Expert System KORDEX for Solving of Urgent Cardiology Problems

The article provides an analysis of the reasons for the need to develop an expert system in emergency cardiology. The principles of development and reasons for modification of the KORDEX expert system which is used for the myocardial infarction prognosis are described. The method of comparative estimation of parameters used to create a knowledge base is considered. Examples of expert rules, including rules that take into account the postponed COVID-19 are shown. The debugging of the expert system and the results of its use in practical medicine are described. © 2023, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Remote Clinical Quality Management of Endovascular Care

To assess the effectiveness of remote clinical quality management of endovascular Aim care. The system of clinical quality management of medical care in myocardial infarction (MI) including the quality of remote control of endovascular care was developed and introduced into the health care system of the Moscow Region as a part of the comprehensive study in 2008-2020. The number of people under the study was 8375. The ground for assessing the effectiveness of remote clinical management in 2019-2020 was the health care system of megapolis. Based on the analysis of 2966 endovascular procedures protocols, the treatment tactics effectiveness of intraoperative decisions was studied after an emergency coronary angiography (ECA) had been performed by interventional cardiologists. The Methods system of remote clinical quality management of endovascular care included a complex of audiovisual communications, computer system processes, mentoring and the algorithm for making an intraoperative decision. The effectiveness of remote clinical quality management of endovascular care was investigated on the number of percutaneous coronary interventions (PCI) in MI, mortality of patients with MI in the Regional vascular center in 2019-2020. The T-criteria was used to assess the reliability. The material statistical processing was carried out in the Statistica 6.0 package calculating adequate statistical indicators and their reliability at p<=0.005. Ratio PCI/ECA in 2019, January-March 2020 counted up to 48.95%. In April-December 2020 it increased up to 71.6% (p<0.001). The frequency of performing Results PCI increased by 1.46 times (p<0.001). Hospital mortality from MI decreased during the following period 2019, April-December 2020 from 9.7% to 8.2% (p = 0.005). Remote clinical management based on telemedicine and mentoring process Conclusion technologies contributes to improving the quality of endovascular care in MI.Copyright © 2021 Angles. All rights reserved.

Acute STEMI : Before and During the COVID-19 Pandemic Single Center Study

Background: During COVID-19 pandemic, the pattern of hospital admissions for acute ST-elevation myocardial infarction (STEMI) has been changing, and increased mortality and morbidity is being noted in these patients. Patient may present with acute myocardial infarction, myocarditis simulating a presentation like STEMI, coronary spasm, myocardial injury not fulfilling the criteria of type 1 & type 2 acute MI and cardiomyopathy. In this study we have tried to determine some important differences among the patients presented with STEMI during The COVID-19 pandemic versus non-COVID-19 era. Method(s): This prospective observational study was carried out in National Heart Foundation Hospital & Research Institute from 8thMarch,2019 to 7th March, 2021. Total 2531 patients were included. The study populations were divided into two groups. Group I: Acute STEMI patients presenting during pre COVID period (n=1385). Group II: Acute STEMI patients presenting during COVID period (n=1146). COVID period was calculated from 8th march, 2020 onward as first case of COVID -19 was detected on that day in Bangladesh. All patients presented with Acute STEMI was included in the study however NSTEMI-ACS, Unstable angina were excluded from the study. Result(s): Male was predominant in both groups. Regarding risk factors Hypertension, Obesity and family H/O of CAD was statistically significant (p<0.05). Acute STEMI patients presented lately during COVID-19 period probably due to lock down& lack of transport facility. Regarding coronary artery disease severity, vessel score was more during COVID period. SV-CAD were more during pre COVID period while DV-CAD & TV-CAD were more during COVID period. Gensini score was also calculated among the study populations, it was 57.21+/-28.42 and 63.16+/- 40.43respectively in group I and group I, which was statistically significant. Regarding treatment options of the patients, primary PCI was less during COVID period, however medical management, elective PCI and Thrombolysis were more during COVID era. Regarding in hospital outcome, acute LVF, cardiogenic shock were more during COVID period which were also statistically significant. [Formula presented] [Formula presented] Conclusion(s): During COVID -19, STEMI patients presented lately in comparison to pre COVID period. Coronary artery Disease were more severe during COVID period as evaluated by Vessel Score & Gensini Score. During COVID -19 period majority of patients got medical management& routine PCI were done more in comparison to primary PCI. In Hospital outcome of STEMI was worse during COVID-19 period in terms of acute LVF & cardiogenic shock. [Formula presented] [Formula presented] [Formula presented]Copyright © 2023

Effect of COVID-19 Pandemic on Acute Coronary Syndrome Clinical Practice Patterns: Findings from a Multicenter Clinician Survey in China

Background: The coronavirus disease 2019 (COVID-19) pandemic has severely affected healthcare systems around the world. This study aimed to investigate the perceptions of cardiologists regarding how the COVID-19 pandemic has affected the clinical practice patterns for acute coronary syndrome (ACS). Method(s): A multicenter clinician survey was sent to 300 cardiologists working in 22 provinces in China. The survey collected demographic information and inquired about their perceptions of how the COVID-19 pandemic has affected ACS clinical practice patterns. Result(s): The survey was completed by 211 (70.3%) cardiologists, 82.5% of whom were employed in tertiary hospitals, and 52.1% reported more than 10 years of clinical cardiology practice. Most respondents observed a reduction in ACS inpatients and outpatients in their hospitals during the pandemic. Only 29.9% of the respondents had access to a dedicated catheter room for the treatment of COVID-19-positive ACS patients. Most respondents stated that the COVID-19 pandemic had varying degrees of effect on the treatment of acute ST-segment elevation myocardial infarction (STEMI), acute non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina. Compared with the assumed non-pandemic period, in the designed clinical questions, the selection of coronary interventional therapy for STEMI, NSTEMI, and unstable angina during the COVID-19 pandemic was significantly decreased (all p < 0.05), and the selection of pharmacotherapy was increased (all p < 0.05). The selection of fibrinolytic therapy for STEMI during the pandemic was higher than in the assumed non-pandemic period (p < 0.05). Conclusion(s): The COVID-19 pandemic has profoundly affected ACS clinical practice patterns. The use of invasive therapies significantly decreased during the pandemic period, whereas pharmacotherapy was more often prescribed by the cardiologists. Copyright: © 2022 The Author(s).

THE PROGNOSTIC VALUE OF THE BIOLOGICAL PROFILE OF INFLAMMATION AND COAGULATION AT HYPERTENSIVE PATIENTS AFTER COVID-19

Objective: The objective of the study was to estimate how the proinflammatory and prothrombotic imbalances correlates with cardiovascular and renal events at hypertensive patients (pts) after Covid-19. Design and method: 40 hypertensive pts, (mean age 58.5 ± 9.6 years, 52.5% males)=group 1 and 40 hypertensive pts recovered after Covid-19, matched for age and sex (mean age 60.4 ± 10.8 years, 55% males)=group 2. Inflammation profile was estimated by serum measurement of C reactive protein (CRP), ferritin (F), interleukin 6 (IL6) and fibrinogen (Fb). Prothrombotic profile was determined by serum measurement of D-Dimer (DD). All pts were evaluated during one year, in order to detect the following complications: unstable angina (UA), non-STsegment elevation myocardial infarction (NSTEMI), ischemic stroke (IS), renal dysfunction (RD): microalbuminuria, proteinuria, chronic kidney disease. Results: In group 1, UA was significantly associated with higher level of CRP (2.25 ± 0.65 mg/L vs 7.32 ± 1.18 mg/L, p = 0.04). In the same group, RD was found in a higher proportion at pts with increased CRP (2.10 ± 0.56 mg/L vs 8.11 ± 1.21 mg/L, p = 0.02). In group 2, UA was also significantly associated with higher level of CRP (3.44 ± 0.62 mg/L vs 9.68 ± 1.15 mg/L, p = 0.03) and with greater proportion of DD (0.35 ± 0.08 mcg/ml vs 1.53 ± 0.12 mcg/ml, p = 0.01). NSTEMI was found in a higher proportion at pts with increased DD (0.42 ± 0.07 mcg/ml vs 1.87 ± 0.15 mcg/ml, p = 0.01). In the same group, RD was significantly more frequent at pts with higher level of IL6 (4.55 ± 0.92 pg/ml vs 8.32 ± 0.85 pg/ml, p = 0.04) and with greater level of F (76 ± 15 ng/ml vs 635 ± 26 ng/ml, p = 0.01). Conclusions: Proinflammatory status seems to predict a worse midterm outcome (one year) concerning cardiovascular and renal events at hypertensive pts, especially after Covid-19. Moreover, proinflammatory and prothrombotic imbalances appears to have more powerful midterm prognostic value for incidence of acute coronary syndromes without ST-segment elevation and for incidence of RD at hypertensive pts recovered after Covid-19.

A Prospective Longitudinal Assessment of Nutrition in the FDNY World Trade Center-Exposed Cohort: An Update

RATIONALE Metabolic syndrome phenotypic characteristics and nutritional intake are modifiable biomarkers of particulate matter (PM) associated aerodigestive and cardiovascular disease. Nutritional questionnaires, such as the Rapid Eating Assessment for Participants (REAP-S), can assess the dietary phenotype of our FDNY World Trade Center-Health Program (WTC-HP) cohort. METHODS Cardiovascular disease (CVD) included myocardial infarction, stroke, unstable angina, coronary artery surgery/angioplasty, or CVD related death. Gastroesophageal reflux disease (GERD) cases were WTC-certified cases. WTC-Lung Injury (WTC-LI) was defined as FEV1<LLN at any time point after 9/11. REAP-S was deployed in the WTC-HP annual monitoring assessment. Clinical and REAP-S data accrued from March, 2018 to October, 2021. Scores (ranging 15-39) were categorized into low-dietary [15-19], moderate-dietary [20-29], and high-dietary [30-39] quality. REAP-S questions were assessed as distinct food categories. Mean± standard deviation (SD) expressed as continuous variables. Student t-tests compared clinical data of those with and without disease. One-way ANOVA was used in a subgroup analysis. Arrival time data, used as a proxy for WTC-particulate matter (WTC-PM) exposure, was a dichotomous variable. RESULTS Subjects (N=3,508) completed REAP-S after the database lock date(July 17, 2019) for our prior publication. Mean REAP-S score for the overall cohort(N= 4,073) was 26.48±4.61. CVD patients, had a mean REAP-S score of 26.51±4.43, age (years) at 9/11 was 44.62±7.02, and BMI (kg/m2) was 30.25±4.41. GERD patients, had a mean REAP-S score of 26.50±4.61, age at 9/11 was 41.03±6.95, and BMI was 29.91±4.32. WTC-LI subjects had a mean REAP-S of 26.40±4.39, age of 40.52±7.13, and BMI was 30.31±4.92. When WTC-LI subjects were categorized into dietary quality groups, it was found that their BMI significantly differed from each other, p=0.034. Subjects that complete their questionnaire after July 17, 2019-prior data lock date, had significantly lower mean REAP-S when compared to those with pre-July 17, 2019 data;26.01±4.46 vs 29.43±4.39 respectively, p<0.001. When comparing those with or without CVD or GERD, there was no significance between their average REAP-S score. CONCLUSIONS The implementation of REAPS into the FDNY WTC-HP annual questionnaire remains successful. Continued accrual of data of these unique dietary phenotypes within our cohort will further enrich our longitudinal data set. While it is unclear why more recent REAP-S data is significantly different, possible contributors include societal and clinical stressors such as aging, COVID-19, and confounding comorbidities. Future studies could focus on further defining and intervening on these risk factors to more positively impact on WTC-aerodigestive and cardiovascular disease.

Trends, Treatment Approaches, and In-Hospital Mortality for Acute Coronary Syndrome in Japan During the Coronavirus Disease 2019 Pandemic.

AIM: The coronavirus disease 2019 (COVID-19) pandemic has left negative spillover effects on the entire health care system. Previous studies have suggested significant declines in cases of acute coronary syndrome (ACS) and primary percutaneous coronary intervention (PCI) during the COVID-19 pandemic. METHODS: We performed a quasi-experimental, retrospective cohort study of ACS hospitalisations by using a multi-institutional administrative claims database in Japan. We used interrupted time series analyses to ascertain impacts on cases, treatment approaches, and in-hospital mortality before and after Japan's state of emergency to respond to COVID-19. The primary outcome was the change in ACS cases per week. RESULTS: A total of 30,198 ACS cases (including 21,612 acute myocardial infarction and 8,586 unstable angina) were confirmed between 1st July 2018 and 30th June 2020. After the state of emergency, an immediate decrease was observed in ACS cases per week (-18.3%; 95% confidence interval, -13.1 to -23.5%). No significant differences were found in the severity of Killip classification (P=0.51) or cases of fibrinolytic therapy (P=0.74). The impact of the COVID-19 pandemic on in-hospital mortality in ACS patients was no longer observed after adjustment for clinical characteristics (adjusted odds ratio, 0.93; 95% confidence interval, 0.78 to 1.12; P=0.49). CONCLUSIONS: We demonstrated the characteristics and trends of ACS cases in a Japanese population by applying interrupted time series analyses. Our findings provide significant insights into the association between COVID-19 and decreases in ACS hospitalisations during the pandemic.

Impact of the COVID-19 pandemic on admission of acute coronary syndrome patients: A local insight from iSTEMI registry

Aims: Despite the spike in COVID-19 hospitalizations, the number of acute coronary syndrome (ACS) admissions has declined significantly. It raises concerns about the long-term consequences of cardiovascular problems. This study aims to provide new insights into our awareness of the pandemic situation in ACS settings. Methods: We performed a single centre retrospective analysis of 397 patients from iSTEMI Registry between March-October 2019 (Pre-COVID-19 pandemic) and March-October 2020 (COVID-19 pandemic) with ACS (i.e., unstable angina (UA), non- ST-segment elevation myocardial infarction (NSTEMI), and STEMI). We analyzed case fatality rate, delay to First Medical Contact (FMC), and troponin findings. Results: The number of ACS patients admissions in March-October 2019 (254 patients) and 2020 (143 patients) had significantly reduced by 43.7%. Admission of ACS significantly dropped for STEMI (35.76%, p=0.048) and NSTEMI (65.70%, p=0.001), but not for UA (31.90%, p=0.262). There was non-significant case fatality rate between-group of STEMI (p=0.168), NSTEMI (p=0.388), or UA (p=0.343). We found a significant delay to FMC during pandemic (39.8%, p=0.000) and correlated with the higher troponin I level (30,6%, p=0.001). Conclusion: This study reveals that local conditions in our institution are similar to the other centers during the COVID-19 pandemic. In parallel to the COVID-19 burden, we will have to deal with the morbidity and mortality caused by delays in FMC and patients severity in the future. Further studies are needed to analyze the factors that decreased ACS patients' admission.

A severe case of bilateral COVID-19 pneumonia with concurrent ischemic stroke and myocardial infarction

Looking at the recent data provided in literature, we can see an association between cardiovascular and cerebrovascular accidents in COVID-19 thought to be related to severe inflammation and prothrombotic environment caused by the virus. This article reports a patient presenting with typical signs and symptoms of SARS-CoV-2 infection including flu like symptoms and respiratory distress. Initially a chest CT was performed that showed characteristic findings of atypical pneumonia caused by SARS-CoV-2 virus which was later confirmed with a nasopharyngeal PCR positive for COVID-19. During the course of admission patient developed unstable angina. Further testing confirmed an acute ST elevation myocardial infarction. While on anticoagulant treatment, patient showed signs of cerebrovascular accident. An emergency brain CT was ordered which did not yield any significant changes supporting our clinical diagnosis. Further diagnostic workup using magnetic resonance imaging disclosed evidence of cerebral ischemia in medial cerebral artery territory. Our study suggests that prophylactic anticoagulant regiment is not reassuring in COVID-19 patients and close observation and vigilance, can help clinicians to act timely and can improve patient survival.

First Interim Analysis of the Italian Dante Study: De-Escalation before Treatment-Free Remission in Patients with Chronic Myeloid Leukemia Treated with First-Line Nilotinib

Introduction: Treatment-free remission (TFR) in chronic myeloid leukemia (CML) is demonstrated to be achievable and recommended for patients (pts) in sustained deep molecular response (sDMR) who can discontinue tyrosine kinase inhibitor (TKI) treatment and maintain responses in ~50% of cases. While the feasibility and safety of TKI cessation have been largely demonstrated, the strategies of TFR optimization are yet to be clarified. Studies (eg. DESTINY) investigating de-escalation, mainly after imatinib, suggested that a stepwise approach may favor TFR outcome. We present the interim results of the phase 2, prospective, multicenter DANTE study (NCT03874858) evaluating de-escalation and TFR in Italian pts with CML in chronic phase (CML-CP) treated with nilotinib (NIL). Methods: Adults with CML-CP treated with NIL 300 mg twice daily (bid) in first-line for ≥3 years who achieved sDMR for ≥1 year (≥MR 4.0;BCR-ABL level ≤0.01% IS) were enrolled in 27 centers. The study consisted of 4 phases: screening (week [wk] −4-0), consolidation (wk 0-48), TFR (wk 48-144), and follow-up (until wk 144). Ongoing treatment with ≥400 mg/day dose was allowed at study entry. During consolidation, pts were treated with NIL 300 mg once daily (qd). At the end of consolidation phase, pts with sDMR entered TFR phase and discontinued NIL;indeed, pts with at least major molecular response (MMR;BCR-ABL ≤0.1% IS), but without sDMR, continued NIL 300 mg qd. At any time, pts with loss of MMR returned to NIL 300 mg bid. During TFR phase, BCR-ABL levels were monitored monthly from wk 52-96, and then every 3 months. Pts on half-dose or full-dose NIL were monitored every 3 months. The primary endpoint is the percentage of pts in full treatment-free remission (FTFR) 96 wks after the start of consolidation phase. FTFR is defined as pts with MMR or better, including those who remained in discontinuation during TFR phase and those who are treated with half the standard dose. Key secondary endpoints include percentage of pts with sDMR at wk 48;TFR rate at wk 96 and 144;BCR-ABL kinetics and safety. The predictive role of digital droplet PCR is also evaluated as an exploratory objective. Results: Overall, 113 pts were screened and 107 entered consolidation phase. This interim analysis included 52 pts who reached the end of consolidation phase by data cut-off period (February 8, 2021). Of these 52 pts, 49 (94.2%) were ongoing by data cut-off and 3 (5.8%) discontinued the study (1 patient due to adverse event (AE) and 2 per patient's decision). Median age at study entry was 49.5 years. Median time from diagnosis was 5.6 years and median dose of prior NIL treatment was 600 mg/day for all pts except one who was on NIL 450 mg/day at baseline. Median duration of last sustained MR4 and MR4.5 were 30 and 16.5 months, respectively. Further details are listed in Table 1. At screening, molecular response categories were MR4.0 in 13.7%, MR4.5 in 23.1% and undetectable MR4.5 in 63.5% of pts. During consolidation phase, 5 (9.6%) pts discontinued prematurely: 2 pts restarted NIL full dose (3.8%) for MMR loss, 2 (3.8%) discontinued for AEs and 1 (1.9%) for pt decision. Overall, 47 pts completed consolidation: of them 40 (76.9%) sustained DMR and 7 (13.5%) maintained MMR but not sDMR. Of the 7 pts not sustaining DMR during consolidation, 6 regained DMR after a median of 4.4 months, while 1 pt was still in MMR by data cutoff. The 2 pts who lost MMR after 5 and 8 months regained MMR and 1 regained DMR by data cutoff after increasing NIL to 300 mg bid. Median time spent in consolidation phase was 11.7 months, and the evolution of response categories over time is shown in Figure 1. During consolidation phase, AEs were observed in 16 pts (30.8%), of them 2 (3.8%) pts had serious AEs: 1 patient had skin ulcers and COVID-19 related pneumonia, while 1 patient had unstable angina. No deaths and disease progressions were observed. Conclusions: DANTE is the first study that showed the safety and feasibility of NIL de-escalation before TFR in CML-CP pts with sDMR. Inter m results suggest that loss of MMR during de-escalation is rare. De-escalation strategy may lead to further improvement of TFR outcome and tolerability and may also preemptively support the identification of pts who may not be ready for discontinuation, with a tailored approach. To date, accuracy in predicting TFR outcome is still low, and the de-escalation setting may sharpen biological and clinical predictive factors, including the potential role of digital PCR. [Formula presented] Disclosures: Breccia: Abbvie: Honoraria;Pfizer: Honoraria;Novartis: Honoraria;Incyte: Honoraria;Bristol Myers Squibb/Celgene: Honoraria. Abruzzese: Incyte: Consultancy, Honoraria;Novartis: Consultancy, Honoraria;Pfizer: Consultancy, Honoraria;Bristol Myers Squibb: Consultancy, Honoraria. Stagno: InCyte: Consultancy, Honoraria;Pfizer: Consultancy, Honoraria, Other: Support for attending meetings and/or travel;Novartis: Consultancy, Honoraria, Other: Support for attending meetings and/or travel, Research Funding. Iurlo: Incyte: Speakers Bureau;Novartis: Speakers Bureau;Pfizer: Speakers Bureau;Bristol Myers Squibb: Speakers Bureau. Sportoletti: AstraZeneca: Consultancy, Honoraria;Janssen: Consultancy, Honoraria;AbbVie: Consultancy, Honoraria. Lemoli: Jazz, Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau;AbbVie, Daiichi Sankyo, Servier: Honoraria, Speakers Bureau;Celgene: Other: Support for attending meetings and/or travel. Siragusa: Novartis, CSL, Behring, Amgen, Novonoridsk, SOBI, Bayer: Consultancy, Honoraria, Speakers Bureau. Chiodi: Novartis: Current Employment.

Acute coronary syndrome in COVID-19 patients

Acute coronary syndrome (ACS) is caused by an acute mismatch between myocardial oxygen demand and its supply. This mechanism is largely associated with the progression of coronary atherosclerosis in combination with an inflammatory response, hypoxemia, and blood procoagulation. Patients with the coronavirus disease 2019 (COVID-19), aggravated by cardiovascular diseases and comorbidities, are at high risk of ACS. Aim. To analyze the publications, which reflects the development of ACS in patients with COVID-19, its pathogenesis, and clinical course. Material and methods. Literature data were searched using Google Scholar, PubMed, ScienceDirect, and Cyberleninka services. The analysis included data from clinical guidelines on COVID-19, data from clinical studies, reports, and systematic reviews. Results. This literature review summarizes and systematizes the data presented in modern publications, highlights the aspects of the clinical course and pathogenetic mechanisms underlying ACS in patients with COVID-19. Conclusion. The pathogenesis of COVID-19 is inextricably associated with the widespread cytopathic effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), uncontrolled immune response that causes systemic inflammation, as well as the coagulation system activation. In patients with COVID-19, along with the atherosclerosis, these mechanisms significantly increase the risk of ACS and can worsen its in-hospital course.

Clinical profile and in hospital mortality of invasively managed patients with suspicion of acute coronary syndrome during the COVID-19 pandemic

Background: The pandemic of COVID-19 significantly changed the treatment of patients with suspicion of ACS and COVID-19 infection. Access to cardiology department and possibility of invasive diagnosis and treatment of ACS are still significantly impaired. Aim: Our aim was to evaluate the characteristic and prognosis of patients with suspicion of ACS and COVID-19 infection. Materials and methods: Our department of cardiology was transformed for Covid unit and was dedicated for diagnosis and treatment of patients with suspicion of ACS. COVID-19 confirmed cases were defined by a positive SARS-CoV-2 polymerase chain reaction (PCR) test. From 14th of October 2020 to 14th of March we performed 39 coronary angiographies. We included 39 patients (27 men) with mean age 69±8.5. In that group 11 patients had NSTEMI, 10 patients had STEMI, 2 patients Tako-Tsubo and 16 unstable angina. All patients underwent coronary angiography, and in 27 patients we performed PCI. Results: In hospital mortality rate was 35% (14 patients). Cardiac arrest was present in 3 (8%) patients and cardiogenic shock in 4 (10%) patients. The rate of NSTEMI was higher in patients who died 7 vs 4 (p=NS) and STEMI were comparable in both groups 4 vs 6, (p=ns). The IL 6 levels in patients who died were 389±278pg/mL, in compare to 101±93pg/mL (p=0.3) who survived. Independent predictors of death were: sex with the OR=1,1 (95% CI: 0.6-2.4), p=0,03 and IL-6 level on admission OR=1,4 (95% CI: 0.6-2.4), p=0,04. There were no statistically significant differences regarding age, left ventricle ejection fraction, CRP levels and oxygen saturation od admission. Conclusion: This study confirms the higher risk of death in patients with ACS and SARS-CoV-2. In the multivariable analysis only sex and Il-6 level on admission were the independent risk factors of the in hospital death. Further investigations of the underlying physiopathological relations between COVID-19 and ACS are needed.

Acute coronary syndrome outside and during the COVID-19 pandemic

Objective: To analyze the register of patients with acute coronary syndrome (ACS) at the clinical cardiological dispensary from september to november 2018-2019 and 2020 during COVID-19. Materials and methods: A retrospective study was conducted, the registry included 952 patients with ACS in 2018 and 1033 patients in 2019, as well as 964 patients in 2020 during the COVID-19 pandemic. Statistical analysis of the material was performed using the Statistica 11.0 software. Results: When analyzing the provision of specialized care to patients with ACS in 2018, the average age of patients was 67 years, the mortality rate was 3.94%. The structure of ACS in 2018 was dominated by patients with ST-segment elevation myocardial infarction (STEMI) - 47%, myocardial infarction without ST-segment elevation (STEMI) occurred in 23%. The proportion of patients with unstable angina pectoris (NS) was 30%. Only 43.6% were registered with coronary heart disease (CHD) before ACS. 12.5% had a history of diabetes mellitus (DM), 31.2% had arterial hypertension (AH). This cardiovascular event recurred in 4% of patients. Average bed-days 9.73. In 2019, the average age of patients was 68 years, the mortality rate was 4.35%. In the structure of ACS in 2019, patients with STEMI were more common 47.5% than with STEMI 28%. The proportion of patients with HC was 24.5%. 52.1% of patients were registered at the dispensary before ACS with a diagnosis of coronary artery disease. A history of diabetes mellitus was in 13.0%, AH in 39.6% of patients. For 3.8% of patients, myocardial infarction in 2019 became recurrent. The average bed-days was 9.92. In 2020, the average age of patients was 66 years, the mortality rate was 6.25%. The structure of patients was dominated by patients with STEMI - 50.5%, STEMI was less common - in 17.5%. The proportion of patients with unstable angina pectoris was 32%. It was revealed that 54.4% were registered in the dispensary before ACS with coronary artery disease. 28.5% had a history of diabetes mellitus, 40.8% - AH. This event was repeated for 4.7% of patients. Average rate, bed-days rate is 8.85. Conclusions: Initial analysis reveals that the group of patients with ACS in 2020 was younger than the group of patients in 2019-2020. ACS in combination with diabetes during the pandemic occurred 2 times more often than in the same period of 2018-2019. The proportion of patients registered with the dispensary increased over the period 2018-2019-2020, however, the mortality rate in the 2020 group had a clear upward trend, which may be due to various reasons, incl. the COVID-19 pandemic. The average number of bed-days also objectively decreased when comparing the 2020 and 2019-2018 patient cohorts, which may be due to the burden on the healthcare system during the pandemic.

The global effect of Covid-19 on acute coronary syndromes management

Aim: Covid-19 has had a dramatic impact on the healthcare systems globally. Despite efforts to maintain systems of cardiovascular care during the pandemic, public health responses to the virus have contributed to adverse cardiovascular outcomes. Herein, we summarize current evidence detailing the impact of Covid-19 on interventional cardiology. Methods: According to PRISMA criteria, a systematic review was performed through Medline, Embase, and Cochrane databases, to identify reports on the impact of Covid-19 on interventional cardiovascular procedures. We identified 50 published studies that met the prespecified inclusion and exclusion criteria. Results: In the acute setting, several datasets report a reduction of acute coronary syndrome (ACS) admission by 40% globally (-40%, 95% CI 37-43 from the National Health Service hospital trusts in England). Most surveys and registries reported a numerically higher impact on NSTEMI/unstable angina cases compared to STEMI (-42%, 95% CI 38- 46 and -23%, 95% CI 16-30 respectively, from the National Health Service hospital trusts in England). In STEMI care pathways, several studies report increased delays between symptom onset and first medical contact (105 min, 95% CI 45-222 during the pandemic vs 71 min, 95% CI 30-180 before it, p<0.001, from the National STEMI registry in Spain), with a subsequent increased duration of the ischaemic period (200 min, 95% CI 140-332 during the pandemic vs 233 min, 95% CI 150-375 before it, p<0.001, from the National STEMI registry in Spain). Importantly, hospital door-to-balloon times were unchanged. Most studies suggest similar in-hospital mortality for STEMI during the pandemic compared to historic controls (1.7% vs 1.8%, p=0.67 from British National Institute of Cardiovascular Outcomes Research database). An increased incidence of mechanical complications were observed (41.2% vs 19.6%, p=0.030, from an Italian monocentric experience). In the United States (New York city), overall mortality from ischemic heart diseases depicted a 2-fold increase during the pandemic (relative change 2.39, 95% CI 1.39-4.09). Of note, in the same city home deaths increased from 35/day in 2013-2017 to 200/day during the pandemic. These data suggest that ACS incidence has not decreased, but more likely patients presenting ischemic symptoms may have not contacted health care services, and have died at home. Conclusions: The Covid-19 pandemic has adversely impacted outcomes in patients with ischemic heart disease (IHD). The diagnosis and treatment of IHD should be designated a health system priority that remains intact during pandemic events as the magnitude of harm induced by its interruption is substantial.

The identification of predictors and characteristics of the course of ACS in patients undergoing COVID-19

COVID-19 pandemic is a global public health burden, which has a rather negative effect on patients with cardiovascular pathology, especially with ischemic heart disease. The aim of this study is to identify predictors that contribute to the onset or development of ACS in patients who have had COVID-19 Methods: This was a three-center prospective study, conducted in the coronary care unit of two medical centers and the Institute of Cardiology in Armenia during the period of February 2020 to February 2021. This study included 393 patients with acute coronary syndrome (ACS) patients who underwent COVID-19 at different times of this period (I group). For comparison, the data of similar 297 patients were analyzed in the period from February 2018 to February 2019 from the same centers without COVD (II group). Admissions were classified as ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), or other ACS (including unstable angina). Medical history, clinical, instrumental and laboratory data were studied in all patients. The data obtained was analyzed for statistical significance using multivariate analyses by SPSS 16. Results: The compared results showed that the number of I group patients with NSTEMI was significantly higher than in the second group (67% vs 49%). The most common complications include arrhythmia (atrial fibrillation, ventricular tachyarrhythmia, and ventricular fibrillation) also increased in first group. Atrial fibrillation (AF) in I group was detected in 12.7% of cases, especially in those patients who have had lung damage and accompanied by more severe hemodynamic disorders. In II group AF was detected in 8.1% cases. Patients have a history of arterial hypertension (AH) and diabetes (D) in I group patients were detected in 79.3% and 28.3% of cases respectively, and in II group in 67.8% and 21.2% cases. Heart failure (HF) occurred in 1 group more often than in II group patients (47% vs 34%). In I group the age of patients was significantly higher than in group II (73±8.6 vs. 69±9.9 p<0.013). Analysis of coronary angiography data showed that, multivessel coronary vessels in I group patients was observed more often than in second group (16.8% vs 7.9%). Conclusions: The results of the present study revealed that older age, AH, diabetes and HF are predictors of ACS in patients with COVID-19. These patients more often develop NSTEMI and are characterized by multivessel coronary artery disease. Among the complications, heart rhythm disturbances, especially AF, are more common.

Association between public media and trends in new acute coronary syndrome presentations during the first COVID­19 wave in the Netherlands.

BACKGROUND: We aimed to evaluate the association between public media and trends in new presentations of acute coronary syndrome (ACS) during the first wave of the coronavirus disease 2019 (COVID­19) in the Netherlands. METHODS: New ACS presentations per week in 73 hospitals during the first half of 2019 and 2020 were retrieved from the national organisation Dutch Hospital Data and incidence rates were calculated. Stratified analyses were performed by region, type of ACS and patient characteristics. RESULTS: After the first confirmed COVID­19 case and during lockdown, numbers declined by up to 41% (95% confidence interval (CI): 36-47%) compared to 2019. This reduction was more pronounced for non-ST-segment elevation myocardial infarction (NSTEMI) (48%; 95% CI: 39-55%) and unstable angina (UA; 50%; 95% CI: 40-59%) than for STEMI (34%; 95% CI: 23-43%). There was no association between ACS and COVID­19 incidence rate per region. After the steep decline, a public campaign encouraged patients not to postpone hospital visits. Numbers then increased, without a rebound effect. Trends were similar irrespective of sex, age or socio-economic status. During the outbreak, compared to coronary artery bypass graft procedures, relatively more (acute) percutaneous coronary interventions for NSTEMI and UA were performed. CONCLUSION: New ACS presentations decreased by up to 41%. Lockdown measures and public campaigns, rather than COVID­19 incidence, were associated with significant changes in new ACS presentations. Even though causality cannot be established, this emphasises the role of the public media and healthcare organisations in informing patients to prevent underdiagnoses of ACS and associated health damage.