups. The first group had patients with normal left ventricular systolic function. The second group had established cardiomyopathy that persisted throughout admission. The third group had patients who were found to have new-onset cardiomyopathy during admission. Results The inpatient mortality, although high and variable, wasn't significantly different between the three groups. Also, there was no significant difference between admission to the intensive care unit, disposition at discharge, or oxygenation status at 24 hours between the three groups. The length of stay in the established cardiomyopathy group was markedly lower, and we suspect that could be due to more aggressive discussions about end-of-life care. Conclusion Early COVID-19 experience at our center revealed a relatively high mortality rate that was primarily due to respiratory failure. The presence of established or new cardiomyopathy didn't appear to alter the outcomes significantly early in the pandemic.
ABSTRACT
Objectives: Our study aimed to investigate the frequency of malignant cardiac arrhythmias in hospitalized patients receiving hydroxychloroquine alone and those receiving a combination of hydroxychloroquine with azithromycin, as well as the quantitative extent of QT prolongation within Tisdale Risk Score (TRS) categories. Background: There have been over 33 million cases of SARS-CoV-2 (COVID-19) resulting in over 600,000 deaths in the United States. As the current COVID-19 pandemic continues, numerous medications have been administered to attempt to treat patients afflicted by the disease. While hydroxychloroquine has been in use for decades for rheumatologic and infectious disease processes, it does have potential cardiotoxicity related to drug-induced QT prolongation. Drug-induced QT prolongation has an increased risk of arrhythmogenicity, potentially progressing into torsades de pointes (TdP) and increased patient mortality. The relationship between QT prolongation and TdP is complex and inexact, but there remains optimism regarding the use of these medications in the treatment of COVID-19 despite limited data on their true efficacy. Methods: We retrospectively identified 75 patients who were admitted with COVID-19 and underwent treatment with hydroxychloroquine for 5 days. The hydroxychloroquine protocol was defined as an initial dose of 400 mg BID for the first day, followed by 400 mg daily for the next 4 days. Baseline demographics, medications, medical histories, lab values, ECG QT intervals, and Tisdale Risk Categories were collected for all patients. Results: Seventy-four (98.7%) patients completed the full course of hydroxychloroquine. There were 41 males (54.7%) and 34 females (45.3%). Average length of stay was 8.9 days (95% CI: 7.5, 10.2). One patient who could not complete the course due to inability to swallow medication tablets. There were no reports of new arrythmias or incidence of torsades de pointes during the study. Seventy-two patients (96%) were taking at least 2 QT prolonging medications. The average corrected QT intervals were as follows: day 1 of admission was 421.62 milliseconds (n = 66, 95% CI: 412.19, 431.05), day 2 was 431.50 ms (n = 30, 95% CI: 416.34, 446.66), day 3 was 433.48 ms (n = 23, 95% CI: 413.34, 453.61), day 4 was 427.59 ms (n = 17, 95% CI: 400.83, 454.35), and day 5 was 444.28 ms (n = 18, 95% CI: 428.43, 460.12). The corrected QT interval prolonged by 22.66 ms from day 1 to day 5 (p = 0.03) in the overall population. Conclusion: There were no patients who experienced arrhythmogenicity or Torsades de Pointes despite a statistically significant increase in QTc intervals after patients received the 5-day course of hydroxychloroquine for treatment of COVID-19.
ABSTRACT
BACKGROUND: Previous studies have suggested that haemodynamic-guided management using an implantable pulmonary artery pressure monitor reduces heart failure hospitalisations in patients with moderately symptomatic (New York Heart Association [NYHA] functional class III) chronic heart failure and a hospitalisation in the past year, irrespective of ejection fraction. It is unclear if these benefits extend to patients with mild (NYHA functional class II) or severe (NYHA functional class IV) symptoms of heart failure or to patients with elevated natriuretic peptides without a recent heart failure hospitalisation. This trial was designed to evaluate whether haemodynamic-guided management using remote pulmonary artery pressure monitoring could reduce heart failure events and mortality in patients with heart failure across the spectrum of symptom severity (NYHA funational class II-IV), including those with elevated natriuretic peptides but without a recent heart failure hospitalisation. METHODS: The randomised arm of the haemodynamic-GUIDEed management of Heart Failure (GUIDE-HF) trial was a multicentre, single-blind study at 118 centres in the USA and Canada. Following successful implantation of a pulmonary artery pressure monitor, patients with all ejection fractions, NYHA functional class II-IV chronic heart failure, and either a recent heart failure hospitalisation or elevated natriuretic peptides (based on a-priori thresholds) were randomly assigned (1:1) to either haemodynamic-guided heart failure management based on pulmonary artery pressure or a usual care control group. Patients were masked to their study group assignment. Investigators were aware of treatment assignment but did not have access to pulmonary artery pressure data for control patients. The primary endpoint was a composite of all-cause mortality and total heart failure events (heart failure hospitalisations and urgent heart failure hospital visits) at 12 months assessed in all randomly assigned patients. Safety was assessed in all patients. A pre-COVID-19 impact analysis for the primary and secondary outcomes was prespecified. This study is registered with ClinicalTrials.gov, NCT03387813. FINDINGS: Between March 15, 2018, and Dec 20, 2019, 1022 patients were enrolled, with 1000 patients implanted successfully, and follow-up was completed on Jan 8, 2021. There were 253 primary endpoint events (0·563 per patient-year) among 497 patients in the haemodynamic-guided management group (treatment group) and 289 (0·640 per patient-year) in 503 patients in the control group (hazard ratio [HR] 0·88, 95% CI 0·74-1·05; p=0·16). A prespecified COVID-19 sensitivity analysis using a time-dependent variable to compare events before COVID-19 and during the pandemic suggested a treatment interaction (pinteraction=0·11) due to a change in the primary endpoint event rate during the pandemic phase of the trial, warranting a pre-COVID-19 impact analysis. In the pre-COVID-19 impact analysis, there were 177 primary events (0·553 per patient-year) in the intervention group and 224 events (0·682 per patient-year) in the control group (HR 0·81, 95% CI 0·66-1·00; p=0·049). This difference in primary events almost disappeared during COVID-19, with a 21% decrease in the control group (0·536 per patient-year) relative to pre-COVID-19, virtually no change in the treatment group (0·597 per patient-year), and no difference between groups (HR 1·11, 95% CI 0·80-1·55; p=0·53). The cumulative incidence of heart failure events was not reduced by haemodynamic-guided management (0·85, 0·70-1·03; p=0·096) in the overall study analysis but was significantly decreased in the pre-COVID-19 impact analysis (0·76, 0·61-0·95; p=0·014). 1014 (99%) of 1022 patients had freedom from device or system-related complications. INTERPRETATION: Haemodynamic-guided management of heart failure did not result in a lower composite endpoint rate of mortality and total heart failure events compared with the control group in the overall study analysis. However, a pre-COVID-19 impact analysis indicated a possible benefit of haemodynamic-guided management on the primary outcome in the pre-COVID-19 period, primarily driven by a lower heart failure hospitalisation rate compared with the control group. FUNDING: Abbott.