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BackgroundConsideration is needed when using Janus kinase (JAK) inhibitors to treat RA in pts aged ≥65 years or those with cardiovascular (CV) risk factors. The JAK1 preferential inhibitor FIL was generally well tolerated in clinical trials[1];safety has not been determined in a real-world setting.ObjectivesTo report baseline characteristics and up to 6-month safety data from the first 480 pts treated with FIL in the FILOSOPHY study (NCT04871919), and in two mutually exclusive subgroups based on age and CV risk.MethodsFILOSOPHY is an ongoing, phase 4, non-interventional, European study of pts with RA who have been prescribed FIL for the first time and in accordance with the product label in daily practice. Baseline characteristics and the incidence of select adverse events (AEs) are assessed in pts aged ≥65 years and/or with ≥1 CV risk factor (Table 1), and in those aged <65 years with no CV risk factors.ResultsAs of the end of June 2022, 480 pts had been treated: 441 received FIL 200 mg and 39 received FIL 100 mg. Of the 480 pts, 148 (30.8%) were aged ≥65 years;332 (69.2%) were aged <65 years. In total, 86 (17.9%) were former smokers, 81 (16.9%) were current smokers and 203 (42.3%) were non-smokers (data were missing for 110 pts [22.9%]). In addition to smoking, the most frequent CV risk factors included a history of hypertension (32.3%), a history of dyslipidemia (10.2%) and a family history of myocardial infarction (8.5%;Table 1).23 pts (4.8%) discontinued treatment due to AEs. Of the 354 pts aged ≥65 years or with ≥1 CV risk factor, infections affected 64 pts (18.1%), 34 (9.6%) had COVID-19, 2 (0.6%) had herpes zoster, and cardiac disorders (angina pectoris, atrial fibrillation, palpitations and tachycardia) affected 5 pts (1.4%);no cases of malignancies were observed. In the subgroup aged <65 years and with no CV risk factors (n=126), infections occurred in 18 pts (14.3%) (9 [7.1%] had COVID-19;3 [2.4%] had herpes zoster) and malignancies (myeloproliferative neoplasm) affected 1 pt (0.8%);no pts had cardiac disorders. There were no cases of deep vein thrombosis or pulmonary embolism in either subgroup.ConclusionIn this interim analysis of FILOSOPHY, no unexpected safety signals emerged at up to 6 months. Although infections and cardiac disorders affected a numerically greater proportion of pts aged ≥65 years or with ≥1 CV risk vs those aged <65 years with no CV risk, longer follow-up on a broader cohort is necessary to further characterize the safety of FIL in different groups of pts with RA.Reference[1]Winthrop K, et al. Ann Rheum Dis 2022;81:184–92Table 1.Baseline characteristics and CV risk factorsBaseline demographics/CV risk factorsAll FIL-treated pts (N=480)≥65 years or with ≥1 CV risk factor (n=354)<65 years and no CV risk factor (n=126)*Female sex, n (%)351 (73.1)252 (71.2)99 (78.6)Age, years, mean (SD)57.6 (11.5)60.4 (10.8)49.6 (9.6)Rheumatoid factor positive, n (%)†228 (47.5)167 (47.2)61 (48.4)Anti-citrullinated protein antibody positive, n (%)‡243 (50.6)176 (49.7)67 (53. 2)Body mass index, kg/m2, mean (SD)27.6 (5.7) n=43728.0 (5.4) n=33126.3 (6.4) n=106RA disease duration, years, mean (SD)10.4 (9.4) n=47810.5 (9.5) n=35310.0 (8.8) n=125Tender joint count 28, mean (SD)8.6 (6.9) n=4578.7 (7.1) n=3408.3 (6.3) n=117Swollen joint count 28, mean (SD)5.6 (5.2) n=4525.7 (5.4) n=3365.4 (4.4) n=116Former smoker, n (%)§86 (17.9)86 (24.3)0Current smoker, n (%)§81 (16.9)81 (22.9)0Non-smoker, n (%)§203 (42.3)130 (36.7)73 (57.9)Family history of myocardial infarction, n (%)41 (8.5)41 (11.6)0Medical history of: n (%) CV disease33 (6.9)33 (9.3)0 Diabetes35 (7.3)35 (9.9)0 Dyslipidemia49 (10.2)49 (13.8)0 Hypertension155 (32.3)155 (43.8)0 Ischemic CNS vascular disorders11 (2.3)11 (3.1)0 Peripheral vascular disease17 (3.5)17 (4.8)0*Includes 53 pts with missing smoking status data who were aged <65 years with no other CV risk factors.†Missing/unknown in 154 pts;‡Missing in 153 pts;§Smoking status data missing in 110 pts (22.9%).AcknowledgementsWe thank the physicia s and patients who participated in this study. The study was funded by Galapagos NV, Mechelen, Belgium. Publication coordination was provided by Fabien Debailleul, PhD, of Galapagos NV. Medical writing support was provided by Debbie Sherwood, BSc, CMPP (Aspire Scientific, Bollington, UK), and funded by Galapagos NV.Disclosure of InterestsPatrick Verschueren Speakers bureau: AbbVie, Eli Lilly, Galapagos, Roularta, Consultant of: Celltrion, Eli Lilly, Galapagos, Gilead, Nordic Pharma, Sidekick Health, Grant/research support from: Galapagos, Pfizer, Jérôme Avouac Speakers bureau: AbbVie, AstraZeneca, BMS, Eli Lilly, Galapagos, MSD, Novartis, Pfizer, Sandoz, Sanofi, Consultant of: AbbVie, Fresenius Kabi, Galapagos, Sanofi, Grant/research support from: BMS, Fresenius Kabi, Novartis, Pfizer, Karen Bevers Grant/research support from: Galapagos, Susana Romero-Yuste Speakers bureau: AbbVie, Biogen, BMS, Lilly, Pfizer, Consultant of: Sanofi, Lilly, Grant/research support from: Lilly, MSD, Roberto Caporali Speakers bureau: AbbVie, Amgen, BMS, Celltrion, Eli Lilly, Galapagos, Janssen, MSD, Novartis, Pfizer, Sandoz, UCB, Consultant of: AbbVie, Amgen, BMS, Celltrion, Eli Lilly, Fresenius Kabi, Galapagos, Janssen, MSD, Novartis, Pfizer, Roche, Sandoz, UCB, Thomas Debray Consultant of: Biogen, Galapagos, Gilead, Francesco De Leonardis Employee of: Galapagos, James Galloway Speakers bureau: AbbVie, Biogen, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, Roche, UCB, Consultant of: AbbVie, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, Grant/research support from: AstraZeneca, Celgene, Gilead, Janssen, Medicago, Novavax, Pfizer, Monia Zignani Shareholder of: Galapagos, Employee of: Galapagos, Gerd Rüdiger Burmester Speakers bureau: AbbVie, Amgen, BMS, Chugai, Galapagos, Lilly, Pfizer, Sanofi, Consultant of: AbbVie, Amgen, BMS, Galapagos, Lilly, Pfizer, Sanofi.
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Kounis syndrome is defined by the appearance of acute coronary events associated to anaphylactic symptoms. The pathophysiological mechanism is still uncertain, however, coronary vasospastic activity secondary to a hypersensitivity type I response is postulated as a triggering factor. In the con-text of an accident due to a massive bee's attack, poisoning syndrome also occurs, where the poison components directly damage the myocardium. Kounis syndrome has been reported in SARS-CoV-2 infection, opening the possibility of other mechanisms, among which the cytokine storm stands out. This narrative review aims to consider the mechanisms of damage in Kounis syndrome secondary to poisoning by a massive bee attack and its relationship with the development of short-term complications.Copyright © 2023 Universidad de Antioquia.
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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.
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Clinical Information Patient Initials or Identifier Number: SHS Relevant Clinical History and Physical Exam: Mr. SHS was admitted in August 2022 for acute decompensated heart failure secondary to NSTEMI, complicated with ventricular tachycardia (VT). CPR was performed for6 minutes on the day of admission and was subsequently transferred to the Cardiac Care Unit. His hospital stay was complicated with Covid-19 infection(category 2b) which he recovered well from. During admission, he developed recurrent episodes of angina. Physical examination was otherwise unremarkable. His ejection fraction was 45%. Relevant Catheterization Findings: Cardiac catheterization was performed, which revealed significant calcification of left and right coronary arteries. There was a left main stem bifurcation lesion (Medina 0,1,1) with subtotal occlusion over ostial the LAD, receiving collaterals from RCA and 90% stenosis over ostial LCx. RCA was dominant, heavily calcified with no significant stenosis. He was counselled for CABG (Syntex score26) but refused. As he was symptomatic, he was planned for PCI to the left coronary system. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: The left main was engaged with a 7F EBU 3.5guiding catheter via transradial approach. Sion Blue wired into LAD and LCx. IVUS catheter couldn't cross the LAD and LCx lesions, hence we decided for up front rotational atherectomy. Sion blue was exchanged to Rotawire with the assistance of Finecross microcatheter. A 1.5mm burr was used at 180000 rpm. After the first run of rotablation, patient developed chest pain and severe hypotension (BP ranging 50/30). 4 inotropes/vasopressors were commenced. The shock was refractory hence an intraarterial balloon pump was inserted. Symptoms and blood pressure improved. Another 2 runs of atherectomy done (patient developed hypotension after each run). IVUS examination then showed calcification of proximal to mid LAD with an IVUS Calcium score of 3. LAD was further predilated with Scoreflex balloon 3.0/20mm at 8-22ATM. LCx was predilated with Scoreflex balloon 2.0/15mm at 12-14ATM. DCB Sequent Please NEO2.0/30mm was deployed at 7ATM at ostial to proximal LCx. Proximal to mid LAD was stented with Promus ELITE 2.5/32mm at 11ATM, which was then post dilated with stent balloon at 11ATM. Ostial LM to proximal LAD (overlap) was stented with Promus ELITE 4.0/28mm at 11ATM. LMS POT was then done with NC Balloon 4.0/15mm at 24ATM. LCx was rewired and kissing balloon technique with NC balloon 4.0/15mm at 14ATM (LAD) and NC balloon 2.0/10mm at 12ATM (LCx) was done, followed by a final POT with NC balloon 4.0/15mm at 14ATM. Final IVUS showed good MSA. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): This patient developed hemodynamic instability with each rotational atherectomy run, hence we decided not to perform rotablation to the circumflex artery. His hemodynamic condition improved with the use of intra aortic balloon pump. IABP use can reduce procedural event rate and potentially reduce long term mortality in appropriately selected patients who are at high risk of adverse events. He was followed up a month following the procedure and remained asymptomatic. For complex, calcified coronary lesions involving the left main stem, coronary artery bypass graft surgery is an alternative option.Copyright © 2023
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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
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Background: Among many complications of coronavirus disease 2019 (COVID-19) there is a wide range of cardiovascular (CV) problems ranging from mild to severe ones. Even asymptomatic patients and those with mild course of COVID-19 may develop severe CV complications. Factors leading to such state have not been extensively studied so far. Purpose(s): We aimed to assess which factors were linked to the severe complications of COVID-19. Method(s): We included 200 consecutive patients admitted to the Department of Cardiology and Adult Congenital Heart Diseases of the Polish Mother's Memorial Research Institute (PMMHRI) due to post-Covid cardiovascular complications. SARS-CoV2 infection was confirmed with real-life PCR testing. Laboratory tests, 24-hour ECG monitoring and echocardiography were performed in all patients from the investigated group. For the purposes of our study severe complications were defined as: Myocarditis, a decrease of ejection fraction >10% from the pre-disease value, thromboembolic complications, angina pectoris requiring myocardial revascularization and the new onset of atrial fibrillation of supraventricular tachycardia. Some patients presented more than one of the above. Statistical analysis was performed using the software Statistica v.13 (TIBCO Software Inc., Palo Alto, CA, USA). Data were presented as mean +/-SD or median (25th- 75th percentile) for continuous variables and as proportions for categorical variables. Comparisons between groups were performed using Student's t-test for independent variables and the Mann-Whitney U test or chi2 test with Yates's correction, as appropriate. For all calculations p-values <0.05 were considered statistically significant. Result(s): Finally, we included 200 consecutive patients (aged 54+/-16 years, 76 males - 38%), hospitalized for COVID-19 complications after a median 3 (2-6) months following the acute phase of infection. On admission patients presented with dyspnea (23%), impairment of exercise tolerance (47%), chest pain (32%), increase in blood pressure (29%), palpitations (25%), weight loss (13%), brain fog (6%), general malaise (11%), headache (5%), limb pain (13%), swelling (14%). Severe complications of COVID-19 were diagnosed in 31 patients (16%).Taking into consideration symptoms, the presence of severe COVID-19 complications was significantly associated with dyspnoea and deterioration of exercise tolerance. In comparison to patients with mild complications, severe ones were linked to age (the older patients, the higher risk), previous history of heart failure and diabetes mellitus. We did not observe statistically significant differences in severity of complications depending on smoking status (Tables 1 and 2). Conclusion(s): Previous history of heart failure and diabetes mellitus as well as symptoms (dyspnoea and deterioration of exercise tolerance) along with older age are related to more severe complications following COVID- 19.
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Background The Duke Activity Status Index (DASI) questionnaire assesses functional capacity of patients with cardiovascular disease (CVD[1]figure 1.). DASI derives a total score and corresponding METs level. We utilised this questionnaire during COVID-19 when face to face (F2F) functional capacity testing was an unavailable outcome measure for cardiac rehabilitation (CR). Aim To evaluate the correlation between DASI METs and the incremental shuttle walk test (ISWT)and establish if it is a reliable tool to estimate functional capacity in patients with cardiovascular disease (CVD). Methods DASI questionnaire was completed over the phone as part of a subjective assessment. Two ISWTs were performed at a F2F appointment prior to starting class, best of two, taken. Measures were repeated post-CR completion. Results 93 patients, 64.5% male, mean age (SD) 65.3 (9.6) years, assessed at baseline. Patients' presentation: 27% NSTEMI, 24% STEMI, 16% Angina, 13% Heart failure and 20% other. Outcomes pre to post CR are shown in table 1. Correlation between DASI METs and the ISWT at baseline was r= 0.32 [weak positive (p<0.05)] and post-CR was r= 0.67[strong positive (p<0.01)]. The ISWT change was similar to the minimum important difference (MID) 70m in the CHD population. There is no MID for the DASI Conclusions Patients attending CR post-pandemic made significant improvements in both the DASI and ISWT. Correlations became stronger post programme, indicating patients may better self-evaluate physical performance after taking part in CR. DASI questionnaire may be a useful alternative outcome measure when F2F exercise testing is not an option. Future work could explore how to prescribe an exercise programme from this and what might represent a meaningful change in this outcome following CR (Table Presented).
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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.
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An 81-years-old with a history of hypertension, dyslipidemia, and chronic ischemic heart disease with prior stent implantation of right coronary artery in 2011. Due to its poor compliance, no recurrent symptoms, and, finally, the COVID-19 pandemic, the patient did not perform any cardiological follow-up during these years. Unfortunately, the last six months he has reported the onset of dyspnea and typical angina due to moderate efforts, undervalued by the patient. Because of the rapid worsening of dyspnea and typical angina in the last 5 days, he went to the local emergency department (ED). The role in/role out routine exams performed in the ED documented a COVID-19 infection. At the ED, his vital signs were normal, with a blood pressure of 135/75 mm Hg, heart rate of 74 regular beats/min, body temperature of 36.5 degreeC, oxygen saturation of 97% in ambient air, and respiratory rate of 16/ min. Of note, the chest x-ray was normal, as well as no alterations were documented at the CTscan performed a few hours later. First-line blood sample tests were within range except for Hb 10 mg/dl. Therefore, a cardiological evaluation was requested. Electrocardiogram (ECG) showed inverted T-waves in V1-4 leads, and echocardiography showed normal left ventricular ejection fraction (FE 55% Simpson), left ventricular anterolateral wall hypokinesia, and severe aortic stenosis (V max 4.78 m/ s, Gr max 4.78 m/s, Gr medium 59 mmHg). Since myocardial necrosis enzymes were increased (T-hs 118.7 ng/dl;CK-MB 6.3 ng/L;NT-ProBNP 761 ng/dl), leading to the suspicion of acute coronary syndrome the patient underwent coronary angiography, showing critical stenoses of the left descending artery (LAD), circumflex (LCX), I obtuse marginal (IOM), and patent stent of the right coronary artery. Therefore, the Heart team deemed the patient at high operatory risk choosing, in agreement with the patient, for a percutaneous coronary intervention (PCI) followed by TAVR. Accordingly, the patients underwent PCI of LAD with the implantation of a Xience-Serra 3.0x15 mm and PCI of LCX with the implantation of an Onyx 2.75x18 mm stent. After COVID -19 resolution, which happen 7 days later, the patient was moved to our cardiology department. Two days later in the same procedure, we performed the first PCI of I-OM with the implantation of a Xience Sierra 3.0x18 mm stent following a TAVI with the implantation of Evolute Pro valve 29 mm. The postprocedure echocardiogram showed an optimal valve position with a transvalvular mean pressure gradient of 4 mm Hg. After six days post-TAVI, for a complete atrioventricular block, the patient also underwent a pacemaker implantation. The patient was finally discharged after 10 from TAVI. Discussion(s): This case report offers several foods for thought. First, the COVID-19 pandemic has negatively affected primary and secondary prevention, even for patients affected by cardiovascular disease. Our patient has postponed clinical checks even when the symptoms reappeared, also because of the concerns lead by the COVID-19 pandemic. Second, completeness and timing of coronary disease revascularization, which in this case was staged and performed before TAVI. Finally, the late occurrence of advanced heart block requiring PM implantation. For instance, in an era of fast-track TAVI, more studies are warranted to identify patients who are at higher risk of late PM implantation.
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Background and Aims : Cardiovascular disease (CVD) affects approximately one third of type 2 diabetes mellitus (T2DM) patients. We aimed to evaluate treatment targets of T2DM patients with CVD. Method(s): This retrospective study included 469 T2DM patients attending a Diabetes Center before COVID-19 (08.2016-12.2019). Data regarding diabetes history, complications and comorbidities, anthropometric parameters, metabolic profile were collected from medical records. Result(s): The patients' mean age was 62.27+/-9.98 and 48.8% were men. The mean diabetes duration was 6.81+/-7.04 years and the metabolic parameters were: BMI 31.78+/-5.32 kg/m2, HbA1c 7.5+/-1.47%, glycaemia 159.96+/-49.31 mg/dl, LDL-cholesterol 99.60+/-42.68 mg/dl, triglycerides 200.33+/-143.37 mg/dl. 203 patients had atherosclerotic CVD (angina, cardiac ischemic disease, peripheral arterial disease). A comparative analysis revealed higher values in CVD patients for age, diabetes duration, abdominal circumference, glycaemia, urinary albumin to creatinine ratio (ACR), p <0.05. Diabetes duration and ACR seemed to be predictive factors for CVD (AUC=0.579, p <0.01, CI=0.52 - 0.63, respectively AUC=0.607, p <0.01, CI=0.52 - 0.68). Regarding treatment targets of CVD patients, 45.5% had systolic blood pressure <130 mmHg, 14.8% had LDL-cholesterol <55 mg/dl, and 26.6% had HbA1c <7%. Conclusion(s): In clinical practice, some T2DM patients fail to achieve cardio-metabolic control even if managed according to the latest ESC recommendations. Copyright © 2022
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Objectives: To compare the severity of COVID-19 infection among known diabetic and known hypertensive patients who were admitted in a tertiary care hospital in Peshawar, Pakistan. Methodology: A cross-sectional clinical study was conducted for comparison in diabetic vs hypertensive patients in the department of medicine of Lady Reading Hospital, Peshawar during the period from April-June 2021. All the patients were admitted in COVID ward and COVID ICU, showed their full consent and active participation in this study. Along with patient's ECG and Echo report, a questionnaire based on Canadian categorization employed for angina grading and NYHA categorization to classify shortness of breath was used. Result(s): The mean age group taken for the sample was (n=140) with maximum age of 84 years. Majority were 102(72.9%) males and females were 38(27.1%). According to laboratory tests performed on patients of COVID-19 about 48(34.4%) of patients showed positive diabetes mellitus findings. Also, patients with positive hypertension found were 67(47.9%). The average stays of patients, at the hospital, was 15-40 days. About 58.3% of mortality was noted in patients with diabetes mellitus, a bulk of patients expired were from ICU-COVID-UNIT and 55.2% was the mortality rate in patients with positive hypertension according to our clinical findings and assessment. About 7.9% of COVID inpatients had cardiac infraction with severe condition and such patients who faced congestive heart failure expired. Almost 56(40%) of the patients were found with severe condition and 63(45%) were diagnosed with moderate condition during their stay at hospital. Conclusion(s): Regardless of age, gender and disease the death rate evaluated was 50%. Moreover, in diabetics and hypertensive patients there should be raised awareness for preventing the severity of disease. Copyright © 2022 Lahore Medical And Dental College. All rights reserved.
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10 Figure 1Flowchart of the study population[Figure omitted. See PDF]ConclusionWe found a substantial drop in screening for anxiety and depression in CR during the first year of the COVID-19 pandemic. Screening practice seems to be improving in the following year but is still far from pre-COVID-19.Please submit this entire document via email to education@bacpr.comThe document should be saved as the surname and initial of the lead author followed by the submission data in the following format:SURNAME INITIAL DAY MONTH YEARFor exampleSmith T 01 05 2022(Deadline: midday, Date: Monday 11th July, 2022)
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Background: Bernard Soulier Syndrome (BSS) and Glanzmann Thrombasthenia (GT) patients present frequent and relevant bleeding complications due to remarkable platelet dysfunction, while thrombotic events are very rare. Aim(s): To report thrombotic events and their management in two unrelated patients with BSS and GT. Method(s): We reviewed clinical records of two unrelated sibling pairs of the Spanish Project of Inherited Platelet Disorders. Cases A1 (female, 61 yr) and A2 (male, 59 yr) were diagnosedwith BSS due to the homozygous GP9 variant c.182A > G [p.Asn61Ser]. Cases B1 (female, 23 yr) and B2 (male, 16 yr) had type II GT caused by homozygous ITGA2B variant c.2113 T > C [p.Cys705Arg]). Result(s): Mucocutaneous bleeding is the lifelong relevant, almost exclusive, clinical feature in A1 (ISTH-BAT = 12) and B1 (ISTH-BAT = 4), while less severe in A2 (ISTH-BAT = 2) and B2 (ISTH-BAT = 2). Case A2, at age of 58 yr, was admitted at the hospital due to angor pectoris and underwent coronary angiography revealing severe disease in right and circumflex coronary arteries. Percutaneous coronary angioplasty (PCA) was performed with implantation of five drug-eluting stent (DES). He was discharged on standard aspirin and clopidogrel treatment. Case B1, was admitted to hospital at age 21 for dyspnea and fever. Laboratory findings showed low hemoglobin and elevated D-Dimer. Computerized tomographic pulmonary angiography showed lingular artery thrombosis. She was withdrawn from oral contraceptives and started full dose LMWH which lasted 5 months. Thrombophilia studies (antithrombin, proteins C and S, lupus anticoagulant and cardiolipin antibodies, FV Leiden and G20210 prothrombin) were negative. Two months after the thrombotic episode she was diagnosed with uncomplicated SARS-Cov- 2 infection. Conclusion(s): These patients illustrate that platelet dysfunction in BSS and GT does not exclude for thrombotic complications, which may be triggered by individual genetic and environmental factors, requiring individualized antithrombotic treatment.
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Background: The risk of cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA) is higher than individuals from the general population due to chronic infammation. Current CV risk screening and management strategies underestimate the actual CV risk in RA. Thus, an adequate CV risk stratifcation has special relevance in RA to identify patients at risk of CV disease. Objectives: To assess the incidence of cardiovascular events in a RA cohort after a 2 years follow-up. Methods: A cohort study was performed in which inclusion criteria were adult RA patients and matched adults in terms of age, sex and CV risk factors (controls). Population over 75 years old, patients with established CV disease and/or stage III chronic kidney disease were excluded. Controls with other infam-matory diseases, pregnant women or any malignancy were also excluded. This study was performed from July-2019 to January-2022. CV risk assessment included risk factors collection and US evaluation consisted in detection of plaques and measurement of the intima-media thickness in both right and left carotid. Results: Overall, a total of 200 cases and 111 healthy controls were enrolled in the study. Demographical and clinical variables were comparable between cases and controls and are shown in Table 1. US study revealed a higher IMT in both right and left carotid arteries with greater presence of plaques in patients than in controls (CI 95% [1.542;3.436], p<0.001). Plaques were found in both carotid arteries in the 32% of cases and 9.91% of controls. The longer duration of RA was related to a higher presence of carotid plaques (95% [1.015;1.056], p<0.001). Eight patients (4%) presented a cardiovascular event, and one of them died (0.5%). The events consisted in 2 angina pectoris, 3 transient ischemic attack, 1 acute myocardial infarction, 1 lacunar stroke and 1 cardiac arrest. Six out those 8 patients demonstrated bilateral plaque presence at baseline. Two patient caused loss of follow up due to death related to Covid-19. Not a single cardiovascular event was reported in the control group. Conclusion: Our results shows that cardiovascular events are increased in RA patients and US study may be useful in predicting an event.
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CASE: A 67 year old woman with no known cardiac history presented after acute onset chest pain while watching TV. The pain was described as a burning, substernal pain associated with shortness of breath and nausea. She had no prior history of similar chest pain and was recently exercising with no complaints. Her pain was not relieved by Tums, so she presented to the ED. A COVID-PCR test was positive on admission, however the patient stated she had the infection three weeks prior to presentation and was asymptomatic. She was given sublingual nitroglycerin which improved her pain. Vital signs and physical exam were unremarkable. Electrocardiogram demonstrated ST elevations in leads V3 and V4 with an initial troponin of 0.1 ng/ml (reference range <0.80 ng/ml). She subsequently was loaded with aspirin, a heparin bolus, and was taken to the cath lab. There, she was found to have a distal LAD spontaneous coronary artery dissection and underwent POBA with restoration of vessel flow. IMPACT/DISCUSSION: Spontaneous coronary artery dissection (SCAD) is a condition predominantly seen in women without conventional risks for coronary disease and an often missed cause of non-atherosclerotic ACS. Most often, patients present with typical chest pain and dynamic ECG changes. Diagnosis of SCAD is made during coronary angiogram, at times with the aid of intravascular ultrasound or OCT. Often, these patients will have associated conditions such as fibromuscular dysplasia, pregnancy/postpartum status, or connective tissue diseases. We describe a unique case of a patient without any cardiac risk factors presenting with SCAD after the resolution of an asymptomatic COVID-19 infection. Cardiac complications of COVID-19 have been extensively described, from myocarditis, myocardial infarction, heart failure, and arrhythmias. However, published literature on the association between COVID-19 and SCAD is sparse, with a few case reports reporting a possible connection. Among these, the majority of patients were acutely symptomatic with COVID-19 and subsequently developed angina during the hospitalization. There was one similar case describing a patient developing SCAD after the resolution of a COVID infection 3 months prior to presentation. However, this patient had factors which could have contributed to the SCAD. SCAD is associated with inflammatory diseases that lead to vessel wall weakness. COVID-19 induces a marked inflammatory and immune response during infection, which has been found to cause endothelial and smooth muscle damage. It is possible the inflammatory response from the infection could promote fragility of coronary vessels and lead to dissection. CONCLUSION: As the relationship between SCAD and COVID-19 continues to be explored, providers must be mindful of the potential cardiac manifestations of the virus. An index of suspicion for SCAD should be maintained in patients with COVID-19 or a history of COVID-19 presenting with acute myocardial infarction with few or no atherosclerotic risk factors.
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Introduction: Low molecular weight heparins are used extensively in anticoagulant therapy, due to their safer profile, in comparison to other anticoagulants. Direct Oral AntiCogulants (DOACs) have been initiated in anticoagulant therapy as a safer treatment choice than coumarin derivatives. Objectives: The aim of this study was to investigate the use of oral and injectable anticoagulants, and especially the place of DOACs in anticoagulant treatment, in a tertiary Hospital of Thessaloniki, Greece. Methods: The data were collected by investigating prescriptions from the Hospital Pharmacy of a tertiary Hospital in Thessaloniki, Greece. Prescriptions of oral and injectable anticoagulants for hospitalized patients were collected during the period from June to September 2021. The consumption of the following oral and injectable anticoagulants was recorded in DDDs: acenocumarol, rivaroxaban, apixaban, dabigatran, heparin, enoxaparin, tinzaparin, bemiparin and fondaparinux. Results: The total amount of anticoagulants used was 53,041 DDDs, of which 97,9% were injectable anticoagulants whereas 2,1% were oral anticoagulants. DOACs represented the 1,8% of the anticoagulants used. The consumption of injectable anticoagulants for the hospitalized patients was 51,936 DDDs, of which 63.5% was enoxaparin, 18.5% was tinzaparin, 6.3% was heparin, 6.1% was bemiparin, and 5.6% was fondaparinux. The consumption of acenocumarol was 176 DDDs and the consumption of DOACs was 929 DDDs, with the percentage of rivaroxaban, apixaban, and dabigatran being 46%, 45% and 9% respectively. Indications with the highest prevalence for patients on enoxaparin was COVID 19, heart failure, stroke, angina pectoris, malignancy. Indications with the highest prevalence for patients on tinzaparin was COVID 19, malignancy, stroke. Indications with the highest prevalence for patients on bemiparin was malignancy, COVID 19, aortic valve disease, stroke. Heart failure, stroke and atrial fibrillation were the indications with highest prevalence in patients on DOACs. Acenocumarol was used mainly for heart failure, stroke and aortic valve stenosis. Conclusion: Injectable anticoagulants, and mainly low molecular weight heparins were the treatment of choice in hospitalized patients. Oral anticoagulants represented only a very small proportion (2,1%) of the anticoagulants used. DOACs have replaced coumarin derivatives, representing the 86% of oral anticoagulants in clinical use. Nevertheless, the percentage of DOACs was very low (1.8%) in the total consumption of anticoagulants, with rivaroxaban and apixaban being the most commonly used DOACs. Injectable anticoagulants, especially enoxaparin, are preferred by the clinicians as a safer choice for managing high risk thrombosis in hospitalized patients. DOACs, Direct Oral AntiCogulants, anticoagulants, NOACs.
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Objective: Characterize patients with hypertensive crisis and evaluate occurrences 30 days after the hypertensive event. Design and method: Cohort study was performed with 583 patients treated between August 2020 and July 2021, from an Emergency Unit in a Hospital specializes in cardiology in São Paulo, Brazil. Inclusion criteria: 18 years old, systolic pressure > 180 mmHg and/or diastolic pressure > 120 mmHg, have telephone contact. A consulting on the electronic medical record was made to identify the elegible patients, whom after were included on the REDCap platform, and 30 days of the hypertensive event, an interview by telephone was made to investigate cardiovascular events. Results: The sample characteristics were: women (53%), 66.24(13.89) years, white ethnicity (78.7%), married (50.5%), high school (27.9%), retired people (77.5%), average [(mean(SD)] monthly income R$2384.6 (R$3438). The mean(SD) systolic/diastolic blood pressure, respectively, in emergency department was 189.74(17.46)/99.28(19.89) mmHg. Hypertensive emergencies were 63.8%, urgencies 27.4% and 8.7% were not possible to classify. The prevalent symptoms in the emergency department were: chest pain (41.2%), dyspnea (34.3%), nausea (11.7%), dizziness (10,4%), radiating pain (10.1%). The most used treatments were: anticoagulant (35.1%), diuretic (28.1%), analgesic (25.3%), ACE inhibitor (23.8.7%). Regarding the performance of tests: 85.6% underwent laboratory tests, 71% electrocardiogram, 36.3% echocardiogram and 30.5% computed tomography. After being treated at the emergency department, 60.1% of patients were discharged, 35.8% hospitalized, 3.8% transferred to other hospitals and 0,3% died. Regarding comorbidities, 97.7% had hypertension, 68.7% high cholesterol, 48.4% diabetes, 34.1% acute myocardial infarction, 25.1% heart failure, 19.6% kidney disease and 12% stroke. Regarding outcomes 30 days after the hypertensive event, 1.4% had some type of stroke, being 85.7% ischemic and 14.3% hemorrhagic, 2.3% had acute infarction of the myocardium, and 2% cardiorespiratory arrest. Also, 14.5% returned to a health service for high blood pressure, and 23.1% for others reasons like angina, bradycardia, aortic aneurysm, covid-19, acute pulmonary edema, epigastric pain, dyspnea. Besides we identify that 4.7% died within 30 days. Conclusions: The findings indicate the need for tertiary systematization, through outpatient follow-up programs for people with hypertensive crisis in emergencies units.
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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.
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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.
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Objectives: The present research studied moral injury and psychological resilience in healthcare professionals amid COVID-19 pandemic. Relationship between moral injury and resilience was explored in addition to finding the difference in study variables based on socio-demographics factors. Methods: This cross-sectional research was carried out from August 2020 to January 2021. A sample of 108 healthcare professionals including doctors, nurses, and paramedical staff was collected through purposive sampling technique. Data was gathered through face-to-face survey method and online forum using psychometrically sound tools. Results: Findings revealed that more than two third of the sample (69.44%) has high level of moral injury which is clinically significant while only 30.56% fall within normal range. Moral injury has significant positive correlation with number of work hours (p < .05) whereas negative correlation with resilience (p < .01) and years of experience (p < .05). Women and health care professionals belonging to psychiatry department have reported to experience significantly high level of moral injury (p < .01). Conclusion: The findings of the study are helpful for stakeholders of health care system to better understand and prepare for the situations that brings moral injury and challenge psychological resilience particularly in times of pandemic, humanitarian crisis, or natural disasters.