Hyponatremia in COVID-19 Is Not Always Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH): A Case Series.

Hyponatremia is a common complication in COVID-19-positive patients and is associated with significant mortality and morbidity. Several cases of COVID-19-related hyponatremia secondary to the Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH) have been reported in the literature, which might suggest that SIADH is almost always the underlying cause of hyponatremia in COVID-19 infections. However, COVID-19-related hyponatremia can have diverse underlying etiologies, similar to hyponatremia in non-COVID-19 patients, and requires a thorough assessment to reach a correct diagnosis and implement appropriate management.

Furosemide-induced haemolytic anaemia in an extreme elderly patient.

Furosemide, a loop diuretic, is commonly used to treat fluid overload symptoms and heart failure. Drug-induced immune haemolytic anaemia is an unusual drug-adverse event. Furosemide-induced haemolysis is even rarer. This case report presents a 91-year-old male who developed acute haemolytic anaemia 3 days after initiating furosemide to treat myocardial infarction complicated with acute decompensated heart failure. He had increased lactate dehydrogenase and unconjugated bilirubin with undetectable haptoglobin, which indicated the destruction of red blood cells. Other causes for haemolytic anaemia, including hereditary, microangiopathic haemolytic anaemia, and paroxysmal nocturnal haemoglobinuria, were also excluded. He improved with drug cessation and a short course of glucocorticoids. This report aims to raise awareness of this rare complication caused by commonly prescribed drugs. Despite a negative result of a direct antiglobulin test, physicians must remain suspicious of drug-induced immune haemolytic anaemia in unclear cases of haemolysis.

Impact of the COVID-19 pandemic on cardiovascular heart disease medication use: time-series analysis of England's prescription data during the COVID-19 pandemic (January 2019 to October 2020).

BACKGROUND: Management of high blood pressure (BP) typically requires adherence to medication regimes. However, it is known that the COVID-19 pandemic both interrupted access to some routine prescriptions and changed some patient health behaviours. AIM: This study, therefore, retrospectively investigated prescription reimbursement of cardiovascular (CVD) medicines as a proxy measure for patient adherence and access to medicines during the pandemic. METHODS: A cohort study of all primary care patients in England prescribed CVD medicines. The exposure was to the global pandemic. Prescriptions were compared before and after the pandemic's onset. Statistical variation was the outcome of interest. RESULTS: Descriptive statistics show changes to monthly prescriptions, with wide confidence intervals indicating varying underlying practice. Analysis of variance reveals statistically significant differences for bendroflumethiazide, potassium-sparing diuretics, nicorandil, ezetimibe, ivabradine, ranolazine, colesevelam and midodrine. After the pandemic began (March-October 2020), negative parameters are observed for ACE inhibitors, beta-blockers, calcium channel blockers, statins, antiplatelet, antithrombotics, ARBs, loop diuretics, doxazosin, bendroflumethiazide, nitrates and indapamide, indicating decelerating monthly prescription items (statistically significant declines of calcium channel blockers, antithrombotic, adrenoreceptor blockers and diuretics) of CVD medicines within the general population. Many data points are not statistically significant, but fluctuations remain clinically important for the large population of patients taking these medications. CONCLUSION: A concerning decline in uptake of CVD therapies for chronic heart disease was observed. Accessible screening and treatment alongside financial relief on prescription levies are needed. A video abstract is (4 min 51 s) available: https://bit.ly/39gvEHi.

A retrospective review of a nurse-led cirrhosis programme in tertiary care during the first year of the Covid-19 pandemic

BackgroundThe CNS team reflected and evaluated the adaption of the hepatology CNS service during the pandemic, exploring new ways of working. During the pandemic many multispecialty elective admissions were cancelled and despite the team redeploying staff we were able to continue to provide ascites management and face-to-face reviews of patients, which significantly increased during this time.AimThe data provides a service review a Clinical Nurse Specialist (CNS) team in reducing hospital admissions and A&E attendances.MethodsA retrospective analysis was completed for 160 “Hot clinic” patients (face-to-face) and 134 HCC surveillance screening patients (converted to a telephone clinic). The data was analysed between January 2020 and December 2020. The data demonstrates how patients continued to access face-to-face reviews and planned day-case drains. Working closely with the medical hepatology team we were able to provide an ongoing service for all patients within hepatology, who following a virtual appointment, needed clinical review. The data was obtained from four CNS-led referral pathways:(i) a “Hot clinic” for liver unit ward discharge follow-ups, (ii) day-case LVPS (Managed by CNS team fed in from “Hot clinic” reviews), (iii) a joint cirrhosis/palliative care MDT for referral of patients between the specialties of gastroenterology, liver and palliative care (iv) a nurse-led alcohol-related (ArLD) cirrhosis clinic.The data collected focused on patient characteristics, length of hospital stay, emergency department attendance avoidance, admission avoidance, fast-track paracentesis rate and compliance with HCC/Variceal surveillance in Cirrhosis.Results294 patients were managed via the nurse-led programme during 2020, service distribution 49% “Hot clinic” reviews;6% referred via other specialities via MDT;45% HCC surveillance clinic.ArLD 48% was the most common aetiology seen in “Hot clinic”, followed by NASH/NAFLD 12%. The most common reason for referral to “Hot clinic” was ascites management 46%, which resulted in 31% of patients having a medication change by the CNS (76% of which were diuretics) 4% were admitted directly to the ward from “Hot clinic” (i.e. disease progression, urgent paracentesis). Of the 74 patients referred for ascites management 49% were enrolled into the day-case paracentesis programme. 200, electively planned drains were inserted as daycase during this timeframe by the CNS team.ConclusionDuring a pandemic the Birmingham liver team were able to adapt their working environment to continue to ensure patients could access specialist care and continue to be seen face-to-face in a safe manner. This led to decreased pressure on emergency admissions.

The story of transjugular intrahepatic portosystemic shunt (TIPSS) at the Royal Free Hospital, 2021–2022: indications and outcomes of 84 procedures

Transjugular intrahepatic portosystemic shunt (TIPSS) is an effective treatment for decompression of portal hypertension and is most commonly indicated in patients with chronic liver disease (CLD) or portal vein thrombosis (PVT). It is a technically challenging intervention. CLD patients are often frail with comorbidities conferring increased procedural risk. We tell the story of one year of procedures at the Royal Free Hospital (RFH), one of the major centres for TIPSS in Europe.A retrospective electronic casenote review was carried out for all patients who underwent TIPSS procedure at the RFH between April 2021 and April 2022. The outcomes of interest were success rate, complications and survival including those who went on to transplantation. A successful procedure was defined as a correctly placed stent with no procedural complications and symptom resolution. Eighty-four (84) patients underwent TIPSS during the 12-month period. Of these, 3 were abandoned: 2 because portal hypertension was absent on direct measurement and 1 due to anatomical infeasibility. Of the 81 completed, the most common indication was diuretic-intolerant ascites (n=32), followed by variceal bleeding (n=27), PVT (n=14), and other indications (n=8). The clinical success rates post-TIPSS for each indication are as follows. For diuretic intolerant ascites, 53.1% (17/32) of patients no longer require large volume paracentesis (LVP), 28.1% (9/21) require LVP at a reduced frequency, 6.3% (2/32) have been transplanted and 1 patient continues to have LVP at the same rate. For variceal bleeding, 85.2% (23/27) of patients have had no further episodes of bleeding. For PVT, 85.7% (12/14) of TIPSS remain patent with no patient requiring surgical intervention. No procedural complications were reported. Overall survival post-TIPSS is 87.7% (71/81) with procedure-related mortality accounting for no deaths. 8 patients who received TIPSS went on to be listed for liver transplant, of those 3 successfully received a graft, 4 remain listed and 1 has died while listed.A high number of TIPSS procedures were performed. The majority were successful with favourable clinical outcomes. Major challenges faced by the service during this time included staff shortages, bed capacity, transfer logistics and the wider impacts of the COVID-19 pandemic. This service depends on the collective expertise and close working of multiple specialties including hepatology, interventional radiology, intensive care and anaesthetics along with logistical and operational support. In an environment where all of these healthcare professionals work together to support the provision of TIPSS, patients can benefit from positive outcomes.

Parvovirus infection causing prolonged QT intervals and cardiac arrest

AimsTo review an unusual case of an infant presenting with parvovirus infection causing prolonged QT intervals and cardiac arrest.MethodsWe reviewed the case history of the patient to discuss the presentation, management and progress since admission.ResultsA 14-month-old boy presented with cough and increased work of breathing for 1 day at district general hospital. He had suspected Parvovirus infection (causing slapped cheeks) 10 days ago. Due to worsening respiratory distress he was tried with various non invasive respiratory support. As he was not responding, he was intubated and ventilated. He was covered with ceftriaxone and acyclovir. During intubation he developed cardiac arrest requiring chest compressions,1 dose of adrenaline and a normal saline bolus. Return of spontaneous circulation happened after 2 minutes. He was transferred to tertiary unit for continuation of care. 2D ECHO showed normal cardiac structure with normal coronary arteries, but markedly dilated left ventricle, left atrium with left ventricular ejection fraction 30%. His was supported with milrinone and adrenaline as inotropes. He was transferred to quaternary centre in view of ECG changes of prolonged QT interval (600msec) global T wave inversion, broad based T wave, poor R wave progression across precordial leads. He was admitted there for 3 weeks before getting discharged to DGH. He received aspirin, bisoprolol, captopril, magnesium strycophosphate, furosemide, spironolactone, lactulose, melatonin, nystatin. After discharge at 1month follow up LVEF was 35%. His NT proBNP peaked to 35000pg/ml during intensive care admission which subsequently normalised to 3000. At discharge QT interval normalised to 480 msec with normal T wave morphology. 24-hour Holter showed sinus rhythm and inverted T waves. Blood cultures showed staphylococcus aureus for which he received 14 days of IV flucloxacillin. His respiratory secretions showed enterovirus, adenovirus and coronavirus 63. His acute kidney injury also resolved. He had normal EEG. His genetic tests for mitochondrial DNA WLS panel and family (parents’ and sibling) genetic tests for prolonged QT were normal. He was seen at cardiac function clinic and inherited arrythmia clinic and diuretics and beta blockers were stopped. Follow up plan about phenotypic exercise testing at later age and avoiding medications causing prolonged QT interval was agreed.ConclusionParvovirus infection can cause transient prolongation of QT interval which can precipitate cardia arrest. In these rare events supporting the child through the acute phase of illness ensures gradual recovery and improvement of the QT prolongation. Currently its not understood as to why this happens but could be postulated to an underlying myocarditis or inflammatory event causing changes in the conducting systems.

Feline infectious peritonitis in a local cat confirmed by rivalta test: a case report

Minmin, a 1-year-old male local cat weighing 4.3 kg has decreased appetite and an enlarged abdominal cavity. Based on physical examination, there was abdominal distension. Routine hematology and blood biochemical examinations were performed which showed chronic inflammation and abnormal liver and kidney function. Radiographic examination and abdominocentesis showed fluid accumulation in the abdominal cavity (ascites) with pale yellow fluid and thickened liquid consistency. The results of the rivalta test showed a positive accumulation of exudate which was characterized by a jellyfish-like formation. The cat was diagnosed with effusive feline infectious peritonitis. The therapies given are diuretic furosemide 5 mg/kg BW (twice a day) intravenously, antibiotic cefotaxime sodium 30 mg/kg BW (twice a day) intravenously, anti-inflammatory dexamethasone 0,5 mg/kg BW (twice a day) subcutaneously, hepato-protector betaine 2.5 mg/kg BW (every two days) subcutaneously, and keto acid 11 mg/kg BW orally (every two days). The results of treatment for one week only provide temporary results in reducing the degree of abdominal distension. The cat died in the sixth month after therapy.

ROLE OF NELUMBO NUCIFERA (LOTUS) STEM AS IMMUNITY BOOSTER AND ANTI-INFLAMMATORY FOOD

In China and India, Nelumbo nucífera, a perennial aquatic plant, has been used as a medicinal herb. The various sections of plants, such as leaves, seeds, flowers and rhizomes, have been reported to have beneficial effects in the treatment of pharyngopathy, pectoralgia, spermatorrhoea, leucoderma, smallpox, dysentery, cough, haematemesis, epistaxis, haemoptysis, haematuria, metrorrhagia, hyperlipidaemia, fever, cholera, hepatopathy and hyperdipsia in the traditional medicine system. Different pharmacological activities such as anti-ischaemic activity, antioxidant activity, hepatoprotective activity, anti-inflammatory activity, anti-fertility activity, antiarrhythmic activity, anti-fibrosis activity, antiviral activity, anti-proliferative activity, anti-diarrhoeal activity, psychopharmacological activity, antipyretic activity, immune-modulatory activity, hypoglycaemic activity, aldose reductase inhibitory activity, antibacterial, aphrodisiac activity, anti-platelet activity, cardiovascular activity, anti-obesity activity, lipolytic activity, hypo-cholesterolaemic activity, hepato-protective activity, anticancer activitydiuretic activity, antioxidant activity have been clinically evaluated for N.nucifera. Different pharmacological activities such as anti-ischaemic activity, antioxidant activity, hepato-protective activity, anti-inflammatory activity, anti-fertility activity, anti-arrhythmic activity, antifibrosis activity, antiviral activity, anti-proliferative activity, anti-diarrhoeal activity, psychopharmacological activity, diuretic activity, antioxidant activity have been clinically evaluated for N.nucifera. A wide number of phytoprinciples from the plant have been isolated. The present review seeks to consolidate the traditional, ethno-botanical, phytochemical and pharmacological data available on N.nucifera stem and to explore its role as an immunity booster and anti-inflammatory food.

Pathophysiologic approach to understanding and successfully treating idiopathic edema: Unappreciated importance of nocturia.

Idiopathic edema (IE), a disorder of females, is characterized by edema and weight gains exceeding 1.4 kg while assuming an upright position followed by nocturia and returning to a non-edematous baseline weight in the morning. There is no successful treatment of IE and the importance of nocturia needs to be emphasized. The major underlying abnormality is an increase in vascular membrane permeability (VMP). We present four cases with differing degrees of IE who were successfully managed by manipulating Starling's forces. While we could not alter the increase in VMP, manipulating oncotic and hydrostatic pressures between both compartments were untenable except to decrease intravascular hydrostatic pressure by sodium restriction. All four cases virtually eliminated daily weight gains and nocturia to improve quality of life considerably, two with the assistance of daily hydrochlorothiazide (HCTZ) and all four by furosemide to accelerate recovery from the weight gain to permit occasional dietary indiscretions to improve quality of life. Two cases with milder forms of IE did not quantify sodium intake as meticulously as cases one and four, who appeared to have greater increases in VMP. IE can be treated successfully by sodium restriction with or without use of HCTZ and furosemide to eliminate the distressing edema, weight gain and nocturia with marked improvement in emotional instability after understanding that the weight gains and nocturia were linked to dietary intake of sodium.

Renin-Angiotensin Aldosterone System Inhibitors and COVID-19: A Systematic Review and Meta-Analysis Revealing Critical Bias Across a Body of Observational Research.

Background Renin-angiotensin aldosterone system (RAAS) inhibitor-COVID-19 studies, observational in design, appear to use biased methods that can distort the interaction between RAAS inhibitor use and COVID-19 risk. This study assessed the extent of bias in that research and reevaluated RAAS inhibitor-COVID-19 associations in studies without critical risk of bias. Methods and Results Searches were performed in MEDLINE, EMBASE, and CINAHL databases (December 1, 2019 to October 21, 2021) identifying studies that compared the risk of infection and/or severe COVID-19 outcomes between those using or not using RAAS inhibitors (ie, angiotensin-converting enzyme inhibitors or angiotensin II type-I receptor blockers). Weighted hazard ratios (HR) and 95% CIs were extracted and pooled in fixed-effects meta-analyses, only from studies without critical risk of bias that assessed severe COVID-19 outcomes. Of 169 relevant studies, 164 had critical risks of bias and were excluded. Ultimately, only two studies presented data relevant to the meta-analysis. In 1 351 633 people with uncomplicated hypertension using a RAAS inhibitor, calcium channel blocker, or thiazide diuretic in monotherapy, the risk of hospitalization (angiotensin-converting enzyme inhibitor: HR, 0.76; 95% CI, 0.66-0.87; P<0.001; angiotensin II type-I receptor blockers: HR, 0.86; 95% CI, 0.77-0.97; P=0.015) and intubation or death (angiotensin-converting enzyme inhibitor: HR, 0.64; 95% CI, 0.48-0.85; P=0.002; angiotensin II type-I receptor blockers: HR, 0.74; 95% CI, 0.58-0.95; P=0.019) with COVID-19 was lower in those using a RAAS inhibitor. However, these protective effects are probably not clinically relevant. Conclusions This study reveals the critical risk of bias that exists across almost an entire body of COVID-19 research, raising an important question: Were research methods and/or peer-review processes temporarily weakened during the surge of COVID-19 research or is this lack of rigor a systemic problem that also exists outside pandemic-based research? Registration URL: www.crd.york.ac.uk/prospero/; Unique identifier: CRD42021237859.

Characteristics, Mortality, and Clinical Outcomes of Hospitalized Patients with COVID-and Diabetes: A Reference Single-Center Cohort Study from Poland

Introduction: Diabetes is a risk factor for severe COVID-course. In this one-center report, we assessed clinical characteristics and risk factors associated with unfavorable outcomes in diabetic patients (DP) hospitalized due to COVID-19. Methods: We retrospectively analyzed data from a cohort of patients with confirmed SARS-CoV2 infection admitted to the University Hospital in Krakow (Poland) , a regional reference center for COVID-19, between March 6th 2020 and May 15th 2021. The data was collected from electronic medical records. Results: We included 5191 patients, mean age 61.98±16.66 years, 2348 (45.2%) women, 1364 (26.3%) DP. DP were older as compared to non-diabetics (median age 70 vs. 62 years, IQR 62-77 and 47-72, p<0.001) with similar gender distribution. DP were characterized by higher mortality (26.4% vs. 15.6%, p<0.001) , longer hospital stay (median 15 vs. 13 days, IQR 10-24 and 9-20, p<0.001) , more frequent ICU admission (15.7% vs. 11%, p<0.001) and more frequent requirement for mechanical ventilation (15.5% vs. 11.3%, p<0.001) . When adjusted for sex and age, the relative risk for in-hospital death, ICU admission and mechanical ventilation was 1.32 (95%CI 1.13-1.54) , 1.4 (95%CI 1.17-1.69) and 1.3 (95%CI 1.08-1.57) , respectively. Multivariable logistic regression showed age, CRP and D-dimer level, history of heart failure, and loop diuretic use were associated with higher risk of death, whereas anticoagulation therapy, ACEI/sartan/mineralocorticoid receptor antagonist use and thiazide use were associated with lower risk. Conclusions: In this large COVID-cohort, DP constituted more than one fourth of hospitalized patients. Their risk of death was ca. 30% higher as compared to non-diabetics, as was the risk of other important clinical outcomes. We identified a number of clinical, laboratory and therapeutical variables associated with risk of hospital death in DP with COVID-19.

Hypoxemic COVID-Pneumonia, Diabetes Mellitus: Combination of Tailored Prednisone, Colchicine, Antithrombotics, Diuretic Improves Prognosis (CocAA-CoLa PLUS Study)

In patients (pts) with diabetes mellitus (DM) , Covid-pneumonia mortality rate >20% has been reported. A low fixed dose of intravenous dexamethasone (Dx) for days (RECOVERY study, 6 mg/d, i.e 0.5 mg/kg/d prednisone equivalent) has been shown to effectively reduce Covid-pneumonia mortality. In an observational study, prognosis was improved with an oral combination of prednisone fixed dose (1mg/kg/d) , direct anticoagulant/aspirin/colchicine/furosemide (DOAACF) . We hypothesized prednisone tailored doses driven by clinical evolution (extra 1mg/kg/d for every increase of O2 flow) added-on DOAACF for days would decrease morbi-mortality. In our monocentric, retrospective study (03.2020-05.2021) , pts with Covid-pneumonia requiring O2 out of the Intensive Care Unit (ICU) were included. According to the Physicians discretionary caring decisions, a control group (no corticoid) , a Dx group, an oral tailored prednisone ≥1mg/kg/d-DOAACF group were compared. The primary endpoint was Day 28 ICU requirement or mortality. Out of 3pts included for hypoxemic Covid-pneumonia, 132 pts had DM (43%) (control n = 28;Dx n = 46;tailored prednisone-DOAACF n = 58) : median age 69y;Males/Females 2.8;BMI 28 kg/m2;cardiovascular history 40%;median SpO2 at room air 92%;median maximal O2 flow 4L/min. Pts characteristics were non statistically different. Prednisone median dose (1.5mg/kg/d) and aspirin-colchicine-furosemide use were significantly higher in the tailored prednisone-DOAACF group in which events rate (12%) was significantly lower (control 50%, p = 0.0003, Dx 37%, p = 0.004) . In the tailored group, no statistical difference observed with pts without DM (13.3%, p = 1) . Out of the ICU, in pts with DM, a five oral drugs combination made of tailored prednisone ≥1mg/kg/d, anti-inflammatory, antithrombotics, diuretic improves hypoxemic Covid-pneumonia prognosis. A randomized trial is needed.

Angiotensin-converting enzyme-2 and interleukin-12 serum level as indicator to severity between COVID-19 patients

The Coronavirus, one of the most rapidly spreading respiratory viruses, caused a worldwide epidemic that killed about six million people. This led to the fast development of several vaccines and drugs to reduce disease severity and speed patient recovery. This study aimed to identify the serum levels of each of the angiotensin-converting enzyme-2 and interleukin-12 .The severity of infection in coronavirus COVID-19 patients was compared to immune levels of these cytokines and receptors in the different cases of COVID-19 patients. This case-control study included 90 blood samples from COVID-19 patients with ages between 15-80 years. Results revealed that the serum levels of both angiotensin-converting enzyme-2 ( ACE-2) and interleukin-12 (IL-12) were measured in COVID-19 patients and the results were compared using an independent T-test, it was found that their levels for interleukin-12 revealed a significant difference (P ≤0.05) in the serum levels of severe cases when compared with non-severe cases. There was an increase in the serum level of IL-12 in severe cases was 33.340 ng/L, in the serum level and in non-severe cases was 20.913 ng/L. ( P ≤0.000), and for angiotensin-converting enzyme-2 this study revealed a significant difference in ACE-2 serum levels in severe cases (P ≤0.05) when compared with the non-severe cases of patients with COVID 19. The serum level of ACE-2 in severe cases was 11.023 ng/ml, and in non-severe cases, it was 5.443ng/ml ( P ≤0.000). It was concluded that the emerging coronavirus works to create an immune storm represented by raising the serum levels of both ACE-2 and IL-12 that contribute to the damage to the alveoli in severely COV-19 patients.

New Trends in the Diagnosis and Management of Hypertension.

Hypertension is the leading risk factor for disability and death globally. This is attributed to two major complications of hypertension, cerebrovascular accidents (CVA) and ischemic heart disease. This update provides a concise overview of several timely hypertension topics. These topics were chosen based on recent significant advances in the field. Examples include the use of renin-angiotensin-aldosterone inhibitors in coronavirus disease 2019 (COVID-19) patients, the landmark Systolic Blood Pressure Intervention Trial (SPRINT), management of resistant hypertension, and primary aldosteronism. The articles reviewed also include other recent landmark clinical trials, prior clinical trials of great significance, and medical societies guidelines. Ten topics were chosen based on their relevance to the practicing clinician. Each topic is discussed in a condensed manner highlighting recent advances in the field of hypertension.

Coronavirus disease 2019 and hypertension: how anti-hypertensive drugs affect COVID-19 medications and vice versa

Introduction. Hypertension, as a medical problem, is one of the most common disorders in cardiovascular disease. High blood pressure has been identified as one of the most familiar risk factors for the ongoing COVID-19 pandemic. We planned to explore the possible interactions between antihypertensive agents and drugs targeting SARS-CoV-2 with broad investigations in the mechanism of action and adverse effects of these medications. Methods. The electronic databases (PubMed, Scopus, and Google scholar) were searched by two of the coauthors to collect the papers relevant to the subject. The keywords searched were angiotensin converting enzyme inhibitors (ACEI), angiotensin-II receptor blockers (ARBs), sympatholytic drugs (alpha-1 blockers, beta blockers), vasodilators (calcium channel blockers, nitrates, hydralazine), diuretics, chloroquine, hydroxychloroquine, lopinavir/ritonavir, remdesivir, favipiravir, interferons, azithromycin, anti-cytokine agents, glucocorticoids, anticoagulant agents, nitric oxide and epoprostenol. Results. QT prolongation, hypokalemia, arrhythmia and increase the serum level of drugs are the most risky adverse effects of medications in patients with COVID-19 on anti-hypertensive drugs. Conclusion. Interaction of the drugs used for COVID-19 patients with anti-hypertensive drugs is an important issue that this review addresses.

Renin–angiotensin–aldosterone system inhibitors to treat COVID-19?: CMAJ

Angiotensin II is the main RAAS agonist and binds to angiotensin receptors expressed on the same targeted cells. [...]both ACE inhibitors and angiotensin receptor blockers (ARBs) exert downregulating effects on angiotensin II activity. In the study by Zhang and colleagues,2 cited by Quinn and colleagues' commentary, the patients on ARBs who were maintained on treatment during their infections had a decreased mortality (adjusted hazard ratio 0.30;95% confidence interval 0.12-0.70;p = 0.01) compared with matched hypertensive patients not on that particular class of drugs. [...]as COVID-19 has a strong component of ACE2 depletion underlying the course of the illness, and as RAAS (angiotensin and aldosterone) stressors promote cytokine-mediated disease in the lungs and cardiovascular-renal system, introducing drugs to block those effects could offer a much-needed lifeline where a 0.3 risk of dying would be quite welcomed.

Ambulatory Management of Worsening Heart Failure: Current Strategies and Future Directions.

Heart failure (HF) is a highly prevalent and morbid disease in the USA. The chronic, progressive course of HF is defined by periodic exacerbations of symptoms, described as 'worsening heart failure' (WHF). Previously, episodes of WHF have required hospitalization for intravenous diuretics; however, recent innovations in care delivery models for patients with HF have allowed a transition from the acute care setting to the ambulatory setting. The development of remote monitoring strategies, including device-based algorithms and implantable haemodynamic monitoring systems, has facilitated more advanced surveillance of patients, aiming to prevent the clinical deterioration that leads to hospitalization. Additionally, the establishment of multidisciplinary HF clinics has provided the setting and resources for the outpatient treatment of WHF, specifically the administration of intravenous diuretics. Here we review the current state of ambulatory HF management, including mechanisms for patient monitoring and treatment, and outline future opportunities for outpatient management of this patient population.

Discontinuation of Antihypertensive Medications on the Outcome of Hospitalized Patients With Severe Acute Respiratory Syndrome-Coronavirus 2.

[Figure: see text].

[Tactics of antihypertensive therapy during COVID-19 pandemic].

Results of foreign and Russian studies indicate a higher mortality rate of patients with concomitant cardiovascular diseases (CVD) due to the new coronavirus infection COVID-19. It has been proven that arterial hypertension, as one of the significant risk factors for the development of concomitant cardiovascular diseases, is associated with a more severe prognosis of COVID-19. This article presents the results of modern studies and large meta-analyzes of necessity and safety of the use of blockers of the renin-angiotensin-aldosterone system in patients with arterial hypertension and COVID-19. The data of studies show that an angiotensin-converting enzyme inhibitor (ACE inhibitor) and a thiazide-like diuretic is a pathogenetically rational combination. It realizes various ways of lowering blood pressure by reducing the activity of the renin-angiotensin-aldosterone system, which is achieved by using an ACE inhibitor, and natriuresis due to diuretics. As an example, a highly effective fixed combination of drugs is considered, characterized by good tolerance, which consists of an ACE inhibitor lisinopril and a thiazide-like diuretic indapamide of prolonged action. The authors expressed the opinion that the appointment of the fixed combination drug Diroton Plus (Gedeon Richter) will contribute to effective control of blood pressure and organoprotection in conditions of increased thrombogenic and prooxidative potential, characteristic of COVID-19 both in the acute stage and within the post-COVID Syndrome.

Ambulatory intravenous furosemide for decompensated heart failure: safe, feasible, and effective.

AIMS: This study aims to establish the feasibility, safety, and efficacy of outpatient intravenous (IV) diuretic treatment for the management of decompensated heart failure (HF) for patients enrolled in the HeartFailure@Home service. METHODS AND RESULTS: We retrospectively analysed the clinical episodes of decompensated HF for patients enrolled in the HeartFailure@Home service, managed by ambulatory IV diuretic treatment either at home or on a day-case unit. A control group consisting of HF patients admitted to hospital for IV diuretics (standard-of-care) was also evaluated. In total, 203 episodes of decompensated HF (n = 154 patients) were evaluated. One hundred and fourteen episodes in 79 patients were managed exclusively by the ambulatory IV diuretic service-78 (68.4%) on a day-case unit and 36 (31.6%) domiciliary; 84.1% of patient episodes under the HF@Home service were successfully managed entirely in an out-patient setting without hospitalization. Eleven patients required admission in order to administer higher doses of IV diuretics than could be provided in the ambulatory setting. During follow-up, there were 20 (17.5%) 30 day re-admissions with HF or death in the ambulatory IV group and 29 (32.6%) in the standard-of-care arm (P = 0.02). There was no difference in 30 day HF readmissions between the two groups (14.9% ambulatory vs. 13.5% inpatients, P = 0.8), but 30 day mortality was significantly lower in the ambulatory group (3.5% vs. 21.3% inpatients, P < 0.001). CONCLUSIONS: Outpatient ambulatory management of decompensated HF with IV diuretics given either on a day case unit or in a domiciliary setting is feasible, safe, and effective in selected patients with decompensated HF. This should be explored further as a model in delivering HF services in the outpatient setting during COVID-19.