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Background: Atrial fibrillation (AF) is the most common arrhythmia in the United States. Concomitant Covid-19 infection and the outcomes of AF are unknown. Objective(s): The study's goals were to analyze the outcomes of AF during the Covid-19 pandemic. Method(s): We conducted a retrospective cohort study based on the 2020 National Inpatient Sample (NIS) of Adults (>18 years) hospitalized for AF as the primary admitting diagnosis based on the ICD-10 codes and stratified these groups into concomitant covid-19 infection vs. non-covid-19 infection. All-cause mortality was our primary outcome, while the rate of ICU admission, length of stay, hospital charges were our secondary outcomes. Temporal trends were assessed using logistic regression. Result(s): In 2020, there were 1,994,985 admissions for atrial fibrillation, out of whom 104,495 (5.3%) had concomitant Covid-19. In the 104,495 AF admissions with covid-19, the mean age was 75y and 56.8% were males. Our results, image 1, showed AF with and without concomitant Covid-19 had similar rates of comorbid conditions including HTN, DM, OSA, CAD. HFrEF, and ESRD. AF patients with Covid-19 infection had a lower prevalence of smoking (31.83% vs. 39.4%, p<.001) and alcohol use (2% vs. 4.2%, p<.001). AF patients from both groups had similar rates of stroke (1.6% vs. 1.0%, p<.001). New AF patients with concomitant Covid-19 had worsening in-hospital outcomes such as shock (12.8% vs. 3.7%, p<.001), admission to the ICU (18.1% vs. 6.4%, p<0.001), higher all-cause mortality (21.8% vs. 3.9%, p<0.001), a longer length of stay (9.96 days vs 6.08 days, p<.001), and total hospital costs ($114,387 vs. $85,830, p<.0001). The incidence of AF catheter ablation on initial hospital admission for AF Covid-19 was lower compared to the AF non-covid-19 patients (.08% vs. 1.39%, p<.001). Conclusion(s): In 2020, Covid-19 infection was an independent predictor of higher all-cause mortality, length of stay, and costs in patients admitted for atrial fibrillation. In addition, these patients were less likely to get catheter ablation on hospital admission. [Formula presented]Copyright © 2023
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BACKGROUND: The incidence and prevalence of heart failure (HF) in the United States has steadily increased in the past few decades. Similarly, the United States has experienced an increase in HF-related hospitalizations which has added to the burden of a resource-stretched healthcare system. With the emergence of the coronavirus disease 2019 (COVID-19) pandemic in 2020, hospitalizations due to the COVID-19 infection sky-rocketed further exacerbating the burden on both patient health and the healthcare system. The focus of this study is to examine how a secondary COVID-19 diagnosis affects the outcome of HF patients, and how a pre-existing diagnosis of heart failure impacts the outcomes of patients hospitalized with COVID-19 infection. METHODS: This was a retrospective observational study of adult patients hospitalized with heart failure and COVID-19 infection in the United States in the years 2019 and 2020. Analysis was conducted using the National Inpatient Sample (NIS) database of the Healthcare Utilization Project (HCUP). The total number of patients included in this study from the NIS database 2020 was 94,745. Of those, 93,798 had heart failure without a secondary diagnosis of COVID-19; 947 had heart failure along with a secondary diagnosis of COVID-19. The primary outcome of our study was in-hospital mortality, length of stay, total hospital charges and time from admission to right heart catheterization, which were compared between the two cohorts. Results: Our main study findings are that mortality in HF patients with secondary diagnosis of COVID-19 infection was not statistically different compared to those who were without a secondary diagnosis of COVID-19. Our study findings also showed that length of stay (LOS) and hospital costs in HF patients who had a secondary diagnosis of COVID-19 were not statistically different compared to those who did not have the secondary diagnosis. Time from admission to right heart catheterization (RHC) in HF patients who had a secondary diagnosis of COVID-19 was shorter in heart failure with reduced ejection fraction (HFrEF) but not in heart failure preserved ejection fraction (HFpEF) compared to those without secondary diagnoses of COVID-19. Finally, when evaluating hospital outcomes for patients admitted with COVID-19 infection, we found that inpatient mortality increased significantly when they had a pre-existing diagnosis of heart failure. CONCLUSION: The COVID-19 pandemic significantly impacted hospitalization outcomes for patients admitted with heart failure. The time from admission to right heart catheterization was significantly shorter in patients admitted with heart failure reduced ejection fraction who also had a secondary diagnosis of COVID-19 infection. When evaluating hospital outcomes for patients admitted with COVID-19 infection, we found that inpatient mortality increased significantly when they had a pre-existing diagnosis of heart failure. Length of hospital stay and hospital charges also were higher for patients with COVID-19 infection who had pre-existing heart failure. Further studies should focus not just on how medical comorbidities like COVID-19 infection, affect outcomes of heart failure but also on how overall strains on the healthcare system, such as pandemics, may affect the management of conditions such as heart failure.
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Coronavirus disease 2019 (COVID-19), initially recognized to cause respiratory system complications, has been found to also affect the cardiovascular system leading to myocardial damage and subsequently causing heart failure. Peripartum cardiomyopathy, though an uncommon condition, may also manifest as heart failure toward the end of pregnancy. This atypical case highlights the potential diagnostic overlap between COVID-19 heart failure and peripartum cardiomyopathy. At this point, there is no recommended algorithm used to distinguish one disease from another.
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Takotsubo cardiomyopathy and acute coronary syndrome are often clinically indistinguishable, making their differentiation challenging for physicians. We present a case of a 65-year-old female who presented with acute chest pain, shortness of breath, and a recent psychosocial stressor. This is a unique case in which our patient, with known history of coronary artery disease and recent percutaneous intervention, favored a misleading initial diagnosis of non-ST elevation myocardial infarction.
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The proceedings contain 67 papers. The topics discussed include: role of endomyocardial biopsy in differential diagnosis of non- -ischemic cardiomyopathy;metformin treatment is associated with improved quality of life and outcome in patients with diabetes and advanced heart failure (HFREF);translational research in the field of inherited arrhythmias;same day discharge via a dedicated radial lounge - results of 1-year experience during the COVID-19 pandemic;functional assessment of microcirculation in takotsubo cardiomyopathy - a pilot study;an interplay of genetics and inflammation affecting left ventricular reverse remodeling in dilated cardiomyopathy;sildenafil inhibits pulmonary hypertension induced by left heart pressure overload in rats;predicting long-term survival after an ischemic stroke;and longitudinal trends in blood pressure, prevalence, awareness, treatment, and control of hypertension in the Czech population. are there any sex differences?.
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Background Despite robust evidence and national guidance recommending cardiac rehabilitation (CR) for heart failure (HF), access remains poor, a situation magnified by COVID- 19. The Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) randomised controlled trial demonstrated the clinical and cost-effectiveness of a novel home-based CR selfmanagement programme. The SCOT:REACH-HF study was designed to provide the understanding of real-world implementation needed for NHS-wide roll-out in a Scottish context. Aim To 1) compare outcome improvements and delivery costs with those identified in the RCT;and 2) identify facilitators of and barriers to real-world implementation. Methods A mixed-method implementation study of REACHHF delivery across six NHS Scotland areas in 2021-22. Health professionals were trained to facilitate delivery of the 12-week programme. We assessed patient- and caregiverreported outcomes (including health-related quality of life, psychological wellbeing) pre-and post-REACH-HF participation. Primary Outcome: Minnesota Living with Heart Failure Questionnaire (MLHF). 136 adults with reduced ejection fraction HF (HFrEF) were recruited, and 101 completed follow-up. 54 participants nominated caregivers, 26 of whom completed follow- up. Qualitative interviews with 20 key health professionals (primarily REACH-HF facilitators) were subject to thematic analysis to explore barriers to and facilitators of implementation. Fidelity, contextual, and economic data were also collected. Results REACH-HF participation resulted in significant gains in health-related quality of life, as assessed by the MLHF, PROM-CR+, and EQ-5D-5L, and Self-Care of Heart Failure Index (SCHFI). MLHF improvements were both statistically significant and met the minimum clinically important difference in 63% of participants (see figure 1). Interviewees were largely positive about REACH-HF - considering it to have 'filled a gap' when no other CR was available - and key issues to support future roll-out were identified. Conclusion Our findings support the scaled roll-out of REACH-HF. This would offer people with HFrEF, and their families and friends, an accessible alternative to centre-based CR. (Figure Presented).
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Background/Introduction: Coronavirus disease (COVID-19) continues to cause considerable morbidity and mortality worldwide. The complication in patients with severe COVID-19 disease include arrhythmias, perimyocarditis (PM), and heart failure (HF). Purpose(s): The important role of echocardiogram (ECHO) and cardiac MRI (CMRI) in the diagnosis of myocarditis in COVID-19 patients in Saudi Arabia has not been assessed. The objective is to assess the diagnostic value of ECHO and CMRI and define phenotypes patterns in the COVID-19 subgroup. Method(s): In this retrospective study, adults with suspected COVID-19 presented with dyspnea and cardiovascular comorbidities were studied between January 2021 and December 2021. We collected 329 patients, (LVEF by ECHO was 44+/-11%). Fifty-two percent (173/329), had HF (HFrEF or HFpEF), thirty-six percent presented with acute coronary syndrome ACS (120/329), and four percent had adult congenital heart disease (ACHD). CMRI was performed in 160 patients (LVEF is 40 +/-11%), and fifty-two were COVID-19 positive. CMRI Phenotypes patterns were described as normal, ischemic, or nonischemic (peri-myocarditis). LVEF was divided by CMRI as (EF>=50 or EF <50%). The average time interval from diagnosis to CMRI was 4-8weeks. Result(s): Sixty percent of patients (221/329) were confirmed COVID-19 infection, the mean age is 54+/-13 years. Ten patients were diagnosed with pulmonary embolism (2/10 were ACHD). peri-myocarditis patterns were found in sixty percent of COVID-19 patients (31/52), five percent (3/52) had an ischemic pattern, and thirty- five percent (18/52) had normal LGE. However, in COVID-19 negative patients, Eighty percent (85/108) had an ischemic pattern, and twenty percent (23/108) had normal LGE. Conclusion(s): In this observational study, CMRI confirms its high diagnostic tool in evaluating myocarditis activity. In COVID-19 patients, two third of the population were found to have peri-myocarditis, with half of them reporting LVEF was >=50 %.
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In order to explore the proteomic signatures of epicardial adipose tissue (EAT) related to the mechanism of heart failure with reduced and mildly reduced ejection fraction (HFrEF/HFmrEF) and heart failure (HF) with preserved ejection fraction (HFpEF), a comprehensive proteomic analysis of EAT was made in HFrEF/HFmrEF (n = 5) and HFpEF (n = 5) patients with liquid chromatography-tandem mass spectrometry experiments. The selected differential proteins were verified between HFrEF/HFmrEF (n = 20) and HFpEF (n = 40) by ELISA (enzyme-linked immunosorbent assay). A total of 599 EAT proteins were significantly different in expression between HFrEF/HFmrEF and HFpEF. Among the 599 proteins, 58 proteins increased in HFrEF/HFmrEF compared to HFpEF, whereas 541 proteins decreased in HFrEF/HFmrEF. Of these proteins, TGM2 in EAT was down-regulated in HFrEF/HFmrEF patients and was confirmed to decrease in circulating plasma of the HFrEF/HFmrEF group (p = 0.019). Multivariate logistic regression analysis confirmed plasma TGM2 could be an independent predictor of HFrEF/HFmrEF (p = 0.033). Receiver operating curve analysis indicated that the combination of TGM2 and Gensini score improved the diagnostic value of HFrEF/HFmrEF (p = 0.002). In summary, for the first time, we described the proteome in EAT in both HFpEF and HFrEF/HFmrEF and identified a comprehensive dimension of potential targets for the mechanism behind the EF spectrum. Exploring the role of EAT may offer potential targets for preventive intervention of HF.
Subject(s)
Heart Failure , Humans , Stroke Volume , Heart Failure/diagnosis , ProteomicsABSTRACT
AIMS: Several patients with heart failure and reduced ejection fraction (HFrEF) do not receive renin-angiotensin-aldosterone system (RAAS) inhibitors at the recommended dose or at all, frequently due to actual or feared hyperkalaemia. Sodium zirconium cyclosilicate (SZC) is an orally administered non-absorbed intestinal potassium binder proven to lower serum potassium concentrations. METHODS AND RESULTS: PRIORITIZE-HF was an international, multicentre, parallel-group, randomized, double-blind, placebo-controlled study to evaluate the benefits and risks of using SZC to intensify RAAS inhibitor therapy. Patients with symptomatic HFrEF were eligible and randomly assigned to receive SZC 5 g or placebo once daily for 12 weeks. Doses of study medication and RAAS inhibitors were titrated during the treatment period. The primary endpoint was the proportion of patients at 12 weeks in the following categories: (i) any RAAS inhibitor at less than target dose, and no MRA; (ii) any RAAS inhibitor at target dose and no MRA; (ii) MRA at less than target dose; and (iv) MRA at target dose. Due to challenges in participant management related to the COVID-19 pandemic, the study was prematurely terminated with 182 randomized patients. There was no statistically significant difference in the distribution of patients by RAAS inhibitor treatment categories at 3 months (P = 0.43). The proportion of patients at target MRA dose was numerically higher in the SZC group (56.4%) compared with the placebo group (47.0%). Overall, SZC was well tolerated. CONCLUSIONS: PRIORITIZE-HF was terminated prematurely due to COVID-19 and did not demonstrate a statistically significant increase in the intensity of RAAS inhibitor therapies with the potassium-reducing agent SZC compared with placebo.
Subject(s)
COVID-19 , Heart Failure , Humans , Heart Failure/drug therapy , Pandemics , Stroke Volume , Potassium , AldosteroneABSTRACT
This audit compared the management of patients with heart failure with reduced ejection fraction (HFrEF) admitted to a district general hospital (DGH) during comparative eight month periods before and during the COVID-19 pandemic. The periods studied were from 1st February 2019 to 30th September 2019 and between the same dates in 2020. We investigated differences in mortality and patient characteristics (age, gender and new or prior diagnosis). For patients who survived to discharge and who were not referred to palliative care, we also investigated whether there were differences in rates of echocardiography and prescription of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor antagonists and beta blockers. We found that the number of cases was lower during the pandemic and there was a lower mortality rate that was not statistically significant. There was a higher proportion of new cases (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.24 to 3.94, p=0.008) and of female patients (OR 2.03, 95%CI 1.14 to 3.61, p=0.019). For survivors, there was a non-significant decrease in prescription rates for ACE inhibitors and angiotensin II receptor antagonists (81.6% vs. 71.4%, p=0.137) that was not seen for beta blockers. The length of stay was increased and there was also an increase in the interval between admission and echocardiography in patients who were newly diagnosed. Regardless of time period, the time before echocardiography was significantly associated with length of stay.
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Case Report: Pulmonary embolism (PE) is a form of venous thromboembolism (VTE) which causes an obstruction of the pulmonary vasculature. Massive PE can be a fatal, accounting for over 100,000 death/year in the US. Incidence of PEs is increased in COVID-19 infections, due to a hypercoagulable state resulting from endothelial injury, stasis and increase in prothrombic factors. We report a case of a 48-year-old male with past medical history of mild form of COVID-19 infection approx. 6 months back. He was brought to the ED after cardiac arrest resuscitated in the ambulance. 3 days prior to the cardiac arrest he presented in the ED for nonspecific upper respiratory tract symptoms, for which he received symptomatic treatment. During that visit all the workup was negative except for sinus tachycardia. The cause of patient's cardiac arrest was found to be massive bilateral PE leading to right ventricular strain, shock, and HFrEF (20%). Our patient received thrombolytic, ECMO, thrombectomy, anticoagulation, and required complex treatment for several complication during hospitalization. Was eventually discharged home recovered. COVID-19 pandemic has been one of the worst in human history, causing millions of deaths. Symptoms of COVID-19 infection vary from mild upper respiratory disease to respiratory failure or severe VTEs. Multiple studies including a large national study in Sweden reported COVID-19 being an independent risk factor for VTEs, risk extending up to 180 days after COVID-19 infection, especially in unvaccinated population as seen in our patient. New variants of SARS-Cov 2 pose a challenge to control the spread of COVID-19 infection. As more studies support COVID-19 infection association with hypercoagulability status, varied nonspecific symptomology of PE remains a diagnostic and treatment dilemma. Physicians should have low threshold for investigating PEs in patients with unexplained sinus tachycardia or non-specific respiratory distress, especially in an unvaccinated post-COVID-19 patient, including historical mild forms of infection. Many studies have arguably advocated "treatment to prevent thrombotic events” in post COVID- 19 infection, however, vaccination remains the corner stone to reduce morbidity and mortality associated with serious thrombotic events like massive PEs in patients exposed to COVID1-19.
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Introduction: Rates of initiation and dose optimization of guideline-directed medical therapy (GDMT) for heart failure patients with reduced ejection fraction are suboptimal nationally. Recently, virtual medicine has been studied as a potential solution to help overcome barriers limiting GDMT optimization. We evaluated GDMT optimization during telehealth visits compared with in-person visits at Parkland Health, a large urban safety-net health system. Method(s): Parkland has a registry of all patients with an ejection fraction <= 40% on transthoracic echocardiography within the last three years. Using this registry data of patients seen in the Parkland cardiology clinic between September 2021 and February 2022, we compared GDMT prescriptions for patients before and after each clinic visit. We defined an optimization event as the initiation of a new class of GDMT, a switch to an angiotensin receptor/neprilysin inhibitor, or an increase in dosage of any class of GDMT. The rise of Omicron variant COVID-19 cases in Dallas led to a nearly universal shift of in-person to virtual visits in December 2021, allowing us to compare GDMT optimization rates between each visit type. Result(s): From 9/12/21 to 12/24/21, there were 147 visits of which 134 (91%) were in-person. Of these in-person visits, 58.2% led to an optimization event. From 12/25/21 to 2/12/22, there were 97 visits of which 84 (89%) were telehealth visits, all conducted by telephone. Of these telehealth visits, 16.1% led to an optimization event (p<0.001). Baseline characteristics of patients from each period were not significantly different (Table 1). Conclusion(s): Our study demonstrated GDMT optimization was significantly lower in telephone visits compared with in-person visits despite each group having similar demographics and medical co-morbidities. This observation should raise concern over increased reliance on telephone-only encounters, especially in urban resource limited populations. (Figure Presented).
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Introduction: Select centers have published local experiences with outpatient (OP) intravenous (IV) diuretic clinics to treat worsening heart failure (HF) and prevent hospitalization. Little is known regarding widespread use of this care strategy in contemporary US practice, including the potential impact of the COVID-19 pandemic. Method(s): Inpatient (IP) and OP claims from Optum (April 2018-March 2021) were utilized to identify instances where patients with HF with reduced ejection fraction (HFrEF) received >=1 administration of IV diuretic. Episodes of care were categorized into hierarchical mutually exclusive groups defined by intensity of care setting, including IP hospitalization, critical care (without IP hospitalization), emergency department (without IP hospitalization), observation unit, nursing facility, and outpatient clinic. Analyses were stratified across pre-pandemic (4/2018-3/2019, 4/2019-3/2020) and COVID-19 pandemic periods (4/2020-3/2021). Result(s): Among 302,397 patients with HFrEF, 56,213 (19%) patients received IV diuretic therapy during the study period, accounting for 94,865 total IV diuretic episodes. Of patients receiving IV diuretics, 44% were female and 20% were Black. Among 85,827 (90%) IV diuretic episodes with available data on location of care, 14% were outpatient clinic visits, 60% were IP hospitalizations, and 21% were ED visits. Critical care, observation unit, and nursing facility locations each constituted ~1-2% of IV diuretic episodes. The proportion of outpatient IV diuretic visits and the overall distribution of IV diuretic episodes was similar over time, spanning the pre-pandemic and COVID-19 pandemic periods (Figure). Conclusion(s): In this cohort of US patients with HFrEF, approximately 1 in 7 care episodes involving IV diuretic therapy occurred in outpatient clinic. The relative proportion of outpatient IV diuretic visits did not meaningfully change during the first year of the COVID-19 pandemic. (Figure Presented).
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Patients with heart failure (HF) who contract coronavirus disease 2019 (COVID-19) are at increased risk for morbidity and mortality. Numerous pathophysiologic mechanisms exist by which COVID-19 infection inflicts cardiovascular damage. For HF patients with reduced ejection fraction (HFrEF), guideline-directed medical therapy should be maintained and optimized in the absence of contraindications. Clinicians should assess currently authorized COVID-19 treatment options prior to initiation. Pharmacists play an essential role in managing patients who have HFrEF and recommending preventive therapy, such as lifestyle modifications and vaccinations, with the goal of optimizing health outcomes during the COVID-19 pandemic. Copyright © 2022, Jobson Publishing Corporation. All rights reserved.
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In this report, we describe the case of a woman with suspected COVID-19 immunization-induced probable catastrophic antiphospholipid syndrome. The patient is a 35-year-old female with a past medical history significant for antiphospholipid syndrome, not on anticoagulation, who presented with a 5-day history of abdominal pain and distention, nausea, vomiting, and shortness of breath. She had received her first dose of the Pfizer COVID-19 vaccine one day prior to the onset of symptoms. After extensive workup at an outside hospital, she was found to be in acute heart failure exacerbated by severe mitral and tricuspid regurgitation. She was transferred to our hospital for escalation of care. EKG showed evidence of prior inferior and septal myocardial infarction. Transesophageal echocardiogram (TEE) showed reduced ejection fraction, severe mitral and tricuspid regurgitation, and a left ventricular thrombus. Cardiac MRI showed subendocardial late gadolinium enhancement indicative of ischemia. However, CTA of the coronary vessels showed no signs of obstruction. Therefore, her acute heart failure was thought to be due to small vessel thrombosis secondary to antiphospholipid syndrome. During admission, she had several absence seizure-like episodes. CT head showed several hypodensities of the deep white matter and brain MRI demonstrated multiple hyperintense T2 FLAIR signal foci with restriction diffusion and enhancement involving the cerebral hemisphere, consistent with subacute strokes attributed to being secondary to antiphospholipid syndrome or embolic from the left ventricular thrombus. She was treated with heparin for suspected catastrophic antiphospholipid syndrome and high-dose corticosteroid therapy for concomitant Systemic Lupus Erythematosus (SLE). She was discharged in a stable condition.
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Introduction/ Background: Multisystem inflammatory syndrome in children is a severe manifestation of COVID-19 infection in children and adolescents. It causes a significant hyper inflammatory response in children and is related to SARS-CoV-2 infection. There is paucity of data on this subject, especially in Sub-Saharan Africa, leading to challenges and delays in diagnosis. Methods: A case of a 17-year Kenyan boy who presented to a tertiary-level facility in Nairobi with abdominal pain and diarrhea for five days, difficulty in breathing and conjunctival injection for 1 day. Three weeks prior to this he had a dry cough and associated sore throat. He hadn't received Covid-19 vaccination. There had been a COVID-19 outbreak at school. Examination at admission revealed he was hypotensive, tachycardic, tachypnoeic, afebrile with normal oxygen saturations. He had distended neck veins with hyperactive precordium and elevated jugular venous pressure, a distended abdomen, tender in the right upper quadrant and a hepatomegaly of 16cm. Results: Investigations revealed multiple organ dysfunction (MOD) including heart failure with reduced ejection fraction (LVEF-30%), acute kidney injury, acute congestive hepatopathy, coagulopathy, elevated inflammation markers and positive SARS-CoV-2 IgG and IgM and a negative COVID 19 PCR test. He received IV antibiotics, daily hemodialysis sessions, inotropic support, high dose steroid therapy and Tocilizumab. He succumbed 8 days after admission. A postmortem revealed necrosis of the glomeruli and tubules, acute hemorrhagic necrosis of hepatocytes with fatty change, hyaline covering alveoli sac inkeeping with acute respiratory distress syndrome. Impact: MIS-C presents a diagnostic challenge and is often mistaken for other medical conditions. This often leads to inappropriate or delayed treatment, hence poor outcomes. A high index of suspicion is warranted. This may present a wakeup call for consideration of extending vaccination to the pediatric age group. Conclusion: Multi-system inflammatory syndrome is a rare COVID 19 complication affecting children and adolescents. It presents difficulty in diagnosis in Kenya considering most adolescents are managed as adults. This case hopes to increase vigilance among health care workers and that more preventive interventions can be implemented to reduce infection in children.
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Introduction: COVID-19-related Multisystem Inflammatory Syndrome in Children (MIS-C) is a rare complication seen 2 to 6 weeks after the resolution of an acute COVID-19 infection. There has been only one described case of COVID-19 related hyperinflammatory syndrome in adults. Here we present a case of COVID-19 associated MIS causing myocarditis and new onset heart failure with reduced ejection fraction in an adult. Case Description: A 23 year-old male presented with fever, fatigue, exercise intolerance, myalgias, headaches, and a positive COVID-19 PCR test approximately 5 weeks earlier. On admission, the patient was noted to be febrile to 102.2, tachycardic, and hypotensive. Physical exam notable for bilateral conjunctival irritation and trace lower extremity edema. Labs on admit were significant for creatine of 1.67, mild transaminitis, BNP 262, Troponin 0.67, and WBC 12.8. Bedside echo performed in the ED was significant for a decreased LVEF 40-45%, global hypokinesis, and collapsible IVC. The patient was empirically treated with vancomycin and zosyn for possible sepsis however blood cultures remained clear and no source of infection was ever identified. Inflammatory markers were elevated with a LDH 252, D-Dimer 588, Ferritin 1,500, CPK 108, and CRP of 28. Angiogram of chest showed no evidence of acute cardiopulmonary/airspace disease, no pulmonary embolism. Troponins peaked at 1.64 and CRP peaked at 37. Discussion: The patient continued to worsen with no obvious source of infection with a pattern of inflammatory markers consistent with MIS in the setting of recent COVID-19 infection. The severity of his presentation prompted treating the patient according to MIS-C guidelines developed for children which included IVIG, IV steroids, and high dose aspirin which resulted in a quick resolution of his fever and improvement in his cardiac function and end-organ labs and markers. Patient was discharged home on aspirin and pantoprazole. Follow up echocardiogram one month later demonstrated a return of normal cardiac function. Conclusion: Our understanding of acute COVID-19 infection, its sequelae, and long term complications is rapidly evolving. A MIS-C-like illness should be considered in adults presenting with atypical clinical findings and a recent COVID-19 infection. Pediatric conditions have the potential to present later in life, as physicians we must remain vigilant in our assessment, especially in the setting of an evolving global pandemic.
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Background: about 25% of patients admitted for HF are readmitted to hospital within 30 days. Fluid congestion is the leading cause for short-term readmission. Lung ultrasound (LUS) has become widely used to assess pulmonary congestion of cardiac origin for hospitalized patients on admission and before discharge but also for patients with HF undergoing outpatient follow-up. Inferior vena cava ultrasonography (IVCUS) seems also to be a useful tool in the care of patients with chronic HF. General practitioners (GPs) can safely use POCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients. Furthermore, they have expressed a need for greater training to diagnose and manage HF. An effective advanced fluid management programme, consisting in an intervention providing tailored therapy guided by intravascular volume assessment, is associated with improving readmission and mortality in HF. However, experts report long waiting lists for HF clinics and emphasize that scheduled follow-up appointments with a cardiologist do not regularly occur within two weeks of discharge, as recommended in guidelines. Purpose: to assess if POCUS, including LUS and IVC collapse index (IVCCI), can help in-hospital management in the general ward and if GPs can early identify signs of fluid overload after discharge, providing early referral and optimal therapy according to 2021 ESC guidelines. Methods: observational pilot study to test routine POCUS performed on hospital admission, before discharge and after 2 weeks in the GP ambulatory setting, after an in-hospital training period. 30-day HR was retrospectively compared to the clinical standard. Results: among 250 consecutive SARS-CoV-2 negative patients admitted to the department of internal medicine, 56 (22.4%) have been hospitalized for acute decompensated HF (17.8% HFrEF, 26.8%, HFmrEF, 55.4% HFpEF). 17 patients (30% M/F 6/11: group 1) underwent POCUS, while 39 patients (70% M/F 25/14, group 2) the standard management. Mean age difference (group1: 80.6±9.6 vs group2: 82.8±8.2) as well as comorbidities were not significant among groups (t-test p<0.19), while mean length of stay (MLS) for group1 (6.5±2.9 days) vs group2 (12±6.2 days) was significant (t-test p<0.001). LUS on discharge excluded persistent congestion in 76.5% (B-lines ≥ 3: 23.5%, yet 75% of these patients had no findings on ascultation), while IVCCI was >50%, 30-50%, <30% respectively in 52.9%,17.6% and 29.4%). 3 patients were evaluated after 2 weeks by GP. The 30-day HR was 5.8% (group1) vs 12.8% (group2) (χ2 test p<0.0012). Conclusions: POCUS seems to have contributed to reduce MLS, encouraging attainment of an optimal volume status at discharge and prescription of an optimal therapy. LUS and IVCUS are simple tools which may be performed soon after discharge by GP, contributing to reduce 30-day HR improving post discharge quality of care.