Type of hospitalisations and in-hospital outcomes in the Italian coronary care unit network at the time of COVID-19 pandemic: the BLITZ-COVID19 Registry.

OBJECTIVE: The aim of the study was to describe the epidemiology and outcome of patients hospitalised during the COVID-19 pandemic in intensive cardiac care units (ICCs). DESIGN: Non-interventional, retrospective and prospective, nationwide study. SETTING: 109 private or public ICCs in Italy. PARTICIPANTS: 6054 consecutive patients admitted to Italian ICCs during COVID-19 pandemic. PRIMARY AND SECONDARY OUTCOME MEASURES: To obtain accurate and up-to-date information on epidemiology and outcome of patients admitted to ICCs during the COVID-19 pandemic, the impact that the COVID-19 infection may have determined on the organisational pathways and in-hospital management of the various clinical conditions being admitted to ICCs. RESULTS: Acute coronary syndromes were the most frequent ICC discharge diagnoses followed by heart failure and hypokinetic arrhythmias. The prevalence of COVID-19 positivity was approximately 3%. Most patients with a COVID-19 diagnosis at discharge (52%) arrived to ICC from other wards, in particular 22% from non-cardiology ICCs. The overall mortality was 4.2% during ICC and 5.8% during hospital stay. The cause of in-hospital death was cardiac in 74.4% of the cases, non-cardiovascular in 13.5%, vascular in 5.8% and related to COVID-19 in 6.3% of the patients. CONCLUSIONS: This study provides a unique nationwide picture of current ICC care during COVID-19 pandemic. TRIAL REGISTRATION NUMBER: NCT04744415.

Cardio-Oncology in the COVID Era (Co & Co): The Never Ending Story.

The pathophysiology of some non-communicable diseases (NCDs) such as hypertension, cardiovascular disease (CVD), diabetes, and cancer includes an alteration of the endothelial function. COVID-19 is a pulmonary and vascular disease with a negative impact on patients whose damaged endothelium is particularly vulnerable. The peculiar SARS-CoV-2-induced "endothelitis" triggers an intriguing immune-thrombosis that affects both the venous and arterial vascular beds. An increased liability for infection and an increased likelihood of a worse outcome have been observed during the pandemic in patients with active cancer and in cancer survivors. "Overlapping commonalities" between COVID-19 and Cardio-Oncology have been described that include shared phenotypes of cardiovascular toxicities such as left ventricular dysfunction, ischemic syndromes, conduction disturbances, myocarditis, pericarditis and right ventricular failure; shared pathophysiologic mechanisms such as inflammation, release of cytokines, the renin-angiotensin-aldosterone-pathway, coagulation abnormalities, microthrombosis and endothelial dysfunction. For these features and for the catalyst role of NCDs (mainly CVD and cancer), we should refer to COVID-19 as a "syndemic." Another challenging issue is the persistence of the symptoms, the so-called "long COVID" whose pathogenesis is still uncertain: it may be due to persistent multi-organ viral attacks or to an abnormal immune response. An intensive vaccination campaign is the most successful pharmacological weapon against SARS-CoV-2, but the increasing number of variants has reduced the efficacy of the vaccines in controlling SARS-CoV-2 infections. After a year of vaccinations we have also learned more about efficacy and side-effects of COVID-19 vaccines. An important byproduct of the COVID-19 pandemic has been the rapid expansion of telemedicine platforms across different care settings; this new modality of monitoring cancer patients may be useful even in a post pandemic era. In this paper we analyze the problems that the cardio-oncologists are facing in a pandemic scenario modified by the extensive vaccination campaign and add actionable recommendations derived from the ongoing studies and from the syndemic nature of the infection.

[Being cardiologist at the time of SARS-CoV-2: what do not forget during the post-pandemic phase?] / Essere cardiologo ai tempi del SARS-CoV-2: cosa non dimenticare nella fase post-pandemia?

In Italy, the epidemic explosion stage of COVID-19 seems to have been overcome; however, the virus has not been eradicated and the re-emergence of some outbreaks of infection substantiates the danger that the disease may persist. It is therefore necessary to keep the level of surveillance high, to maintain social distancing measures and to act in the control of disease risk factors of a serious or complicated course. Among the risk factors of severe COVID-19 in addition to age, male gender, hypertension and cardiovascular diseases, a major role seems to be played by other cardiovascular risk factors conditioned by an unhealthy lifestyle such as obesity, metabolic syndrome, diabetes and smoking. The new phase requires the maintenance of measures that avoid crowding and close interpersonal contact especially during exercise, in addition to controlled access to hospitals. This will require the reorganization of the traditional methods of cardiovascular prevention and rehabilitation activities, such as gyms and collective educational sessions, and the dilution of outpatient checks. The risk that this scenario may worsen the already suboptimal control of cardiovascular risk factors is therefore real. We do not currently know how long this new phase will last, therefore it is necessary to give impetus to new tele-health initiatives to stimulate the adoption of a healthy lifestyle in primary prevention and tele-monitoring and tele-rehabilitation programs in secondary prevention.

[ANMCO Position paper: Pulmonary circulation diseases and COVID-19]. / Position paper ANMCO: Malattie del circolo polmonare e COVID-19.

The new coronavirus disease 2019 (COVID-19), which is causing hundreds of thousands of deaths worldwide, is complex and can present with a multi-organ localization. One of its worst complications is an interstitial pneumonia with acute respiratory failure also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which requires non-invasive or invasive ventilation. A severe coagulopathy with poor prognosis is found in 5-10% of cases. SARS-CoV-2 is manifesting as a multi-dimensional disease and, recently, unique co-existing pathophysiological and clinical aspects are being defined: (i) an increased immune and inflammatory response with the activation of a cytokine storm and consequent coagulopathy, which promote both venous thromboembolic events and in situ thrombosis localized in small arterioles and pulmonary alveolar capillaries; (ii) a high intrapulmonary shunt, which often accounts for the severity of respiratory failure, due to reduced hypoxic pulmonary vasoconstriction with pulmonary neo-angiogenetic phenomena. Furthermore, the high incidence of venous thromboembolism in COVID-19 patients admitted to the intensive care unit and the autoptic findings of in situ micro-thrombosis at the pulmonary vascular level, suggest that in this disease coagulopathy, unlike septic disseminated intravascular coagulation, is driven towards a hyper-thrombogenic state, giving rise to a debate (with ongoing studies) about the preventive use of anticoagulant doses of heparin to reduce mortality. The aim of this position paper from the Italian Association of Hospital Cardiologists (ANMCO) is to highlight the main implications that COVID-19 infection has on the pulmonary circulation from a pathophysiological, clinical and management point of view.

ANMCO POSITION PAPER: The cardiological clinical activities in the transition phase of the COVID-19 pandemic

Infections by SARS CoV2 - COVID-19 became in a short time a worldwide health emergency. The present SARS-CoV-2 pandemic induced in a short time, an unprecedented impact on public health and on the pre-existing care pathways. In order to appropriately address this epidemiological emergency, urgent solutions were needed, such as remodelling or stopping hospitalization and deferrable clinical activities to avoid spreading the SARS-CoV-2 infection. After the first emergency lockdown phase, care pathways must guarantee healthcare to patients and preserve the safety of the healthcare personnel and of all the other subjects that refer to the cardiological surgeries. Rigorous prescriptive appropriateness of the requested exams with consequent reduction of unnecessary examinations is an essential requirement to preserve prioritized diagnostic and care pathways to patients in need, minimizing the risks connected to the SARS-CoV-2 contagion in hospitals. Telemedicine services represent a valid answer to cardiovascular disease patients’ need for care and assistance, including those in quarantine and voluntary isolation. These services successfully contribute to fight the spread of the virus guaranteeing at the same time therapy and support through remote services that must therefore be considered a resource to be implemented and enhanced. This document has to be used by the healthcare personnel working in hospitals and in district offices, if applicable, and aims at managing patients, in complete safety and considered not suspect/not probable (‘not at risk’) of SARS-CoV-2 infection, eligible for diagnostic activity and subsequent therapy in outpatient surgeries. In particular, this document provides indications for patient evaluation to prevent COVID-19 exposure, gives general indications on managing appointments and waiting rooms, on how to strictly adhere to environmental safety measures, on the proper use of Individual Protective Equipment (IPE). It also provides specific indications for outpatient service procedures, like electrocardiogram, cardiologic examination, cardiologic checkup, Dynamic Holter Electrocardiogram, Transthoracic Echocardiography, Echo Stress, Transoesophageal Echocardiography, Bike Ergometer stress test, Ergospirometry, Outpatient Checkup of implantable electronic cardiac devices.

ANMCO POSITION PAPER: The management of suspect or confirmed COVID-19 patients needing urgent electrophysiology and/or electrostimulation procedures

The aim of this document is the management and organization of patients in need of urgent access to electrophysiology (EP) and pacing procedures during the COVID-19 emergency. Specifically, non-deferrable procedures or irreplaceable with a drug therapy prior to the resolution of the COVID-19 virus emergency [pacemaker (PM) implant/replacement/urgent defibrillator (implantable cardioverter-defibrillator, ICD) or arrhythmic storm or other indication of non-deferrable ablation]. The pacing and electrophysiological procedures urgent as they may be, less and less frequently represent situations of emergency, therefore for almost all cases, it is possible to perform a swab test to determine the positivity to COVID-19 of the patient. In cases where this is not possible, due to situations of emergency, the recommendations and procedures we have indicated are advisable, if not mandatory, in order to avoid the spreading of the virus to healthcare personnel and other patients.