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Aims: At our Trust, all severe inpatient hypoglycaemic episodes in individuals with diabetes (defined as a hypoglycaemic episode requiring injectable treatment) are reported to NaDIA-Harms (National Diabetes Inpatient Audit). We conducted a detailed review of the care of all these events to improve patient safety. In this study, we assessed the risk of 12-month mortality following an episode of severe inpatient hypoglycaemia. Method(s): Reportable NaDIA harms of patients admitted during the period 2018-2022 were recorded into a dataset. Applicable patient records were reviewed at 12 months following the event to see how many patients were deceased and details of comorbidities at the time of the severe hypoglycaemic episode were collected. Result(s): To date, of 107 inpatients who experienced a severe hypoglycaemic episode 55% were deceased within 12 months. In patients admitted during the peak of the Covid-19 pandemic recorded as year April 2020/March 2021, 80% of patients who had a NaDIA hypoglycaemic event died within 12 months. Conclusion(s): Mortality rate following an episode of inpatient hypoglycaemia appears to be several-fold higher than previous reported rates of 4.45%-22.1% for community-dwelling individuals who experience a severe hypoglycaemic event. This maybe partially explained by the increased frailty, polypharmacy and multimorbidity among this cohort, but there is evidence linking hypoglycaemia with cardiovascular mortality. Although no causality between severe inpatient hypoglycaemia and death can be inferred from this study because of the observational nature, it does highlight the importance preventing inpatient episodes of hypoglycaemia through effective monitoring and proactive treatment modification.
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Introduction: The Severe Acute Respiratory Syndrome Coronavirus-2 have been associated with cardiovascular adverse events including acute myocardial infarction due to a prothrombotic and hypercoagulable status, and endothelial dysfunction. Case report: We report the case of a 62-year-old women, admitted to the hospital via the emergency room for acute chest pain and dyspnea. A nasopharyngeal swab was positive for COVID19 real-time reverse transcriptase-polymerase chain reaction 11 day ago. On admission, she was hypotensive with systolic blood pressure measering 87 mmHg and tachycardic with 117 beats/min, oxygen saturation (SO2) was 94%. An 18-lead ECG revealed an infero-postero-lateral ST-elevation myocardial infarction with right ventricular involvement and a seconddegree- Mobitz Type 1 atrioventricular block. The coronary angiography from the right femoral artery showed acute thrombotic occlusion of the first diagonal branch with TIMI 0 flow and acute thrombotic occlusion of proximal right coronary artery with TIMI 0 flow. The most likely diagnosis was myocardial infarction secondary to a non-atherosclerotic coronary occlusion. The angioplasy was performed with dilatations with a semi compliant balloon, bailout implant of BMS, manual thrombus aspiration and intracoronary injection of tirofiban in the right coronary artery. The myocardial revascularization was ineffective. The patient developed significant severe hemodynamic instability and cardiac arrest for pulseless electric activity after 24 hours. Conclusion(s): The COVID-19 outbreak implies deep changes in the clinical profile and therapeutic management of STEMI patients who underwent PCI. At present, the natural history of coronary embolism is not well understood;however, the cardiac mortality rate are hight. This suggests these patients require further study to identify the natural history of the condition and to optimize management to improve outcome.
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Background: Coronavirus disease 2019 (COVID-19) is associated with increased risk of cardiovascular mortality. However, little is known about the combined effect of coronary artery disease (CAD) and COVID-19 on mortality. We aimed to investigate the incidence of cardiovascular and all-cause mortality in COVID-19 patients with CAD. Methods: This multicenter retrospective study identified 3,336 COVID-19 patients admitted between March and December 2020. Data points were manually reviewed in the patients' electronic health records. Multivariate logistic regression was used to assess whether CAD and its subtypes were associated with mortality. Results: This study shows that CAD was not an independent predictor of all-cause mortality (odds ratio (OR): 1.512, 95% confidence interval (CI): 0.1529 - 14.95, P = 0.723). However, there was a significant increase in cardiovascular mortality in patients with CAD compared to those without (OR: 6.89, 95% CI: 2.706 - 17.53, P < 0.001). There was no significant difference in all-cause mortality in patients with left main artery and left anterior descending artery disease (OR: 1.29, 95% CI: 0.80 - 2.08, P = 0.29). However, CAD patients with a history of interventions (e.g., coronary stenting or coronary artery bypass graft) showed increased mortality compared to those solely treated by medical management (OR: 1.93, 95% CI: 1.12 - 3.33, P = 0.017). Conclusions: CAD is associated with a higher incidence of cardiovascular mortality but not all-cause mortality in COVID-19 patients. Overall, this study will help clinicians identify characteristics of COVID-19 patients with increased risk of mortality in the setting of CAD.
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Background: Patients with COVID-19 have an increased risk of cardiovascular adverse events during the acute phase. However, the long-term cardiovascular outcomes are unknown. Objective(s): We aimed to determine the long-term effects of COVID-19 in the cardiovascular system. Method(s): This is a multicenter, observational, retrospective registry conducted at 17 centers in Spain and Italy. Consecutive patients older than 18 years who underwent a real-time reverse transcriptase-polymerase chain reaction (RT-PCR) for SARS-CoV2 in the participating institutions were included. Patients were classified into two groups, according to the results of the RT-PCR: COVID-19 positive or negative. The primary outcome was cardiovascular (CV) death at 1-year. The secondary outcomes included acute myocardial infarction, stroke, heart failure hospitalization, pulmonary embolism, and serious cardiac arrhythmias at 1-year. Outcomes were compared between the two groups. An independent clinical event committee adjudicated events. Result(s): A total of 4427 patients were included, 3578 (80.8%) patients with COVID-19 and 849 (19.2%) without COVID-19. COVID-19 patients were older, had a higher rate of classical cardiovascular risk factors, except for active smoking, and had fewer comorbidities. At a median time of 13.5 (IQR 11.8-15.8) months, after an adjustment by baseline characteristics, there was no difference in CV death (1.4% vs. 1.1%;HR 1.03 [0.49-2.18];p=0.941) between patients with COVID-19 and without. However, COVID- 19 patients experienced higher rate of venous thromboembolism (VTE) (3.9% vs. 0.6%, HR 6.11 [2.46-15.16];p=0.001), major bleeding (2.9% vs. 0.5%, HR 5.38 [1.95-14.84];p=0.001), and serious cardiac arrhythmias (2.6% vs. 0.9%, HR 2.25 [1.07-4.73];p=0.033). During follow-up, between discharge and end of follow-up, COVID-19 patients did not experience a higher risk of adverse cardiovascular outcomes (composite of CV death, any MI, ischemic stroke, systemic arterial thrombosis, VTE, heart failure hospitalization, or any serious arrhythmia) compared to patients without (HR 0.80;[0.53-1.21];p=0.298). Conclusion(s): At 1-year follow-up, COVID-19 was not associated with an increased risk of cardiovascular death but with a higher risk of VTE events, major bleeding, and serious cardiac arrhythmias. COVID-19 was not associated with a higher risk of adverse cardiovascular events during follow-up.
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Cardiovascular disease (CVD) is the leading cause of death in most developed countries, including the United States, with a significant economic impact. Lifestyle changes and the administration of antiplatelet medication, like aspirin, may significantly contribute to the secondary prevention of CVD in adults. For years, aspirin has been utilized for both secondary and primary cardiovascular disease prevention. Aspirin has been extensively used because of the belief that it may have a positive impact on primary prevention, despite the debate surrounding its usage. This study briefly examines usage patterns and discusses the potential variables and factors that can decrease the ability of aspirin to prevent cardiovascular disease. The present study also explore the key studies of aspirin use in the context of recent recommendations. The risk of bleeding has been observed to significantly rise, although large randomized clinical studies have demonstrated a reduction or absence of CVD events. Prevention strategies for cardiovascular disease with low-dose aspirin are no longer advised for persons at intermediate risk. To determine whether taking aspirin is worth the potential dangers, the benefits must be evaluated.Copyright © 2022 Novyi Russkii Universitet. All rights reserved.
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Background In the USA and other countries, cardiac deaths have been elevated above background rates since the start of the COVID pandemic. This could be directly due to COVID or indirectly due to health system dysfunction (reduced access to optimal cardiac care during pandemic years). Methods Analysis of rates of circulating respiratory viruses, vaccination and cardiac death rates compared to background/usual in multiple countries. Results Cardiac deaths in the USA and most other countries with cause-specific data available since 2020, have been elevated. Excess mortality due to cardiac causes in 2021 was higher in countries with low vaccination rates against COVID. An exception to this trend has been Australia in 2021. In 2022, Australia (like other countries) exhibited elevated rates of cardiac deaths compared to baseline. In 2021, when Australia was pursuing a COVID-zero policy of lockdowns and border closures, which also led to a near Influenza-zero status, cardiac deaths were substantially reduced compared to baseline (Figure). Conclusion The relationship between circulating respiratory virus rates and cardiac deaths is strong in both directions, indicating likely direct causation. In hindsight, this relationship also explains pre-pandemic winter spikes and summer drop-offs in cardiac deaths. Although "COVID fatigue" is common, a policy allowing high rates of circulating COVID and tolerating sub-optimal vaccination rates directly leads to excess cardiac deaths. [Formula presented]Copyright © 2023 American College of Cardiology Foundation
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This article summarizes the top 20 research studies of 2021 identified as POEMs (patient-oriented evidence that matters) that did not address the COVID-19 pandemic. Sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists prevent adverse cardiovascular and renal outcomes in patients with type 2 diabetes mellitus and also reduce all-cause and cardiovascular mortality. Most older adults (mean age, 75 years) with prediabetes do not progress to diabetes. Among patients in this age group with type 2 diabetes treated with medication, an A1C level of less than 7% is associated with increased risk of hospitalization for hypoglycemia, especially when using a sulfonylurea or insulin. For patients with chronic low back pain, exercise, nonsteroidal anti-inflammatory drugs, duloxetine, and opioids were shown to be more effective than control in achieving a 30% reduction in pain, but self-discontinuation of duloxetine and opioids was common. There is no clinically important difference between muscle relaxants and placebo in the treatment of nonspecific low back pain. In patients with chronic pain, low- to moderate-quality evidence supports exercise, yoga, massage, and mindfulness-based stress reduction. For acute musculoskeletal pain, acetaminophen, 1,000 mg, plus ibuprofen, 400 mg, without an opioid is a good option. Regarding screening for colorectal cancer, trial evidence supports performing fecal immunochemical testing every other year. For chronic constipation, evidence supports polyethylene glycol, senna, fiber supplements, magnesium-based products, and fruit-based products. The following abdominal symptoms carry a greater than 3% risk of cancer or inflammatory bowel disease: dysphagia or change in bowel habits in men;rectal bleeding in women;and abdominal pain, change in bowel habits, or dyspepsia in men and women older than 60 years. For secondary prevention in those with established arteriosclerotic cardiovascular disease, 81 mg of aspirin daily appears to be effective. The Framingham Risk Score and the Pooled Cohort Equations both overestimate the risk of cardiovascular events. Over 12 years, no association between egg consumption and cardiovascular events was demonstrated. Gabapentin, pregabalin, duloxetine, and venlafaxine provide clinically meaningful improvements in chronic neuropathic pain. In patients with moderate to severe depression, initial titration above the minimum starting dose of antidepressants in the first eight weeks of treatment is not more likely to increase response. In adults with iron deficiency anemia, adding vitamin C to oral iron has no effect. In children with pharyngitis, rhinosinusitis, acute bronchitis, or acute otitis media, providing education combined with a take-and-hold antibiotic prescription results in 1 in 4 of those children eventually taking an antibiotic.Copyright © 2022 American Academy of Family Physicians.
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Objective: The aim of this study is to investigate the arrhythmic events and short-term cardiovascular (CV) outcomes in patients hospitalized with COVID-19 infection in a single Taiwan tertiary center. Method(s): A retrospective study was carried out on 186 confirmed COVID-19 infection patients admitted to our hospital between May, 2021 and September, 2021. We investigate their CV symptoms, vital signs, laboratory examinations, arrhythmic events, and major adverse cardiovascular events (MACE), including ischemic stroke or systemic embolism, myocardial infarction, CV death, and heart failure (HF) during hospitalization. Result(s): During the hospitalization, 29.6% of patients had an elevation of cardiac enzymes, 67.2% had an elevation of d-dimer level, and 7.5% had abnormal NT-pro BNP level. The most common recorded arrhythmia is sinus tachycardia (22%), followed by atrial arrhythmia (12.4%, including atrial fibrillation 7.0%), sinus bradycardia (3.2%), ventricular arrhythmia (1.6%), and paroxysmal supraventricular tachycardia (1.1%). A total of 68 patients (36.6%) had arrhythmic events during hospitalization. During the mean follow-up of 2.8 months, 17 patients (9.1%) developed MACE, including 6 ischemic strokes, one pulmonary embolism, one peripheral artery occlusive disease, 3 HF, and 7 CV death. The total mortality rate is 19.9%. The hospitalized patients with arrhythmic events were associated with a higher incidence of intubation (32% vs 15%, p = 0.0062), MACE (22% vs 2%, p < 0.001), and mortality (37% vs 10%, p < 0.001) than those without arrhythmic events. Conclusion(s): The patients hospitalized with COVID-19 infection were associated with higher CV manifestations and arrhythmic events in Taiwan. Those patients with arrhythmic events were associated with higher morbidity and mortality.
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Cardiovascular complications are frequently reported in COVID-19 patients and are associated with increased mortality during hospitalization. However, no data exists on cardiac involvement in patients recovered from COVID-19 infection. Our study suggests a need for closer follow-up among COVID-19 recovered subjects including echocardiographic assessment of left ventricular function to elucidate long-term cardiovascular outcomes by early detection of left ventricular dysfunction.Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.
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PURPOSE/HYPOTHESIS: Given the economic and health impact of COVID-19, it is critical to develop optimal inpatient programs to prevent its long term sequalae.1,2 Current guidelines advocate the use of pulmonary rehabilitation (PR) in patients with COVID-19.3 However, there is a lack of concrete information on PR in an inpatient setting for COVID-19. Therefore, we synthesized literature on the safety, feasibility and efficacy of inpatient PR on pulmonary outcomes and quality of life (QoL) in individuals with COVID-19. We hypothesized that inpatient PR would improve outcomes in this population. NUMBER OF SUBJECTS: The pooled sample consisted of 718 participants (F=35.2%, age=36-71 y). MATERIALS AND METHODS: Using PubMed, Web of Science, Cochrane Library and Embase, 3 researchers screened 474 articles for eligibility with the search terms: (covid-19 or coronavirus or 2019-ncov or sars-cov-2 or cov-19 *) AND (respiratory or pulmonary) AND (physical therapy or physiotherapy or rehabilitation). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used. Nine articles were finalized using the inclusion criteria: publication date >2019, age >18 y, inpatient setting, and English language. Subsequently, reviewers extracted relevant information and appraised using the Physiotherapy Evidence Database (PEDro) score. RESULT(S): Studies were mainly retrospective (retrospective chart review=5, prospective observational=4);and had PEDro score of 4/10. Inpatient PR ranged from 2 to 12 weeks. The primary outcomes included six-minute walk distance (6MWD), pulmonary function and QoL. Within group analyses (n = 9) showed that inpatient PR improved 6MWD statistically and clinically (mean improvement 111-204.7 m). In all the studies (n = 3) that offered comparisons with a no PR group (n = 3), inpatient PR offered a statistically significantly benefit in this population. Further analysis showed improvements in exercise capacity were in a dose-response fashion and were related to disease severity (n = 2). Within group changes were noted in FEV1 and FVC values (n = 3). For QoL data (n = 6), within group improvements were noted only in 3 studies. Inpatient PR was reported to be safe by all studies that reported adverse events (n = 4). CONCLUSION(S): Current review suggests that inpatient PR was safe, feasible and induced large improvements in exercise capacity in individuals with COVID-19. These findings concur with data on the use of PR in chronic pulmonary diseases.4 This is important as exercise capacity is regarded as a strong predictor of cardiovascular mortality.5 The divergent results on pulmonary function and QoL may be due to the heterogeneity of PR duration, QoL measures and disease severity.6,7 Limitations included retrospective designs, small sample size and variance in protocols. Future research should be directed on improving methodological rigor of studies. CLINICAL RELEVANCE: Our study provides valuable evidence that inpatient PR is safe and may accelerate improvement in exercise capacity in individuals with COVID-19.
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Background and Aim: Insulin resistance (IR) is strongly associated with endothelial dysfunction. There is also evidence that endothelial dysfunction is associated with COVID 19 infection. Triglyceride glucose (TyG) index is newly defined promising surrogate index for IR as a cardiometabolic risk marker. It has been found to be associated with coronary artery calcification and high risk of cardiovascular disease. No data are currently available taking into account the effects of the TyG index on mortality in non-diabetic COVID 19 patients with myocardial injury. We aimed to investigate whether TyG predicts the in hospital mortality in non-diabetic COVID 19 patients with myocardial injury Methods: This was a retrospective study. 218 non-diabetic patients who have myocardial injury due to COVID 19 infection were included in the study. Blood samples including high-sensitivity (hs) cardiac troponin (cTn), triglycerides, eGFR, haemoglobin, platelet, D-Dimer, CRP, albumine, uric acid, ferritin and plasma fasting glucose (PFG) concentrations, were collected from the antecubital vein from each patient after at least 8 h of fasting. The TyG index was calculated as follows: log [serum triglycerides (mg/dL) x plasma glucose (mg/dL)/2]. We defined myocardial injury as cTn concentrations >99th percentile upper reference limit. The study cohort was divided into 2 groups as those survivors and non-survivors. Triglyceride and fasting blood glucose were evaluated in a separate multivariate analysis model (model 1). The receiver operating characteristics (ROC) curve analysis was used to evaluate the sensitivity and specificity of the TyG and it's cut-off value in determining the in-hospital mortality. Survival evaluations for the low-and high TyG groups were determined by using Kaplan-Meier and long-rank test Results: 169 patients were survivors and 49 patients were non-survivors. D-Dimer and CRP levels were more higher in non-survivors group (p<0.01 and p<0.01 respectively). Non survivor patients had also higher TyG index than the others (p<0.01) (Table 1). Age, CHF, uric asid, TG, TyG were found to be independently associated with in-hospital mortality in univariate anaylsis. We used AUC value for diagnostic accuracies and discriminatory performances of the TyG (AUC:0.786, CI 95% 0.721-0.852, p<0.001), TG (AUC:0.738, CI 95% 0.656-0.820, p<0.001), and PFG (AUC:0.660, CI 95% 0.573-0.748, p=0.001) for detecting the in-hospital mortality. The receiver operating characteristics curve analysis revealed a cut off value of TyG index greater than 4.97 predicts the development of in hospital mortality in non-diabetic COVID 19 patients with myocardial injury with a 82% sensitivity, and a 66% specificity. Conclusion(s): A TyG above 4.97 was found as a risk factor for in hospital mortality in non-diabetic COVID 19 patients with myocardial injury. TyG may be a part of cardiovascular mortality to identify individuals at high risk for nondiabetic COVID 19 patients with myocardial injury.
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Introduction: Transesophageal echo (TEE) is routinely used to exclude left atrial appendage (LAA) thrombus prior to direct current cardioversion (DCCV) for atrial fibrillation (AF). However, the COVID-19 pandemic accelerated the use of non-invasive modalities such as cardiac computed tomography (CCT) to avoid aerosolizing viral particles during intubation, such as with introduction of a TEE probe. CCT is not routinely used as a clinical strategy to exclude LAA thrombus prior to DCCV. Therefore, we sought to determine the feasibility of CCT-guided DCCV.Hypothesis: CCTguided elective cardioversion for atrial arrhythmias is a feasible modality to rule out left atrial appendage thrombus. Method(s): We identified patients at Abbott Northwestern Hospital who underwent CCT in lieu of or in addition to TEE within 24 hours of elective DCCV for AF or atrial flutter from March 2020 to February 2022. Thirty-day outcomes were collected including cerebrovascular accident (CVA), myocardial infarction, cardiovascular death, re-hospitalization, arrhythmia recurrence, and overall mortality. Delayed imaging, 90 seconds after arterial phase, was obtained to exclude LAA thrombus. Result(s): Thirty-two patients were included in our analysis, 10 (31%) were female. Ten (31%) presented with new-onset of AF. CCT did not identify LAA thrombus in any patient. Post-DCCV, the mean time to arrhythmia recurrence was 16.5 days (SD: 9.3). At 30 days, 11 (34%) had been rehospitalized but mostly for elective procedures. There was no CVA or mortality reported at the 30-day follow-up. Conclusion(s): CCT-guided elective cardioversion for atrial arrhythmias was evaluated for feasibility in a small pilot. In patients who had no LAA thrombus on CCT and subsequently underwent cardioversion, there were no CCT-related complications, CVA, or deaths at 30 days. Many patients benefit from early DCCV rather than waiting with uninterrupted anticoagulation. CCT guidance is a feasible alternative to TEE but needs further prospective comparison to TEE and uninterrupted anticoagulation in this clinical setting.
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Background: Heart failure (HF) patients are predisposed to recurrences and disease destabilizations, especially during the COVID-19 outbreak period. In this scenario, telemedicine could be a proper way to ensure continuous care. The purpose of the study was to compare two modalities of HF outpatients' follow up, the traditional in-person visits and telephone consultations, during the COVID-19 pandemic period in Italy. Method(s): We performed an observational study on consecutive HF outpatients. The follow up period was 12 months, starting from the beginning of the COVID-19 Italy lockdown. According to the follow up modality, and after the propensity matching score, patients were divided into two groups: those in G1 (n = 92) were managed with traditional in-person visits and those in G2 (n = 92) were managed with telephone consultation. Major adverse cardiovascular events (MACE) were the primary endpoints. Secondary endpoints were overall mortality, cardiovascular death, cardiovascular hospitalization, and hospitalization due to HF. Result(s): No significant differences between G1 and G2 have been observed regarding MACE (p = 0.65), cardiovascular death (p = 0.39), overall mortality (p = 0.85), hospitalization due to acute HF (p = 0.07), and cardiovascular hospitalization (p = 0.4). Survival analysis performed by the Kaplan-Meier method also did not show significant differences between G1 and G2. Conclusion(s): Telephone consultations represented a valid option to manage HF outpatients during COVID-19 pandemic. They were comparable to traditional in-person visits.
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SESSION TITLE: Critical Care Presentations of TB SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: We present a case of tuberculous pericarditis and cardiac tamponade due to suspected sequela of SARS-Coronavirus 19 (COVID-19) infection. It is important for clinicians to include tuberculosis (TB) in the differential diagnoses for patients presenting with presumptive viral pericarditis and tamponade. CASE PRESENTATION: A 52-year-old Hispanic man with chronic kidney disease not on hemodialysis was admitted with shortness of breath, fluid overload, hypoxemia and concern for uremic pericarditis. The patient tested positive for COVID-19 to which the symptoms were initially attributed, and he was treated with steroids, remdesevir, tocilizumab and hemodialysis. The patient incidentally had a positive QuantiFERON gold test obtained before initiating hemodialysis. On day 60 of hospitalization, the clinical exam abruptly deteriorated with stuporous mentation, hypotension, and cool skin. Bedside point of care echocardiography revealed a new large circumferential pericardial effusion with right ventricular diastolic collapse and increased respiratory variation in peak E-wave mitral inflow velocity consistent with tamponade physiology. Emergent pericardiocentesis was performed, and hemodynamic instability resolved immediately after aspiration of 750 milliliters of frank pus. Empiric antibiotics were initially given for pyogenic pericarditis. When the pericardial fluid later tested positive for acid-fast bacilli and adenosine deaminase, anti-TB therapy was started. The hospitalization was further complicated by septic shock and cardiac arrest. Though found to have a re-accumulated pericardial effusion on bedside ultrasound peri-arrest, there was no tamponade physiology (suggestive of at least a partial response to the TB treatment in the setting of overall poor underlying reserve). DISCUSSION: The coexistence of COVID-19 and tuberculous pericarditis with tamponade has been reported to date in one other case to our knowledge. COVID-19 with massive pericardial tamponade is rare and a careful diagnostic approach involving multi-modality imaging with bedside echocardiogram is invaluable in the evaluation and treatment of obstructive shock. In this case, we hypothesize that the COVID-19 infection may have led to re-activation of latent TB despite treatment of COVID-19 with corticosteroids (which are an adjunct tuberculostatic treatment in patients with tuberculous pericarditis). Tuberculous pericarditis with tamponade is a relatively uncommon manifestation of extrapulmonary TB and is a major cause of cardiovascular death and morbidity. Even with aggressive antituberculosis therapy, 30-60% of patients may need surgical pericardiectomy for constrictive pericarditis. CONCLUSIONS: This case highlights the need to consider possibility of concomitant viral and TB pericarditis in the diagnostic differential for tamponade. More histopathologic or post-mortem examinations of COVID-19 pericarditis cases are needed. Reference #1: Asif T, Kassab K, Iskander F, Alyousef T. Acute pericarditis and cardiac tamponade in a patient with COVID19: a therapeutic challenge. Eur J Case Rep Intern Med. 2020 May 6;7(6):001701. Reference #2: Barrett et al. Increase in disseminated TB during the COVID19 pandemic. Int J Tuberc Lung Dis. 2021 Feb 1;25(2):160-166. Reference #3: Wong SW, Ng J. K.X., Chia YW. Tuberculous pericarditis with tamponade diagnosed concomittantly with COVID19: a case report. Eur Heart J Case Rep. 2020 Dec 28;5(1):ytaa491. eCollection 2021 Jan. DISCLOSURES: No relevant relationships by Jaskiran Khosa No relevant relationships by Walter Klein No relevant relationships by Amy Tran No relevant relationships by Michael Ulrich
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Introduction: The therapeutic benefits of sleep in the critically ill has been extensively studied in the medical literature.1 Chronic insomnia increases a patient's risk of delirium, cortical atrophy, diabetes, cancer, cardiovascular death from arterial hypertension, myocardial infarction and heart failure.2 Insomnia reduces interaction during videocalls with family and limits co-operation with physiotherapy, medical and nursing interventions, potentially delaying rehabilitation and recovery. Objectives: To improve sleep by introducing an individualised melatonin regimen and a multidisciplinary targeted approach to managing insomnia in an adult intensive care unit. Methods: A retrospective analysis was conducted in a single centre UK adult ICU. Data was retrieved from pharmacy dispensing records, electronic medical notes and prescriptions from September 2020 to March 2021. The primary outcome was resolution of insomnia. Other information collected included causes of insomnia, referral to psychology for cognitive behavioural therapy (CBT), prevalence and resolution of delirium, adverse effects, and death. Each patient received a tailor made regimen based on Bellapart et al's original concept of mimicking the natural endogenous secretion of melatonin.3 However, unlike previous studies3,4,5 dosing was modified and adjusted according to patient response. A loading dose of 0.75 to 3mg was administered at 21:00 followed by a smaller hourly dose of 0.25 to 0.5mg between 22:00 and 03:00. Additionally, the duration of treatment continued for as long as therapeutic benefit was realised, which included post discharge from ICU. Prior experience of conventional melatonin dosing did not demonstrate therapeutic benefit from the original pilot study and when nursing staff inadvertently omitted the hourly dose between 10pm and 3am. Adverse effects were documented. Sleep hygiene measures were introduced and standardised where possible e.g. ear plugs, eye mask, dim lights, environmental noise reduction and minimal night time physical interventions from nursing and medical staff. The principal investigator referred to psychology patients who expressed fear and anxiety as a cause of insomnia. Results: 132 patients were admitted during September 2020 to March 2021. 30 patients received tailor made melatonin regimens (22.7%). The medical notes of four (13.3%) patients could not be accessed for data collection and were, therefore, excluded from the study. The primary outcome of resolution of insomnia occurred in 23 out of 26 (88.4%) patients. At the time of ICU discharge, delirium had occurred in 15 patients (57.7%), resolved in 10 patients (66.7%), three (20%) patients remained intermittently delirious, one remained continuously delirious, and one died. Mechanical ventilation, environmental noise, necessary medical and nursing interventions throughout the night and infection accounted for 23 (88.4%) of patients' insomnia. Fear or anxiety were expressed by eight (30.8%) patients as a cause of insomnia whilst medicines e.g. steroids, beta blockers accounted for six patients (26.1%). Seven patients (26.9%) expressing fear or anxiety were referred to psychology for adjunctive CBT. One patient experienced excessive daytime drowsiness, which resolved with dose regimen adjustment. One patient died of a cause unrelated to melatonin. Conclusion: An individualised melatonin regimen combined with a multidisciplinary targeted approach can result in resolution of insomnia in ICU patients, with minimal risk of adverse effects.
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Background: Patients with diabetes mellitus (DM) are at increased risk for intubation, death, and other complications from COVID-19. However, the importance of a patient’s glycemic control preceding the COVID-19 infection is less well understood. Method: From March to November 2020, data from adult patients with confirmed COVID-19 admitted to Rush University System for Health (RUSH) was studied. Patients with both a pre-existing history of diabetes mellitus (DM) and a hemoglobin A1c (HbA1c) measurement during their hospitalization were included. Based on their HbA1c, patients were then divided into 4 groups: adequate glycemic control (≤ 6.5), mild elevation (6.5 – 7.4), intermediate elevation (7.5 – 8.4), and severe elevation (≥ 8.5). Multivariable logistic regression, adjusted for age, body mass index, and pre-existing history of atrial fibrillation, coronary artery disease, hypertension, and chronic obstructive pulmonary disorder, was performed with glycemic control group as a predictor for 60-day mortality and severe COVID-19, which was a composite of 60-day mortality or requiring the intensive care unit, non-invasive positive pressure ventilation, or mechanical ventilation. Major adverse cardiac events (MACE) were defined as nonfatal myocardial injury, nonfatal stroke, or cardiovascular death. Results: Of the 1682 patients admitted, 774 had pre-existing DM, and 534 had HbA1c measurement during their hospitalization. The median HbA1c value was 8.0% (interquartile range 6.6% – 9.9%). In our entire cohort, 75 (14.0%) and 280 (52.4%) patients suffered 60-day mortality and severe COVID-19 infection, respectively. When adjusting for baseline characteristics and comorbidities, patients with mild (adjusted odds ratio [aOR] 2.39 [CI 1.04 – 5.83];p < 0.05) and intermediate (aOR 3.59 [CI 1.49 – 9.12];p < 0.01) HbA1c elevation were at increased risk of 60-day mortality compared to those with adequate glycemic control;no statistically significant difference was present in those with severe elevation (aOR 2.19 [CI 0.95 – 5.44];p = 0.08). Furthermore, only the mild HbA1c elevation group was at increased risk for severe COVID-19 infection (aOR 1.88 [CI 1.06 – 3.38];p < 0.05). Those with intermediate (aOR 1.77 [CI 0.94 – 3.33];p = 0.08) or severe (aOR 1.57 [CI 0.92 – 2.70];p = 0.10) HbA1c elevation were not at higher risk for severe COVID-19 infection. When comparing other 60-day outcomes, there was no difference between the glycemic groups in MACE, life-threatening arrhythmia, deep venous thrombosis, acute renal failure requiring renal replacement therapy, and pulmonary embolism (Table 1). Discussion: In our cohort, patients with DM with an HbA1c of 6.5 – 8.4 were at increased risk of 60-day mortality, while those with an HbA1c of 6.5 – 7.4 were at an increased risk of severe COVID-19 infection.
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Background: TAVR has emerged as a revolutionary treatment for patients with symptomatic and severe AS, irrespective of surgical-risk profile. Novel transcatheter heart valves (THV) with a lower profile, ease of use and expected longer durability are being developed to target younger and low-risk population. Myval is a 14Fr-balloon expandable THV with a skirt to minimize the occurrence of paravalvular leak (PVL), and has been recently approved for commercial use in Brazil. We sought to report our initial experience with this novel device. Methods: Single-center, single arm, open label prospective registry encompassing all consecutive patients referred to TAVR in our Institution between December 2020 and November 2021. Indication for TAVR was according to current international guidelines. Clinical and echocardiographic outcomes were defined accordingly to VARC-III criteria. Results: A total of 39 patients were enrolled so far. Mean age was 79.5 years, 42% were female and mean STS score was 4%. Pre-procedures mean gradient and aortic valve area were 53.3 mmHg and 0.7cm2, respectively. All procedures were performed under minimalist approach using percutaneous, femoral access. Two patients were treated for bicuspid aortic stenosis and four patients underwent a valve-in-valve procedure. Procedure success was achieved in 100% of the cases, and post-procedure echocardiogram revealed a mean residual gradient of 5 mmHg, with PVL greater than mild in a single case. Permanent pacemaker was required in only 2 patients, and mean hospital stay was 3.1 days. At 30-days, there were two deaths, one due to COVID in a patient who presented major access bleeding requiring prolonged hospital stay, and another one a cardiovascular death. Conclusion: In our initial experience with the Myval THV, valve performance and 30-day clinical results were encouraging. Low rates of complications were observed, comparable to the best last-generation THV. At the time of the meeting, three-month clinical and echocardiographic FU will be available.
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The article considers the urgent problem of combating cardiovascular diseases (CVDs) in the Nizhny Novgorod region, including the high prevalence of CVDs and the timely identification of risk factors. The changes in mortality from all and individual causes was analyzed. Attention was paid to the negative impact of the coronavirus disease 2019 (COVID-19) pandemic on the health of people suffering from noncommunicable diseases. We also described the necessity to improve healthcare efficiency for CVD patients by improving the complex of managerial and preventive measures.
ABSTRACT
Background and aims: During the COVID-19 pandemic, outpatient services transitioned mostly to virtual care. It is unknown if virtual Urgent TIA Clinic care outcomes are comparable to those of in-person visits. We, therefore, compared the risk of major adverse cardiovascular events (MACE) at 12 months between first virtual and in-person Urgent TIA Clinic visits. Methods: A virtual TIA Clinic was implemented in March 2020 in a Regional Stroke Center as an urgent response to the COVID-19 pandemic. We conducted a retrospective observational study by interrogating prospectively collected data from the London Ontario Stroke Registry. We used 26 epidemiological weeks from 2019 (in-person, prepandemic) and 2020 (virtual, pandemic). We included patients with and without a final diagnosis of stroke or TIA. The primary outcome was MACE (stroke, acute coronary syndromes, heart failure hospitalizations, and cardiovascular death) at 12 months. We applied propensity score weighted Cox regression analyses to control for risk factors, vascular comorbidities, presenting symptoms, diagnostic investigations, and secondary prevention therapies (see table for a comprehensive list), further adjusted for the final diagnosis (cerebrovascular vs. non-cerebrovascular event). Results: We included1153 patients, 700 assessed in-person and 453 virtually. The median age was 70 years, and 53% were females. MACE occurred in 27 (3.9%) in-person and 14 (3.1%) virtual care patients at 12 months, a statistically non-significant difference (adjusted HR 0.95, 95%CI 0.46 to 1.99;P=0.90). Conclusions: We found no differences in MACE at 12 months between in-person and virtual care visits in an Urgent TIA Clinic. (Table Presented).
ABSTRACT
Introduction: Although the effects of SARS-CoV-2 infection on the cardiovascular system are well known in the acute phase, the cardiovascular impact in the elderly population surviving respiratory COVID-19 infection after 1-year follow-up has not been sufficiently studied. Methods: Observational registry of 240 elderly patients (75 years or older) consecutively admitted for and surviving COVID-19 respiratory infection between March 1 and April 30, 2020. The incidence of major cardiovascular events [MACE] (cardiovascular death [CD], acute coronary syndrome [ACS], cerebrovascular disease [CVD], venous thromboembolic disease [VTE], and heart failure [HF]) was prospectively analyzed. Results: The mean age was 83.8 ± 5.6 years (range 75-103 years). A total of 54.2% were women. Most patients had a personal history of cardiovascular risk factors: hypertension (83.3%), diabetes mellitus (27.9%), dyslipidemia (43.8%). Among the main cardiological comorbidities, a history of atrial fibrillation was the most frequent (18.8%). Of note was the high percentage of institutionalized patients (37.1%) and those with moderate-severe dementia (16.7%). After a mean follow-up of 352.2±70.4 days, 13.8% of patients died and 9.6% had MACE, the most frequent being heart failure (7.5%), with no differences in the severity or overall evolution of the acute disease. Of the 33 patients who developed HF, only 3 died of cardiovascular causes. Only 2 patients suffered a stroke, in both cases without a history of AF or anticoagulants. Only 2 patients had a thromboembolic event (0.8%). The low incidence of thrombotic events may be due in part to the high rate of anticoagulation and chronic antiplatelet therapy and the high percentage of prophylactic heparin prescription at discharge, as well as the fact that only cases with clinical repercussions. COPD, CKD, institutionalization and moderate-severe dementia are associated with an increased risk of MACE, although only COPD and prescription of loop diuretics were identified as independent risk markers in the multivariate analysis. Conclusions: In elderly COVID-19 survivors, the incidence of MACE after one year of follow-up is high, the main manifestation being heart failure. COPD and the prescription of loop diuretics were identified as independent risk markers for the development of MACE in the multivariate analysis. Baseline clinical characteristics Cox survival analysis.Predictors of MACE.