Serum catestatin is correlated with clinical parameters in non-critical COVID-19 patients

Introduction: Catestatin (CST) is a peptid with imunomodulatory, antiinflammatory, and antimicrobial activities. Acute coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus can cause a systemic disease range unpredictably from mild flu-like disease to multiple organ failure. Despite many studies and scientific interest for COVID 19, there is lack of information regarding correlation between serum CST levels and clinical course od COVID 19. There are only few studies investigated CST plasma levels at COVID 19 patients, but mostly at ICU-patients, and those studies revealed that COVID 19 patients release significant amounts of CST in the plasma and CST predicts a poor COVID-19 outcome. In our work the aim was to demonstrate plasma CST levels and correlation with clinical outcome in a group of severe COVID 19 patients admitted in non-ICU department. Method(s): The subjects were patients admitted during second surge of COVID 19 in April and May 2020 in non-ICU unit for COVID 19 patients (high dependency unit) in Infectology department of University Hospital Split, Croatia. The reason of admission was pulmonary infiltrates and COVID 19 positivity confirmed with nucleic acid test. In study were included 32 subjects (25 females, 7 males) (Table 1). An enzyme-linked immunosorbent assay was used for serum CST levels assessment. Result(s): We found significant positive correlation between serum CST levels and: C-reactive protein (r = 0.423, p = 0.008), D-dimers (r = 0.395, p = 0.013), hsTNT (high sensitivity troponin T) (r = 0.603, p < 0.001), proBNP (N-terminal-pro brain natriuretic peptide) (r = 0.569, p < 0.001), and hospitalisation days (r = 0.388, p = 0.014). There was significant difference between groups of participants with SOFA < 3 (n = 18) and SOFA > 3 (n = 14) in catestatin serum levels (7.25 +/- 3.66 vs. 11.05 +/- 9.52 ng/ml;p = 0.065). Conclusion(s): This study confirmed that serum CST levels could have important role as clinical prognostic parameter among non-ICU COVID 19 patients.

Atrio-Ventricular Conduction Abnormalities in Multisystem Inflammatory Syndrome in Children

Purpose of study Since mid-April 2020 in Europe and North America, clusters of pediatric cases with a newly described severe systemic inflammatory response with shock have appeared. Patients had persistent fevers >38.5 C, hypotension, features of myocardial dysfunction, coagulopathy, gastrointestinal symptoms, rash, and elevated inflammatory markers without other causes of infection. The World Health Organization, Centers for Disease Control, and Royal College of Paediatrics associated these symptoms with SARS-CoV-2 as multisystem inflammatory syndrome in children (MIS-C). Cardiac manifestations include coronary artery aneurysms, left ventricular systolic dysfunction evidenced by elevation of troponin-T (TnT) and pro-B-type naturietic peptide (proBNP), and electrocardiogram (ECG) abnormalities. We report the clinical course of three children with MIS-C while focusing on the unique atrioventricular (AV) conduction abnormalities. Case #1:19-year-old previously healthy Hispanic male presented with abdominal pain, fever, and non-bloody diarrhea for three days. He was febrile and hypotensive (80/47 mmHg) requiring fluid resuscitation. Symptoms, lab findings, and a positive COVID-19 antibody test were consistent with MIS-C. Methylprednisolone, intravenous immunoglobulin (IVIG), and enoxaparin were started. He required epinephrine for shock and high flow nasal cannula for respiratory distress. Initial echocardiogram demonstrated a left ventricular ejection fraction (LVEF) of 40% with normal appearing coronaries. Troponin and proBNP were 0.41 ng/mL and proBNP 15,301 pg/mL respectively. ECG showed an incomplete right bundle branch block. He eventually became bradycardic to the 30s-50s and cardiac tracing revealed a complete AV block (figure 1a). Isoproterenol, a B1 receptor agonist, supported the severe bradycardia until the patient progressed to a type 2 second degree AV block (figure 1b). A second dose of IVIG was administered improving the rhythm to a type 1 second degree AV block. An IL-6 inhibitor, tocilizumab was given as the rhythm would not improve, and the patient soon converted to a first-degree AV block. Cardiac magnetic resonance imaging showed septal predominant left ventricular hypertrophy and subepicardial enhancement along the basal inferior/anteroseptal walls typical for myocarditis. Case #2: 9-year-old previously healthy Hispanic male presented after three days of daily fevers, headaches, myalgias, diffuse abdominal pain, and ageusia. He was febrile, tachycardic, and hypotensive (68/39 mmHg). Hypotension of 50s/20s mmHg required 3 normal saline boluses of 20 ml/kg and initiation of an epinephrine drip. Severe hypoxia required endotracheal intubation. After the MIS-C diagnosis was made, he was treated with IVIG, mehtylprednisolone, enoxaparin, aspirin, and ceftriaxone. Due to elevated inflammatory markers by day 4 and patient's illness severity, a 7-day course of anakinra was initiated. Initial echocardiogram showed mild tricuspid and mitral regurgitation with a LVEF of 35-40%. Despite anti-inflammatory therapy, troponin and proBNP were 0.33 ng/mL and BNP of 25,335 pg/mL. A second echocardiogram confirmed poor function so milrinone was started. Only, after two doses of anakinra, LVEF soon normalized. Despite that, he progressively became bradycardic to the 50's. QTc was prolonged to 545 ms and worsened to a max of 592 ms. The aforementioned therapies were continued, and the bradycardia and QTc improved to 405 ms. Patient #3: 9-year-old African American male presented with four days of right sided abdominal pain, constipation, and non-bilious non-bloody emesis. He had a negative COVID test and unremarkable ultrasound of the appendix days prior. His history, elevated inflammatory markers, and positive COVID- 19 antibody were indicative of MIS-C. He was started on the appropriate medication regimen. Initial ECG showed sinus rhythm with normal intervals and echocardiogram was unremarkable. Repeat imaging by day three showed a decreased LVEF of 50%. ECG had since changed to a right bundle branch block. Anakinra as started and steroid dosing was increased. By day 5, he became bradycardic to the 50s and progressed to a junctional cardiac rhythm. Cardiac function normalized by day 7, and anakinra was subsequently stopped. Thereafter, heart rates ranged from 38-48 bpm requiring transfer to the pediatric cardiac intensive care unit for better monitoring and potential isoproterenol infusion. He remained well perfused, with continued medical management, heart rates improved. Methods used Retrospective Chart Review. Summary of results Non-specific T-wave, ST segment changes, and premature atrial or ventricular beats are the most often noted ECG anomalies. All patients initially had normal ECGs but developed bradycardia followed by either PR prolongation or QTc elongation. Two had mild LVEF dysfunction prior to developing third degree heart block and/or a junctional escape rhythm;one had moderate LVEF dysfunction that normalized before developing a prolonged QTc. Inflammatory and cardiac markers along with coagulation factors were the highest early in disease course, peak BNP occurred at approximately hospital day 3-4, and patient's typically had their lowest LVEF at day 5-6. Initial ECGs were benign with PR intervals below 200 milliseconds (ms). Collectively the length of time from initial symptom presentation till when ECG abnormalities began tended to be at day 8-9. Patients similarly developed increased QTc intervals later in the hospitalization. When comparing with the CRP and BNP trends, it appeared that the ECG changes (including PR and QTc elongation) occurred after the initial hyperinflammatory response. Conclusions Although the mechanism for COVID-19 induced heart block continues to be studied, it is suspected to be secondary to inflammation and edema of the conduction tissue. Insufficiency of the coronary arterial supply to the AV node and rest of the conduction system also seems to play a role. Although our patients had normal ECG findings, two developed bundle branch blocks prior to more complex rhythms near the peak of inflammatory marker values. Based on the premise that MIS-C is a hyperinflammatory response likely affecting conduction tissue, our group was treated with different regimens of IVIG, steroids, anakinra, and/or tocilizumab. Anakinra, being an IL-1 inhibitor, has been reported to dampen inflammation in viral myocarditis and tocilizumab has improved LVEF in rheumatoid arthritis patients. Based on our small case series, patient's with MISC can have AV nodal conduction abnormalities. The usual cocktail of IVIG and steroids helps;however, when there are more serious cases of cardiac inflammation, adjuvant immunosuppresants like anakinra and toculizumab can be beneficial. (Figure Presented).

Covid 19 presenting as stroke and MI

Its now a well known fact that covid 19 causes coagulopathy that has been associated with the inflammatory phase of coronavirus disease (COVID-19) and might be involved in this concurrency. Here we present a case of a 55y old female with no underlying comorbidity presented with the chief complaints of mild slurry speech and weakness over the right side of the body from last 8 h. Noncontrast brain computed tomography (CT) scan showed early signs of ischemia in left middle cerebral artery (MCA) territory, and a CT angiogram demonstrated a carotid atheromatous plaque with a superficial thrombus causing 40% stenosis in the left proximal internal carotid artery (ICA), however no intracranial artery occlusion was found. On ecg patient had ST segment depression in and depression in v5 and v6 leads with transthoracic echocardiogram showed lateral wall hypokinesia of the left ventricle, with qualitative troponin-T positive. There were no respiratory or other symptoms compatible with COVID-19 infection or chest pain. Chest CT ruled out inflammatory/infectious signs in the lung parenchyma, and Rapid antigen testing for covid 19 was negative on admission however RTPCR for SARS-CoV-2 was positive. Patient was initially loaded with dual anti platelets and lmw heparin and was subsequently managed with aspirin 150 mg, clopidogrel 75 mg and atorvastatin 40 mg with resolution of the chest pain and slurry speech.

Effect of the COVID-19 pandemic on young stroke

Background & Objective: Covid-19 infection has diverse effect on human health. We aimed to evaluate the effect of COVID-19 pandemic on the young stroke cases in an emergency services in a tertiary hospital in Istanbul, Turkey. Method: A total of 86 patients younger than 50 years confirmed to have stroke seen between January 1, 2019 and December 31, 2020 were included in the study. The year 2019 was defined as the pre-pandemic period and the year 2020 as the pandemic period. The patients' stroke type, localization, mortality, laboratory and imaging data were evaluated. Results: Eighty-six patients were included in the study. The mean age was 38.69±5.39 years, 49 (57%) were female. Of the patients, 78 (90.7%) were ischemic and 8 (9.3%) were hemorrhagic stroke. In the pandemic group, ischemic stroke was observed in 55 (96.5%) and hemorrhagic stroke in 2 (3.5%) (p=0.010). While the mean age of the patients in the survival group was 39.24±5.70 years, it was 36.61±3.38 years in the mortality group (p=0.008). While the mortality was 18 (20.9%) overall, it was 16 (18.6%) patients during the pandemic period, and 2 (2.3%) patients in the pre-pandemic period, the difference was statistically significant. (p=0.014). Conclusion: COVID-19 infection appear to increase the risk of ischemic stroke and worsens the mortality among the young. More comprehensive and prospective studies are needed to confirm this observation. © 2023, ASEAN Neurological Association. All rights reserved.

The Role of Inflammatory Markers in Predicting Mortality in Critical COVID-19 Patients: A Single- Center, Retrospective, Observational Study

Introduction: This study aims to assess the association of inflammatory markers with the clinical progression of patients diagnosed with COVID-19. Material(s) and Method(s): Critically ill patients with COVID-19 were included. Prealbumin, lactate dehydrogenase (LDH), transferrin, procalcitonin, ferritin, D-dimer, troponin T and C-reactive protein (CRP) were monitored. A comparison was performed between patients regarding their need for mechanical ventilation, duration of hospital and intensive care unit stay, discharge, mortality, complications, and response to treatment in order to reveal potential correlations. Result(s): A total of 107 patients were enrolled in the study. D-dimer levels on the 3rd and 6th days were significantly higher in the exitus group. Prealbumin and transferrin levels measured at baseline and on days three and six were significantly lower in the exitus group compared to the surviving group (p< 0.05). In the exitus group, the procalcitonin, CRP, LDH, troponin T, and ferritin levels were significantly higher on days zero, three, and six as compared to the surviving group (p< 0.05). Conclusion(s): Our results suggest that inflammatory markers may be useful as early indicators of mortality in COVID-19 patients.Copyright © 2023 Bilimsel Tip Yayinevi. All rights reserved.

Retrospective cohort study on the increase of bnP and troponin-t in pediatric patients positive to covid-19.

Background: According to data from the World Health Organization updated to September 30, 2022, SARS-CoV-2 is a viral disease, that infected six hundred million people and claimed six and a half million victims in all over the world. Some authors describe the alteration of blood parameters in pediatric age following COVID-19 such as: anomalies of the leukocyte formula, CK-MB and LDH enzymes, C reactive protein (PCR) and procalcitonin (PCT). Based on these studies we wanted to focus on two cardiac biomarkers: type B natriuretic peptide (BNP) and high sensitivity cardiac troponin (cTnT-hs). In order to suggest a strategy aimed at preventing the possible occurrence of cardiovascular complications in children we monitored them in patients with specific anti-SARS-CoV-2 immunoglobulins (IgG). Method(s): From November 2020 to December 2021, 53 children with positive IgG to SARS-CoV-2 by immunochromatographic method were tested for BNP and cTnT-hs. Samples collected in potassium EDTA tubes were tested for BNP by a fluorescence immunoassay. cTnT-hs was determined with an electrochemiluminescence sandwich test, which employs two specific monoclonal antibodies directed against cardiac troponin. The BNP cutoff is 100 pg/mL for patients aged 1 to 14 years, while that of cTnT-hs is 14 ng/L. All patients were monitored from hospitalization to discharge. Result(s): At least one of the two biomarkers resulted pathologic in 35 (66%) patients, while 18 (34%) were negative. The 35 pathologic cases were distributed as follows: 12 were simultaneously positive for cTnT-hs and BNP;13 were only positive for BNP, and 10 only positive for cTnT-hs. Sick children had a BNP mean value of 634 pg/mL at hospitalization, and of 94 pg/mL at discharge. For cTnT-hs, the initial mean value was 46 ng/l and the final was 17 ng/L. Twelve children with both altered values were monitored for a longer time, as they returned negative more slowly. Repeated dosages of the two analytes from hospitalization to discharge, showed a constant decrease over the time. After about ten days from the first dosage, both parameters returned to values near to the relative cutoffs. Conclusion(s): Measuring BNP and cTnt-hs can be useful for screening and monitoring pediatric patients positive for anti-SARSCoV-2 IgG.Copyright © 2022 EDIZIONI MINERVA MEDICA.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) complicating myocarditis

Myocarditis can lead to myocardial infarction in the absence of coronary artery obstruction. We report a case of probable myocarditis, complicated by myocardial infarction with non-obstructive coronary arteries. A 19-year-old man presented with chest pain typical of myocarditis. He was a smoker but was otherwise well. Electrocardiogram revealed diffuse ST-elevation and echocardiography revealed a thin, akinetic apex. Troponin-T levels on admission were raised leading to an initial diagnosis of myocarditis being made. However, late gadolinium enhancement study on cardiac magnetic resonance imaging demonstrated transmural enhancement typical of ischaemia. Coronary angiogram was normal, leading to a likely diagnosis of myocardial infarction with non-obstructive coronary arteries. It is important to highlight that coronary assessment remains important when working up for myocarditis, as myocardial infarction with non-obstructive coronary arteries can often complicate myocarditis in cases of normal angiography. Another important lesson was on how cardiac magnetic resonance imaging provided vital evidence to support underlying ischaemia despite normal coronary angiogram, leading to a diagnosis of myocardial infarction with non-obstructive coronary arteries. Myocardial infarction with non-obstructive coronary arteries remains a broad 'umbrella' term and cardiac magnetic resonance imaging, as well as more invasive coronary imaging techniques during angiography, can further assist in its diagnosis. Our case provides a reminder that myocardial infarction with non-obstructive coronary arteries, although increasingly recognised, remains under-diagnosed and can often overlap with peri-myocarditis, highlighting the need to employ multi-modality imaging in guiding management.Copyright © The Author(s) 2021.

Successful Use of Biventricular Assist Devices in Fulminant Myocarditis

Background Fulminant myocarditis can cause biventricular dysfunction with a mortality rate over 40%. We report a case with severe biventricular failure due to fulminant myocarditis that was successfully supported by left and right ventricular assist devices. Case A 65-year-old woman presented with chest pain, abdominal pain and diarrhea. She was hypotensive and labs revealed elevated troponin-T of 13.5 ng/mL and lactate of 4.3 mmol/L. She was positive for COVID by antigen testing. She was started on multiple vasopressor infusions and admitted to the intensive care unit. Echocardiogram revealed a severely reduced left ventricular ejection fraction of 15% and severe global hypokinesis. The following day, she developed a wide complex tachycardia that was refractory to amiodarone, lidocaine and multiple defibrillation attempts. She was transferred emergently to the cardiac cath lab where coronary angiography revealed an isolated 70% stenosis of the distal left circumflex artery. A Swan-Ganz catheter was placed that yielded a cardiac index by Fick of 1.2 L/min/m2, systemic vascular resistance of 1270 dynesseccm-5 and mixed venous oxygen saturation of 35%. Decision was made to emergently insert an Impella CP device. That evening, she developed complete heart block and transvenous pacing wire was inserted. Due to frequent suction alarms, decision was made to insert ProtekDuo device, which resulted in hemodynamic stabilization. A temporary coronary sinus pacing lead for atrial capture was inserted to improve atrioventricular synchrony. After several days of monitoring, repeat echocardiogram showed complete recovery of biventricular function and Impella CP and ProtekDuo devices were removed. Decision-making The decision of early implantation of ProtekDuo device was made to provide adequate blood flow to the left ventricular assist device for hemodynamic support. In addition, increased atrioventricular synchrony via insertion of temporary coronary sinus pacing wire improved cardiac output. Conclusion Fulminant myocarditis involving biventricular dysfunction can be supported by the use of simultaneous left and right ventricular assist devices.Copyright © 2023 American College of Cardiology Foundation

Tocilizumab- a Treatment Option for Torsades De Pointes in Covid-19 Patients

Background The incidence of ventricular arrhythmias (VA) in Coronavirus disease 2019 (COVID-19) patients ranges from 1.6 to 5.9%. COVID-19 can trigger a systemic inflammatory response, which may unmask arrhythmias. Here we discuss a challenging case of COVID-19 that manifested as recurrent Torsades de Pointes (TdP). Case A 39-year-old female with no known past medical history presented with a complaint of multiple syncopal episodes in the last two days. Initial electrocardiograms (EKG) showed a heart rate of 62 with frequent premature ventricular contractions (PVCs) and a prolonged corrected QT(QTc) interval of 520ms. Frequent PVCs soon converted to TdP with loss of consciousness which was managed with successful direct current cardioversion (DCCV). However, the patient relapsed into TdP, warranting another successful DCCV. COVID-19 workup came back positive. Electrolytes were within normal limits;however, C-reactive protein (CRP) and troponin T levels were elevated. Decision-making The patient was started on intravenous (IV) magnesium for 24 hours. Following another episode of self-limiting TdP, IV isoproterenol was started, and tocilizumab was given. An echocardiogram showed no evidence of structural heart disease. During the hospital course, telemetry showed PVCs that decreased in frequency paralleled with a decrease in CRP and troponins. Repeat EKGs showed normalization of QTc interval. The patient declined implantable device placement or procedures and was eventually discharged with a heart monitor and a beta blocker. On follow-up, the patient denied any symptoms since the discharge, QTc remained normal, and the heart monitor did not show any VA. Conclusion Management of TdP generally involves magnesium, IV isoproterenol, and transvenous pacing. However, as described in this case, tocilizumab can cause QT interval shortening and a reduction in CRP and cytokine levels and may be beneficial for use in COVID-19 patients with QT prolongation and VA, including TdP. There are no strict guidelines for arrhythmias in COVID-19 patients. Accordingly, more studies need to be done to follow this patient population managed with tocilizumab for their eventual outcomes.Copyright © 2023 American College of Cardiology Foundation

A Case of Massive Pulmonary Embolus Extending into a Patent Foramen Ovale: An Impending Catastrophe

Background Massive pulmonary embolus (PE) is a life-threatening condition, however thrombus in transit in the setting of patent foramen ovale (PFO) poses catastrophic risk including systemic thromboembolism. Case An 88 year-old with history of COVID-related PE in 2020 previously on anticoagulation (AC) presented with chest pain & dyspnea. She was found to have lower extremity DVTs & extensive PE in the main pulmonary arteries & its branches. Transthoracic echo (TTE) revealed severe right ventricular dysfunction & right atrial (RA) thrombus in transit that extended into a PFO with right to left shunt. She was hemodynamically stable, but hypoxic on 4L/min of oxygen with a ProBNP 7712 pg/L, Troponin T 104 ng/dl, & pulmonary embolism severity (PESI) score of 104 (10% risk of 30 day mortality). Decision-making Due to the high PESI score & thrombus burden with risk of systemic thromboembolism, a multidisciplinary PE Response Team reached a consensus to pursue urgent mechanical thrombectomy. Inari FlowTriever system was successfully used for thrombectomy & retrieval of the RA clot in transit, with rapid improvement in right sided pressures. Repeat TTE showed no residual clot or shunting. Patient was placed on AC with plan for future PFO closure. Conclusion A multidisciplinary team approach was pivotal in managing this complex case with potential for hemodynamic compromise & systemic thromboembolism. We also demonstrate that mechanical thrombectomy is a feasible strategy for retrieving RA clot in transit. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Pseudo-ventricular tachycardia- Diagnostic enigma in the emergency department: A case report

Ventricular tachycardia (VT) is a type of broad complex tachycardia originating from a focus in the ventricle. It is one of the four important rhythms which can lead to cardiac arrest. Accurate and timely diagnosis of true VT is the cornerstone for proper management in the emergency department (ED). We present an interesting case of an electrocardiographic artifact mimicking VT, which led to a diagnostic dilemma in the ED.Copyright © 2023 Rehman, Albaroudi, Akram, Ahmad, licensee HBKU Press.

Case report: COVID-19-related acute pericarditis mimicking acute anterior myocardial infarction

Introduction: Coronavirus disease 2019 (COVID-19) was described for the first time in December 2019. Symptoms include cough, fever, myalgia, headache, dyspnea, sore throat, diarrhoea, nausea, vomiting, and loss of smell or taste. Viral-induced myocarditis and pericarditis have been described in developed countries, and SARS-CoV-2 is cardiotropic. Pericarditis can mimic myocardial infarction (MI) in its presentation and ECG findings. Case report: A 46-year-old smoker with no previous medical condition presented with left-sided chest pain, sweating, trouble breathing, palpitations, and left-hand numbness. He denied having reduced effort tolerance, orthopnea, or paroxysmal nocturnal dyspnea. Three weeks earlier, he was infected with Covid-19 category 2A infection. On examination, he is haemodynamically stable, and his respiratory and cardiovascular exams were unremarkable. His ECG showed anterior ST elevation, and the bedside echocardiography showed no hypokinesia or pericardial effusion. High-sensitive cardiac troponin T reached 5000. The emergency team contacted the on-call cardiologist for primary PCI. After analysing the serial ECG and bedside echocardiography, he decided against primary PCI due to acute pericarditis. He was started on intravenous diclofenac acid and colchicine. His pain subsided after 3 days with NSAIDs and colchicine. He was reviewed back in the clinic and had a normal ECG and ECHO. Discussion(s): Pericardial disease caused by COVID-19 has been more common since the pandemic outbreak. Mycobacterium tuberculosis, Borrelia burgdorferi, Parvovirus B19, and Epstein-Barr virus are the most common infecting agents. Most cases of acute pericarditis in developing nations are due to tuberculosis infection. Nearly half of all patients who had previously recovered from COVID-19 infection have now presented with new cardiac MRI findings indicating pericardial involvement. Fibrosis and/or oedema may be linked to persisting active pericarditis following infection resolution, which may lead to short and long-term clinical consequences. Conclusion(s): The ST elevation in post-covid patients does not always signify myocardial infarction. Despite complaints and ECG findings, this could not be an acute myocardial infarction, for which clinicians should have a high index of suspicion.Copyright © 2023

Common Biomarkers Associated with Delirium in Hospitalized Patients with COVID-19 at the Epicentre of Turkish Coronavirus Outbreak: A Case-Control Study.

Introduction: To investigate the differences in biochemical characteristics between Coronavirus Disease 2019 (COVID-19) patients with and without delirium in non-intensive care (IC) COVID-19 units was aimed. Methods: This study was designed as an observational, single-centered, and case-control study consisting of 43 delirious patients and matched 45 non-delirious patients admitted to non-IC COVID-19 units. Delirium was diagnosed by a consultant psychiatrist according to the DSM-5 delirium diagnostic criteria. Independent variables such as laboratory tests at the time of admission, clinical features, and patient characteristics were obtained from electronic medical records by researchers. In the primary analyses, binomial logistic regression models were used to investigate the factors associated with delirium, which was identified as the outcome variable. Multivariate logistic models were then adjusted for potential confounding factors, including age, gender, history of neurocognitive disorders and Charlson Comorbidity Index (CCI). Results: We observed higher levels of urea, d-dimer, troponin-T, proB-type natriuretic peptide, and CCI in patients with delirium compared to patients without delirium. We also observed lower levels of estimated glomerular filtration rate (eGFR), serum albumin, and O2 saturation and a decrease in the length of stay at the hospital. After adjusting for confounding factors such as gender, age, and comorbidity, we found that urea (adjusted estimate=0.015; 95% Confidence Interval [CI]=0.058-0.032, P=0.039), urea/creatinine ratio (adjusted estimate=0.008; 95% CI=0.002-0.013, P=0.011), and troponin-T (adjusted estimate=0.066; 95% CI=0.014-0.118, P=0.014) were independent biomarkers associated with delirium. Conclusion: Delirium is associated with higher urea levels and urea/creatinine ratios in COVID-19 patients. In addition, the relationship between troponin-T and delirium may help understand the potential link between the brain and the heart in COVID-19. Additional multi-centred studies with larger sample sizes are needed to generalise these results.

CRT-100.96 Effect of COVID-19 Pandemic on Six-Month Mortality and Clinical Outcomes of Patients With ST-Elevation Myocardial Infarction

Background: The coronavirus disease 2019 (COVID-19) infection has changed everyday clinical practice with a shortage of solid data about its implications on ST-elevation myocardial infarction (STEMI) patients. Aim: To evaluate the impact of COVID-19 on six-month clinical outcomes of patients with STEMI and determine the mortality predictors after STEMI during the COVID-19 pandemic. Methods: This prospective observational study was conducted on consecutive STEMI patients with confirmed COVID-19 infection who were presented to our hospital between April and October 2021. A total of 74 COVID-19 patients were included (group I) and were compared to 148 STEMI patients with matched baseline clinical parameters to the COVID-19 cases (group II). We compared the two cohorts' rates of major adverse cardiovascular events (MACEs;composite of death from any cause, recurrent MI, target-vessel revascularization, and stroke) at six months. Results: COVID-19 STEMI patients were more likely to present with angina equivalent symptoms, had higher Killip class at admission, and higher levels of high-sensitive cardiac Troponin T and serum C-reactive Protein. The six-month rates of MACEs were significantly higher in STEMI patients with COVID-19 compared to non- COVID-19 patients (41.9% vs. 16.9%, respectively;P<0.001) and were mainly due to higher in-hospital mortality (20.3% vs. 6.1%, respectively;P=0.001). The independent predictors of Six-month mortality in STEMI patients during the COVID-19 pandemic were the absence of ST resolution, low systolic blood and higher Killip class on admission, presence of severe MR and atrial fibrillation, and anterior wall STEMI. Conclusion: STEMI patients with superimposed COVID -19 infection had worse clinical outcomes with almost three times higher in-hospital mortality and six-month MACEs.

Multisystem inflammatory syndrome: A case report

Background: Multisystem inflammatory syndrome is a rare but severe complication of Coronavirus 19 infection (COVID-19) occurring about 2-12 weeks after the initial infection. It was initially reported in children (MIS-C) but later identified in adults (MIS-A). We report a case of MIS-A in a patient presenting with myocarditis.\ Method: Case report Results: A 36 years old female admitted due to 3 days history of fever and severe epigastric pain. She had exposure to a relative with COVID-19 3 weeks prior to symptoms and antigen test done was negative. On the day of admission, she started to experience shortness of breath and easy fatigability during activities of daily living. Upon examination, she was hypotensive requiring vasopressors. 12 lead ECG showed acute anteroseptal wall myocardial infarction and 2D echocardiography revealed hypokinesia of the entire interventricular septum and inferior left ventricular free wall, and reduced ejection fraction (EF) at 43.3%. Coronary angiogram showed normal findings. On work-up, she had mild normochromic, normocytic anemia, normal serum lipase, elevated AST 222 (<34 U/L), ALT 250 (<49 U/L), Troponin T > 2000 ng/L, CPK-Total 669 (<192 U/L), Ferritin 456.90 (<204 ng/ml), ESR 13 mm/hr, CRP 24 (<6 mg/L) and procalcitonin 0.35 (<0.5 ng/ml). Infectious workup revealed negative results and PCR for COVID-19 was negative. However, further workup revealed COVID-19 Enzyme Linked Fluorescent Assay (ELFA) IgG positive at 44.75 (>1.00) and IgM negative. The patient was managed as a case of MIS-A and was started on intravenous immunoglobulin (IVIg) and short course steroids with significant improvement in symptoms. On the 10th day of hospitalization, follow-up 2D echocardiography showed improvement in previously noted ventricular wall hypokinesia and normalization of EF to 55.8%. The patient was discharged well and improved. Conclusion(s): Diagnosis of MIS-A is challenging in patients without a previously known COVID-19. A positive serology result is required to fulfill the case definition of MIS-A. Determining a history of COVID-19 and its relationship to a patient's clinical course is important for making diagnosis and determining subsequent management.

Severe Covid-19 and acute pulmonary hypertension: 24-month follow-up regarding mortality and relationship to initial echocardiographic findings and biomarkers.

INTRODUCTION: Critically ill Covid-19 patients are likely to develop the sequence of acute pulmonary hypertension (aPH), right ventricular strain, and eventually right ventricular failure due to currently known pathophysiology (endothelial inflammation plus thrombo-embolism) that promotes increased pulmonary vascular resistance and pulmonary artery pressure. Furthermore, an in-hospital trans-thoracic echocardiography (TTE) diagnosis of aPH is associated with a substantially increased risk of early mortality. The aim of this retrospective observational follow-up study was to explore the mortality during the 1-24-month period following the TTE diagnosis of aPH in the intensive care unit (ICU). METHODS: A previously reported cohort of 67 ICU-treated Covid-19 patients underwent an electronic medical chart-based follow-up 24 months after the ICU TTE. Apart from the influence of aPH versus non-aPH on mortality, several TTE parameters were analyzed by the Kaplan-Meier survival plot technique (K-M). The influence of biomarkers for heart failure (NTproBNP) and myocardial injury (Troponin-T), taken at the time of the ICU TTE investigation, was analyzed using receiver-operator characteristics curve (ROC) analysis. RESULTS: The overall mortality at the 24-month follow-up was 61.5% and 12.8% in group aPH and group non-aPH, respectively. An increased relative mortality risk continued to be present in aPH patients (14.3%) compared to non-aPH patients (5.6%) during the 1-24-month period. The easily determined parameter of a tricuspid valve regurgitation, allowing a measurement of a systolic pulmonary artery pressure (regardless of magnitude), was associated with a similar K-M outcome as the generally accepted diagnostic criteria for aPH (systolic pulmonary artery pressure >35 mmHg). The biomarker values of NTproBNP and Troponin-T at the time of the TTE did not result in any clinically useful ROC analysis data. CONCLUSION: The mortality risk was increased up to 24 months after the initial examination in ICU-treated Covid-19 patients with a TTE diagnosis of aPH, compared to non-aPH patients. Certain individual TTE parameters were able to discriminate 24-month risk of morality.

An international, stepped wedge, cluster-randomized trial investigating the 0/1-h algorithm in suspected acute coronary syndrome in Asia: the rational of the DROP-Asian ACS study.

BACKGROUND: More than half of the world's population lives in Asia. With current life expectancies in Asian countries, the burden of cardiovascular disease is increasing exponentially. Overcrowding in the emergency departments (ED) has become a public health problem. Since 2015, the European Society of Cardiology recommends the use of a 0/1-h algorithm based on high-sensitivity cardiac troponin (hs-cTn) for rapid triage of patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS). However, these algorithms are currently not recommended by Asian guidelines due to the lack of suitable data. METHODS: The DROP-Asian ACS is a prospective, stepped wedge, cluster-randomized trial enrolling 4260 participants presenting with chest pain to the ED of 12 acute care hospitals in five Asian countries (UMIN; 000042461). Consecutive patients presenting with suspected acute coronary syndrome between July 2022 and Apr 2024 were included. Initially, all clusters will apply "usual care" according to local standard operating procedures including hs-cTnT but not the 0/1-h algorithm. The primary outcome is the incidence of major adverse cardiac events (MACE), the composite of all-cause death, myocardial infarction, unstable angina, or unplanned revascularization within 30 days. The difference in MACE (with one-sided 95% CI) was estimated to evaluate non-inferiority. The non-inferiority margin was prespecified at 1.5%. Secondary efficacy outcomes include costs for healthcare resources and duration of stay in ED. CONCLUSIONS: This study provides important evidence concerning the safety and efficacy of the 0/1-h algorithm in Asian countries and may help to reduce congestion of the ED as well as medical costs.

Serological Study on Covid-19 Patients with a Focus on Cardiovascular Disease Marker

Background: The COVID-19 pandemic is caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus, which causes life-threatening illness and mortality. One of the most critical risk factors for severe COVID-19 and COVID-19 mortality is cardiovascular disease (CVD) that develops during infection. Objective: To determine the most common CVD that occurred during infection with COVID-19 patients and the link between CVD and Fate. Material and methods: A descriptive cross-sectional study was conducted between July 22 and April 10 2022 to describe the frequency of CVD among 100 COVID-19 patients, as well as to detect the serological cardiovascular markers with mortality rates of those patients who attended Al-Karama Teaching Hospital in Baghdad governorate, Al-Shafaa Hospital, and Al-Ramadi Teaching Hospital in Al-Anbar governorate. Blood samples from all of the patients were taken for cardiovascular serological markers, as per the manufacturer's instructions. Results: The mean age of the COVID-19 patients with CVD was 65 23.83.83 (83.0%). Thrombosis, heart failure, myocarditis, myocardial infarction or acute coronary syndrome, hypertension, myocardial injury, angina, and pulmonary embolism were found in 83 (83.0%) of the 100 confirmed COVID-19 cases using IgM antibodies against SARS-CoV-2 by ELIZA in the following frequencies: 21, 9, 9, 7, 10, 11, 8, 5, and 3 respectively. ELIZA discovered COVID-19 patients with CVD utilizing IgG antibodies against SARS-CoV-2 in the remaining 17 cases (17.0%). Troponin-T, Ferritin, D-dimer, Leukocyte, B Urea, CRP LDH were 58.60 ±40.70, 368.36±265.75, 2523.05±1727.60, 15.00±7.67, 103.49±60.74, 33.13±35.74, 525.40±459.86, 4.11±2.13, respectively, among COVID-19 heart failure patients. Troponin-T, Ferritin, D-dimer, Leukocyte, B Urea, CRP LDH were 33.61±34.70, 481.20±181.89, 3361.15±14.26, 20.08±10.54, 76.71±28.02, 22.76±19.73, 536.35±798.14, 3.61±2.11, respectively among COVID-19 Myocarditis patients. Conclusion: There was no significant variation in mortality across the various CVD of COVID-19 cases, There were no significant differences in cardiovascular serological markers in different age groups of among CVD of COVID-19 cases. © 2022, ResearchTrentz Academy Publishing Education Services. All rights reserved.

Markers of Infection-Mediated Cardiac Damage in Influenza and COVID-19.

INTRODUCTION: Influenza and the coronavirus disease 2019 (COVID-19) are two potentially severe viral infections causing significant morbidity and mortality. The causative viruses, influenza A/B and the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) can cause both pulmonary and extra-pulmonary disease, including cardiovascular involvement. The objective of this study was to determine the levels of cardiac biomarkers in hospitalized patients infected with influenza or COVID-19 and their correlation with secondary outcomes. METHODS: We performed a retrospective comparative analysis of cardiac biomarkers in patients hospitalized at our department with influenza or COVID-19 by measuring high-sensitivity troponin-T (hs-TnT) and creatinine kinase (CK) in plasma. Secondary outcomes were intensive care unit (ICU) admission and all-cause in-hospital mortality. RESULTS: We analyzed the data of 250 influenza patients and 366 COVID-19 patients. 58.6% of patients with influenza and 46.2% of patients with COVID-19 presented with increased hs-TnT levels. Patients of both groups with increased hs-TnT levels were significantly more likely to require ICU treatment or to die during their hospital stay. Compared with COVID-19, cardiac biomarkers were significantly higher in patients affected by influenza of all age groups, regardless of pre-existing cardiovascular disease. In patients aged under 65 years, no significant difference in ICU admission and mortality was detected between influenza and COVID-19, whereas significantly more COVID-19 patients 65 years or older died or required intensive care treatment. CONCLUSIONS: Our study shows that increased cardiac biomarkers are associated with higher mortality and ICU admission in both, influenza and SARS-CoV-2-infected patients. Cardiac biomarkers are higher in the influenza cohort; however, this does not translate into worse outcomes when compared with the COVID-19 cohort.

A case of mRNA COVID-19 vaccine-associated myocarditis in a child

Background and Aim: Accumulation of cases is needed to determine whether vaccines should be recommended for children because of their potential to cause myocarditis in healthy children. Method(s): We report a case in which changes in laboratory data, electrocardiogram (ECG), and magnetic resonance imaging (MRI) were tracked at our hospital. Result(s): A 12-year-old girl developed fever a day after receiving the second dose of the COVID-19 vaccine. Three days after vaccina-tion, she also developed chest pain and went to a hospital. ECG showed ST-T segment elevation. However, the symptoms were mild, and she was treated with antipyretics and analgesics. The next day, she visited the hospital again because she had mild chest pain. ECG showed a negative T-wave, and she was referred to our hos-pital. Her real-time reverse-transcription polymerase chain reac-tion tests for COVID-19 yielded negative results. Computed tomography revealed no anatomical abnormalities of the coronary arteries. The serum concentration of troponin T was elevated by 131 ng/L. Echocardiography showed the left ventricular ejection fraction to be 64%. MRI showed a normal T2 value on T2-weighted imaging;however, extracellular volume increased by 33%. Although the Lake Louise criteria was not met, we diagnosed the condition as myocarditis. She was hospitalized for 2 days and discharged without the need for steroids or gamma globulin treat-ment to relieve her symptoms. Although these findings improved 17 days after vaccination, late gadolinium enhancement was noticed on MRI. Conclusion(s): The COVID-19 vaccine-related myocarditis (C-VAM) in this case was mild and like as cases in Europe and the United States. The risk of COVID-19 associated myocarditis is more than three times the risk of C-VAM. In addition, the mor-tality rate for COVID-19 associated myocarditis is higher than that for C-VAM. The need for a vaccine to protect populations from COVID-19 should be properly recognized. However, because the symptoms of C-VAM are mild, there may be many potential patients with C-VAM. Therefore, it may be advisable to avoid strenuous exercise for approximately 1 week after vaccination. Further research is needed to determine the long-term outcomes of C-VAM because of the late enhancement identified on MRI.