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The experience of managing patients with COVID-19 around the world has shown that, although respiratory symptoms predominate during the manifestation of infection, then many patients can develop serious damage to the cardiovascular system. However, coronary artery disease (CHD) remains the leading cause of death worldwide. The purpose of the review is to clarify the possible pathogenetic links between COVID-19 and acute coronary syndrome (ACS), taking into account which will help to optimize the management of patients with comorbid pathology. Among the body's responses to SARS-CoV-2 infection, which increase the likelihood of developing ACS, the role of systemic inflammation, the quintessence of which is a "cytokine storm" that can destabilize an atherosclerotic plaque is discussed. Coagulopathy, typical for patients with Covid-19, is based on immunothrombosis, caused by a complex interaction between neutrophilic extracellular traps and von Willebrandt factor in conditions of systemic inflammation. The implementation of a modern strategy for managing patients with ACS, focused on the priority of percutaneous interventions (PCI), during a pandemic is experiencing great difficulties due to the formation of time delays before the start of invasive procedures due to the epidemiological situation. Despite this, the current European, American and Russian recommendations for the management of infected patients with ACS confirm the inviolability of the position of PCI as the first choice for treating patients with ACS and the undesirability of replacing invasive treatment with thrombolysis.Copyright © 2023 Stolichnaya Izdatelskaya Kompaniya. All rights reserved.
ABSTRACT
The experience of managing patients with COVID-19 around the world has shown that, although respiratory symptoms predominate during the manifestation of infection, then many patients can develop serious damage to the cardiovascular system. However, coronary artery disease (CHD) remains the leading cause of death worldwide. The purpose of the review is to clarify the possible pathogenetic links between COVID-19 and acute coronary syndrome (ACS), taking into account which will help to optimize the management of patients with comorbid pathology. Among the body's responses to SARS-CoV-2 infection, which increase the likelihood of developing ACS, the role of systemic inflammation, the quintessence of which is a "cytokine storm" that can destabilize an atherosclerotic plaque is discussed. Coagulopathy, typical for patients with Covid-19, is based on immunothrombosis, caused by a complex interaction between neutrophilic extracellular traps and von Willebrandt factor in conditions of systemic inflammation. The implementation of a modern strategy for managing patients with ACS, focused on the priority of percutaneous interventions (PCI), during a pandemic is experiencing great difficulties due to the formation of time delays before the start of invasive procedures due to the epidemiological situation. Despite this, the current European, American and Russian recommendations for the management of infected patients with ACS confirm the inviolability of the position of PCI as the first choice for treating patients with ACS and the undesirability of replacing invasive treatment with thrombolysis.Copyright © 2023 Stolichnaya Izdatelskaya Kompaniya. All rights reserved.
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Aim. To study clinical and anamnestic data, as well as inhospital outcomes in patients with ST elevation myocardial infarction (STEMI) with prior coronavirus disease 2019 (COVID-19) compared with previously uninfected STEMI patients. Material and methods. This prospective study included 181 patients treated for STEMI. The patients were divided into 2 groups, depending on the anti-SARS-CoV-2 IgG titer as follows: the main group included 62 seropositive patients, while the control group - 119 seronegative patients without prior COVID-19. Anamnesis, clinical and paraclinical examination, including electrocardiography, echocardiography, coronary angiography, were performed. Mortality and incidence of STEMI complications at the hospital stage were analyzed. Results. The mean age of the patients was 62,6+/-12,3 years. The vast majority were men (69,1% (n=125)). The median time from the onset of COVID-19 manifestations to STEMI was 60,00 [45,00;83,00] days. According to, the patients of both groups were comparable the severity of circulatory failure (p>0,05). Coronary angiography found that in patients of the main group, Thrombolysis In Myocardial Infarction (TIMI) score of 0-1 in the infarct-related artery was recorded much less frequently (62,9% (n=39) vs, 77,3% (n=92), p=0,0397). Patients of the main group demonstrated a lower concentration of leukocytes (9,30*109/l [7,80;11,40] vs 10,70*109/l [8,40;14,00], p=0,0065), higher levels of C-reactive protein (21,5 mg/L [9,1;55,8] vs 10,2 mg/L [5,1;20,5], p=0,0002) and troponin I (9,6 ng/mL [2,2;26,0] vs 7,6 ng/mL [2,2;11,5], p=0,0486). Lethal outcome was recorded in 6,5% (n=4) of cases in the main group and 8,4% (n=10) in the control group (p=0,6409). Both groups were comparable in terms of the incidence of complications (recurrent myocardial infarction, ventricular fibrillation, complete atrioventricular block, stroke, gastrointestinal bleeding) during hospitalization (p>0,05). Conclusion. Patients with STEMI after COVID-19, despite a more burdened history and higher levels of C-reactive protein and troponin I, compared with STEMI patients without COVID-19, did not differ significantly in clinical status, morbidity, and inhospital mortality.Copyright © 2023, Silicea-Poligraf. All rights reserved.
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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: Treating acute STEMI patients by primary PCI has dramatically fallen globally in covid era as there is chances of potential threat of spreading Covid among the non-Covid patient. Thereby, thrombolysis of acute STEMI patient either by Streptokinase (STK) or Tenecteplase (TNK) in grey zone till Covid RT PCR report to come, was the mode of treatment of acute myocardial infarction patient in our hospital. Post thrombolysis, Covid positive cases were managed conservatively in a Covid dedicated unit. Covid negative cases were treated by rescue PCI of the culprit lesion. Exact data on benefit of thrombolysis either by TNK or STK of STEMI patients in Covid era, is not well addressed in our patient population. Thereby, we have carried out this prospective observational study to see the outcomes of thrombolysis and subsequent intervention. Method(s): STEMI Patient who represented to our ER with chest pain and ECG and hs-TROP-I evidenced acute ST segment elevated myocardial infarction (STEMI), were enrolled in the study. Total 139 patients enrolled (Male:120, Female :19);average age for Male: 54yrs., female was: 56yrs. All patients were admitted in the grey zone of CCU where thrombolysis done either by TNK or STK. Positive for COVID-19, were patients excluded from intervention and managed conservatively in Covid-19 dedicated ward. Covid Negative patients were kept transferred to CCU green zone. Result(s): COVID-19 test was carried out on all studied patients. Among them, Covid-19 positive were 7.9% (11) patients and managed conservatively in dedicated Covid ward, Covid-19 negative were 92.1% (128). Primary PCI was performed in 5.03% (7). Rest was managed by Pharmacoinvasive therapy either by TNK or STK. Thrombolysis by Tenecteplase in 64% (89), Streptokinase in 17.9% (25) patient, 12.9% (18) patient did not receive any thrombolysis due to late presentation and primary PCI done in 5.4% (7). On average 2.1 days after Fibrinolysis, elective PCI carried out. Data analysis from 48 patients;chest pain duration (3.71 +/-2.8 hr., Chest pain to contact time 3.3+/-2.8hr., Chest pain to needle time 7.2 +/-12.7hr., thrombolysis to balloon time 117.5+/-314.8hr., as many of the patient develop LVF post thrombolysis. More than 50% stenosis resolution observed in 41.6% (20) patients, chest pain resolution with one hour of thrombolysis observed in 43.8% (21) patients and development of LVF in 20.8% (10) patients. Door to needle time was 30 min. At presentation of STEMI;Ant Wall MI 46.8% (65), Inferior Wall MI 52.5% (73) and high Lateral 0.7% (1). Average Serum hs Trop-I was 16656 for male and 12109 for female. LVEF were 41% for male and 48% for female. HbA1C were in Male 8.34%: Female 8.05%, SBP for Male 120mmHg: Female 128 mmHg. Total, 88 stents were deployed in 83 territories. CABG recommended for 5.03% (7) patients, PCI in 58.3% (81), remaining were kept on medical management. Stented territory was LAD 45.7% (37) and RCA 39.5% (32) and LCX 14.8% (12). Common stent used;Everolimus 61.4% (54), Sirolimus 25% (22), Progenitor cell with sirolimus 2.3%(2) and Zotarolimus 11.4% (10) Conclusion(s): In the era of COVID-19, in this prospective cohort study, on acute STEMI patient management, we found that Pharmaco therapy by Tenecteplase and Streptokinase, reduced patient symptom and ST resolution partially. Therefore, coronary angiogram and subsequent Rescue PCI by Drug Eluting Stents (DES) are key goals of complete revascularization.Copyright © 2023
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Background: The Coronavirus Disease 2019 (COVID-19) pandemic had disrupted established medical care systems worldwide, especially for highly time-sensitive acute conditions such as stroke. Strategies to maintain the quality of stroke care during the COVID-19 outbreak are crucial to prevent indirect mortality and disability due to suboptimal care. Objective: We conducted a single center analysis to compare the time-based measures for acute ischemic stroke care quality before and during the COVID-19 pandemic. Methods: A retrospective study was done utilizing the Registry of Stroke Care Quality (RES-Q) database. All acute ischemic stroke patients who presented within 4.5 hours of symptom onset in Makati Medical Center were included. Patient characteristics, treatment received, in-hospital time-based measures of stroke care quality and clinical outcomes were compared between the two periods-pre-COVID-19 and COVID-19. Results: There were 151 patients during the pre-COVID-19 period and 108 patients during the COVID-19 period who presented to the hospital with acute ischemic strokes within 4.5 hours of symptom onset. There was significantly higher NIHSS scores on admission and MRS scores on discharge during the COVID-19 period. There was no significant difference in the door-to-scan time, door-to-needle time and door-to-groin time between the two periods. Conclusion: There is no significant change in the acute ischemic stroke care quality on the basis of in-hospital time-based measures: door-to-scan time, door-to-needle time, and door-to-groin time, between the pre-COVID-19 and COVID-19 periods. Further studies on pre-hospital challenges are recommended to identify specific targets for improvements in stroke care during pandemics. © 2023, ASEAN Neurological Association. All rights reserved.
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Coronavirus disease 2019 (COVID-19) predominantly manifests with signs of respiratory system injury;however, multi-systemic manifestations may occur. Renal pathology develops in up to 80% of patients with COVID-19. The aim of the study was to describe the case of isolated massive polyuria of unknown etiology in the patient with severe COVID-19-related pneumonia complicated by pulmonary embolism (PE). A 54-year-old male with bilateral pneumonia, related to COVID-19, developed PE. The next day after successful thrombolysis with alteplase (90 mg) the diuresis of the patient began to increase and fluctuated between 5000 mL and 8000 mL. The diuresis returned to normal ranges two weeks after PE episode. The rise of the diuresis was not accompanied by electrolyte disorders and elevation of serum creatinine. Changes in the urine tests were minimal, only once the urine protein was detected (0.25 g/L). The highest urine excretion was observed in evening hours (16.00-24.00). Chest CT on the day 14 after the patient's admission revealed 90% of lung tissue injury, cranial CT showed no brain abnormalities, including hypothalamus and pituitary gland. The patient's condition met neither diagnostic criteria of acute kidney injury, nor acute interstitial nephritis, nor pituitary gland damage. The course of the polyuria in the presented case was benign (self-limiting, no blood electrolyte abnormalities, compensated by oral rehydration only). Polyuria in patients with COVID-19 may not be a life-threatening condition that does not require active treatment.Copyright © 2021 EDIZIONI MINERVA MEDICA.
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Introduction: By the time of graduation medical students need to be equipped to recognise and manage acute stroke and TIA (Transient Ischemic Attack). Despite inclusion of acute stroke and TIA in our local curriculum less than 10% of students (2/30) reported directly observing stroke thrombolysis. Due to COVID restrictions no student was able to attend TIA clinic. To improve students practical understanding of assessment and management of acute stroke and TIA a simulation-based teaching session was designed. Method(s): The simulation session consisted of a hyperacute stroke assessment (2 scenarios) and management simulation and a simulated TIA clinic (3 scenarios). Students were asked to complete a pre-course and postcourse questionnaire regarding their confidence in 8 domains, on a continuous scale 0 to 5. Result(s): There were 23 participants over 2 sessions. 18/23 completed the pre-course questionnaire and 16/23 the post-course questionnaire. The mean confidence reported by students increased in all domains: recognition of acute stroke from 3.3 to 4.8;identifying candidates for thrombolysis, 3.1 to 4.6;discussing thrombolysis with a patient or carer, 2.3 to 4.1;knowing when to call for senior support, 3.1 to 4.3;asking for a patient to be transferred to facilitate acute stroke care, 2.2 to 4.2;recognising a TIA, 2.8 to 4.9;requesting investigations for TIA, 2.5 to 4.6;and discussing anticoagulation with a patient from 2.9 to 4.4. Conclusion(s): Improvements in confidence of medical students in assessing and managing acute stroke (including thrombolysis) and TIA can be achieved through a stroke medicine themed simulation session.
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Objective: To describe ischemic stroke due to floating thrombus of ascending aorta occurring as acute and subacute complication of SARS-CoV-2 infection. Material(s) and Method(s): consecutive identification in clinical practice of ischemic strokes secondary to aortic arch thrombosis and history of acute or recent Covid-19 infection. Result(s): two patients had ischemic stroke with evidence of aortic arch thrombosis. The first case had concomitant acute Covid-19 infection, the second had recent Covid-19 infection. Both patients underwent intravenous thrombolysis, and subsequent anticoagulation. One patient died due to cerebral hemorrhage. Discussion and Conclusion(s): aortic arch thrombosis can be an incidental finding in acute ischemic stroke in patients with concomitant and recent COVID-19 disease. However, the infection may lead to thrombosis in non-atherosclerotic vessels and to cerebral embolism. Our findings support active radiological search for aortic thrombosis during acute stroke in patients with acute or recent COVID-19 disease.Copyright © 2022
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Background and Purpose: When the coronavirus disease 2019 (COVID-19) outbreak became paramount, medical care for other devastating diseases was negatively impacted. In this study, we investigated the impact of the COVID-19 outbreak on stroke care across China. Method(s): Data from the Big Data Observatory Platform for Stroke of China consisting of 280 hospitals across China demonstrated a significant drop in the number of cases of thrombolysis and thrombectomy. We designed a survey to investigate the major changes during the COVID-19 outbreak and potential causes of these changes. The survey was distributed to the leaders of stroke centers in these 280 hospitals. Result(s): From the data of Big Data Observatory Platform for Stroke of China, the total number of thrombolysis and thrombectomy cases dropped 26.7% (P<0.0001) and 25.3% (P<0.0001), respectively, in February 2020 as compared with February 2019. We retrieved 227 valid complete datasets from the 280 stroke centers. Nearly 50% of these hospitals were designated hospitals for COVID-19. The capacity for stroke care was reduced in the majority of the hospitals. Most of the stroke centers stopped or reduced their efforts in stroke education for the public. Hospital admissions related to stroke dropped =40%;thrombolysis and thrombectomy cases dropped =25%, which is similar to the results from the Big Data Observatory Platform for Stroke of China as compared with the same period in 2019. Many factors contributed to the reduced admissions and prehospital delays;lack of stroke knowledge and proper transportation were significant limiting factors. Patients not coming to the hospital for fear of virus infection was also a likely key factor. Conclusion(s): The COVID-19 outbreak impacted stroke care significantly in China, including prehospital and in-hospital care, resulting in a significant drop in admissions, thrombolysis, and thrombectomy. Although many factors contributed, patients not coming to the hospital was probably the major limiting factor. Recommendations based on the data are provided.Copyright © 2020 Authors. All rights reserved.
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Biomimetic strategies can be adopted to improve biopharmaceutical aspects. Subsequently, Biomimetic reconstitutable pegylated amphiphilic lipid nanocarriers have high translational potential for systemic controlled drug delivery;however, such an improvised system for systemic aspirin delivery exploring nanotechnology is not available. Systemic administration of aspirin and its controlled delivery can significantly control blood clotting events, leading to stroke, which has immediate applications in cardiovascular diseases and Covid-19. In this work, we are developing aspirin sustained release pegylated amphiphilic self-assembling nanoparticles to develop reconstitutable aspirin injections by solvent-based co-precipitation method with phase inversion technique that leads to novel "biomimetic niosomal nanoparticles (BNNs).” DOE led optimization is done to develop Design of space for optimized particles. Upon reconstitution of solid powder, the particle size was 144.8 ± 12.90 nm with a surface charge of -29.2 ± 2.24 mV. The entrapment efficiency was found to be 49 ± 0.15%, wherein 96.99 ± 1.57% of the drug was released in 24hr showing super case II transport-based drug release mechanism. The formulation has the least hemolysis while showing significant suppression of platelet aggregation. MTT assay does not show any significant cytotoxicity. This is a potential nanoparticle that can be explored for developing aspirin injection, which is not available.
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Case report - Introduction: Catastrophic Antiphospholipid Syndrome (cAPS) is the most severe form of antiphospholipid syndrome with a high mortality;it is characterised by multiorgan involvement that develops within a short time frame and usually consists of microvascular thrombosis. We present the case of a 50-year-old lady with recurrent microvascular and macrovascular thromboses who was initially treated with endovascular stents and amputation progressing to require immunosuppression and anticoagulation, to include steroids, rituximab, intravenous immunoglobulin and plasma exchange. Case report - Case description: A 50-year-old lady presented to the Emergency Department with bilateral leg and abdominal pain. Her comorbidities included type two diabetes, psoriasis, three miscarriages, borderline personality disorder and a heavy smoking history. Clinical examination revealed pulse deficits in the distal lower limbs with gangrene evidence of ischaemia on her toe digits. CT angiogram demonstrated complete thrombus of the Infrarenal abdominal aorta extending to the common iliac and external iliac arteries bilaterally. Thrombolysis ensued and an aortic stent was inserted with symptom relief. Two weeks later readmission occurred with bilateral leg pain;Ultrasound Doppler revealed a tight stenosis at the distal aortic region. Initial management consisted of Intravenous heparin but worsening ischaemia resulted in insertion of kissing stents at the aortic bifurcation. The patient's pain settled with no residual arterial compromise. One month later the patient was re-admitted with bilateral leg pain and necrotic right toes;this led to a right forefoot amputation. A triphasic bilateral finger colour change was noted with ischaemic pain and livedo reticularis on lower limbs, with a decision to institute Iloprost and methylprednisolone ensued. Antiphospholipid antibodies returned showing triple positivity. Management subsequently included addition of IV rituximab, plasma exchange, IVIG and sildenafil. Two months later the patient was re-admitted with complete lower limb paralysis due to a complete thrombus of the aortic bi-iliac stent;thrombolysis ensued with good result. A further admission 1- month later occurred due to sepsis and an infected necrotic left forefoot resulting in an above knee amputation. No further endovascular stenting was advised to risk of embolic seeding following medical management. Case report - Discussion: We have described a case of cAPS on a previously asymptomatic female patient who presented with diffuse peripheral and central thromboses. Our patient suffered from intraabdominal organ infarction and subsequent acute kidney injury, recurrent arterial and venous occlusion over a period of 12 months and previous pulmonary emboli. Livedo reticularis and gangrene were visible cutaneous manifestations of this disorder on our patient. cAPS accounts for less than 1% of APS and has a high mortality of 50% which means early and frequent discussion with specialist centres is important. In addition to the clinical features described in our patient, laboratory features included moderate thrombocytopaenia and evidence of haemolysis (raised bilirubin and LDH). The cAPS registry demonstrates that the majority of patients are female (72%) with a mean age of 37 years, 46% have primary APS, 40% suffer from SLE and 9% from other autoimmune diseases. This patient does not have a secondary autoimmune condition. The most common clinical features to present before cAPS develops include foetal loss, previous DVT or thrombocytopaenia, two of which our patient demonstrated. The prognosis and clinical features of cAPS have been shown to depend on the extent of thrombosis, organs affected and the presence of a systemic immune response from affected tissues. Treatment options available for cAPS consist of multiorgan support, anticoagulation and immunosuppression, in the form of glucocorticoids, rituximab, IV Immunoglobulin and plasma exchange. Our patient required all of these due to accelerating thrombosis as determined b new gangrene, ongoing livedo reticularis rash and thrombocytopenia. Case report - Key learning points: Our case demonstrates the importance of keeping a high index of suspicion for cAPS as up to 46% will have this as their first presenting feature of APS - including our patient. On her admission to hospital particular attention was paid to clinical examination which suggested Raynauds and a skin rash consistent with livedo reticularis - this prompted a rheumatology consult, serology testing, starting Iloprost and tertiary centre transfer. The diagnosis was secure with high titre of IgG anticardiolipin antibody, anti Beta-2 glycoprotein 1 antibodies and Lupus Anticoagulant detected- all on two occasions more than 12 weeks apart. Patients may present to surgical specialties in view of peripheral vascular symptoms and signs. It would be appropriate to identify patients with APS early to prevent multiple surgeries or considerations for endovascular stents, as they are frequently not successful. This case highlights the need for discussion and education within the multidisciplinary setting for patients with APS, including surgical teams. Finally, the risk of immunosuppression for patients who have received rituximab can persist for up to 12 months following treatment and this lady also had the co-morbidity of diabetes. This patient's risk stratification was high in view of COVID-19 and she was advised to shield until government guidelines ended last year. Currently she is doing well without new symptoms and she will be reviewed at 6 months following rituximab, in the Autumn of 2021.
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INTRODUCTION: This case report discussed and reviewed an atypical presentation of COVID 19 involving superior mesenteric artery thrombosis with associated ischemic colitis. Thrombosis had been reported in up to 50 percent of patients with severe COVID -19. The pathophysiology of thrombosis in COVID 19 infection may include increasing blood viscosity and endothelial damage. DESCRIPTION: Case: A 59-year-old male with GERD, hiatal hernia, and diverticulitis was presented with ten days history of abdominal pain and vomiting, which later became coffee ground in nature. He was diagnosed with COVID 19 seven days before his presentation. Lab work showed hypokalemia with lactic acidosis, polycythemia, leukocytosis, thrombocytosis, and elevated D dimer. Esophagogastroduodenoscopy demonstrated actively bleeding Mallory Weiss tear successfully treated with bipolar circumactive probe cautery (BICAP). The patient's abdominal pain worsened, and a repeat CTA abdomen revealed a superior mesenteric artery thrombosis with thickening of the distal small bowel and ascending colon. Vascular surgery was consulted, and performed catheter-assisted tPA thrombolysis to the SMA. Atrial fibrillation, diverticulitis, and other possible causes were eliminated as etiologies. DISCUSSION: Acute mesenteric ischemia is a rare abdominal emergency. Due to rapid deterioration, early diagnosis and treatment are momentous for management. Severe abdominal pain and hematemesis are the keys to starting the evaluation. Initial investigation should include basic labs with a coagulation profile;the most common abnormalities are polycythemia, metabolic acidosis, lactic acidosis, and leukocytosis. CTA provides exquisite detail of the vascular anatomy and beneficial information regarding other bowel pathologies. After diagnosis, definitive management with fluid resuscitation, antibiotics, and IV high dose unfractionated heparin, if not contraindicated, should be initiated immediately. Recently, catheter-directed procedures for intravascular thrombectomy have been used with tPA. CONCLUSION(S): In our case, we attempted to emphasize the importance of a high index of suspicion with proper history, physical examination, and appropriate imaging for proper diagnosis and management of this life-threatening incident.
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Background: Coronary heart disease is the leading cause of death in the world. Premature CAD is due to a rapidly progressive form of atherosclerosis. Acute myocardial infarction is a devastating disease when it occurs in a young patient particularly who is a single earning member of their family. With increasing rates of traditional CV risk factors such as diabetes mellitus (DM), obesity, hypertension, hyperlipidemia, and smoking, especially among adolescents, it is likely that coronary artery disease will become even more prevalent in this study group. In young adults, particularly females, more likely to have atypical symptoms of CAD, which leading to late presentation. Finally, this study group have higher rate of nonadherence to medication and lifestyle modifications. To know whether the angiographic characteristics and clinical profile differ from elderly group. The purpose of this study is for identification and documentation of change in disease trend towards very young population. Method(s): This observational study was conducted in GMKMCH Salem after getting approval from the institutional ethical committee over the period of 6 months from January 2022 to June 2022. * Informed written consent was obtained. * 62 subjects who presented to our institute with ACUTE MYOCARDIAL INFARCTION (ST elevation MI) with less than or equal to 40 years if age were enrolled into the study out of 438 total STEMI Patients over a period of 6 months, after excluding patients having Preexisting Cardiomyopathy, Prior coronary artery disease underwent CABG/PTCA, Moderate and Severe valvular heart disease and Age younger than 18. * 6 patients were taken up for Primary PCI and 26 (in hospital) and 27 (outside hospital) were thrombolysed with streptokinase and taken up for Pharmacoinvasive Therapy in our institute. * Demographic and clinical parameters were collected. They underwent Coronary Angiogram and Percutaneous Coronary Intervention(PCI). * All statistical studies were carried out using Statistical Package for Social Sciences software (SPSS). Results and observations: There were total 62(14.1%) patients in our study population out of 438 STEMI case over a period of 6 months. Age of presentation were ranging from 23 to 40 years(mean age 33.67 years). There was male preponderance [n=59 (95.20%) vs 3(4.80%)]. Among risk factors, smoking constituted the most 48(77.41%), followed by hypertension 12(19.35%), diabetes 17(27.41%) and dyslipidemia 4(6.45%). Anterior wall MI in 41(66.12%) patients was the most common type, followed by inferior wall MI in 21(33.88%) and non-ST segment elevation MI was not included. Primary PCI were done 6 (9.67%) and Thrombolysis was done in 53(85.48%), out of which it was successful in 51(82.25%) patients. Angiography was done in 59(95.16%) of patients. SVD in 45(76.27%) patients was the commonest, followed by DVD in 5(8.41%), TVD in 1(1.69%) and LM in 3(5.08%). 5(8.47%) patients had Branch vessel disease and minimal CAD in coronary angiography. LAD 36 (61.01%) was singularly the most common vessel involved. PCI was done in 22(35.48%) of patients. 3 cases were died in our study population. One patient died after LAD stenting due to cardiogenic shock and 2 patients were died before angiography. Conclusion(s): Based on the observation from our study, Smoking is the most common risk factor in young adults. The trend of AMI in young patients is growing due to physical inactivity and post COVID-19 state, in addition to the conventional risk factors. Choice of initial revascularization strategy could be pharmaco-invasive stratergy in young age and Post-COVID-19 patients with acute ST-elevation myocardial infarction, because about 1/3 of the study population were undergone PCI. Remaining patients were managed without stenting with medical management. The primary prevention of MI, particularly focus on risk factor modification such as smoking cessation and enhance physical activity. Younger patients had low prevalence of conventional risk factors than elders. And also reduced mortality noted. During coronary an iography, additional diagnostic stools should be used to diagnose microvascular dysfunction which is more prevalent in this study population. Copyright © 2022
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Background and Aims: The aim of this project was to compare the performance of Addenbrooke's acute stroke team from September 2018 - September 2021 to the UK National Stroke Service Model time-targets for hyperacute stroke management. This period was chosen to cover performance before and during COVID, because the pandemic instigated radical changes in hyperacute stroke management processes and team structure in Addenbrooke's Hospital. From this audit, we hoped to determine the effects of these changes - the strengths and weaknesses of different team and process permutations to advise the development of an ideal stroke service model. Method(s): Data on door-to-1st responder time, door-to-CT time, door-to-thrombolysis time, door-to-thrombectomy time and door-toconsultant time for patients presenting during working hours (Mon-Fri, 0900-1700) from September 2018 to September 2021 was extracted from Addenbrooke's Hospital SSNAP database. Statistical analysis revealed a non-parametric distribution, thus median time and IQR were calculated for comparison between different covering teams. Kruskal- Wallis analysis was used to compare data of different teams, and subsequently, if significance was identified, pairwise Mann-Whitney U tests were conducted to determine statistically different groups. Result(s): Door-to-1st responder, door-to-CT, door-to-thrombolysis, door-to-thrombectomy, and door-to-consultant time varied over the 3 years depending on cover. Group 4 was identified as having significantly lower door-to-1st responder and door-to-consultant times. Conclusion(s): Better staffing and top-down prioritisation for consultant review were identified as factors supporting quicker management. Reduction of door-to-CT time, simplification of CT algorithm for rapid thrombolysis and expansion of thrombectomy services were identified as changes which could potentially improve hyperacute stroke management in Addenbrooke's Hospital. (Figure Presented).
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Background: Treatment of pulmonary embolism, which is a life-threatening clinical condition, varies according to the different clinical presentations and experiences of the healthcare centers. Pulmonary embolism response teams (PERT) might improve outcomes of pulmonary embolism with faster evaluation and increases the usage of advanced treatment methods. In this study, the effects of PERT in the treatment of pulmonary embolism were investigated. Method(s): Patients diagnosed with pulmonary embolism in our hospital between 01.03.2019 and 28.02.2022 were retrospectively analyzed. Patients, who were diagnosed with PE for the first time and over 18 years of age, were included in the study. The data of the patients was obtained from the patient files. Hospitalization rates, referral rates, treatment approaches, and early-term outcomes were evaluated. Result(s): Nine-eight patients with pulmonary embolism were evaluated by the PERT during the study period. The mean age was 62.8+16.4 years and 59% were male. Nine patients had a history of fracture twelve patients had recently had Covid-19 infection and 6 patients had a history of long-term traveling. Twenty-nine patients had a proven deep venous thrombosis.All patients with intermediate-low risk were treated medically. 59.2% of the patients were hospitalized. The rate of catheterdirected thrombolysis was 37.8% (n=37). Systemic thrombolytic therapy was performed on two patients. One patient with a metastatic brain tumor was treated with low-molecular-weight heparin. Catheter-directed procedures were performed in 37 patients. The time from diagnosis to reperfusion was 243 minutes. There was one pericardial effusion and onemortality. In the 30-day follow- up there was no re-hospitalization and mortality. Conclusion(s): Treatment of pulmonary embolism still varies according to clinical experience. PERT might help with early triage and treatment of patients with pulmonary embolism. Experienced specialists in this team might contribute to clinical recovery by performing advanced treatment methods and decreasing the risk of chronic thromboembolic pulmonary hypertension in the long term and improving the clinical outcomes by increasing quality of life.
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Purpose: The COVID-19 pandemic caused by the coronavirus SARS-CoV-2 has resulted in a global health care crisis. The provision of CT imaging services by radiology departments for COVID-19 patients poses multiple challenges. Thus, the clinical indications and utility of thoracic CT, determined by whether it subsequently alters patient management, in COVID-19 patients is important to establish. Current literature is not well established specifically for the 'Delta' SARS-CoV-2 variant. Methods and Materials: This is a single tertiary hospital centre retrospective review of all consecutive confirmed COVID-19 cases admitted during the peak of the 'Delta' variant wave in Australia who underwent a chest CT. Clinical indication for chest CT and patient management plan pre and post CT were ascertained. Result(s): During this period, 1403 patients were admitted with COVID-19 and 92 patients underwent CT of the thorax, with 18 patients scanned urgently. There were 73 CTPA, 14 CT Chest and 5 HRCT studies. 20 patients were in ICU at the time of scan. Regarding the clinical indications for thoracic CT, 72.8% of studies were to evaluate for pulmonary emboli, 16.2% for assessment of COVID-19 pneumonia complications, 5.4% for tuberculosis and 6.5% for other indications. 21 (23%) of these studies resulted in a change in management with 2 patients having a major change in management (thrombolysis, CT guided aspiration) whilst 19 had minor changes. Of 73 CTPA studies, 11 (15%) patients had evidence of pulmonary embolism. 6 patients underwent a second chest CT for diverse reasons. Conclusion(s): In conclusion, 6% of patients in the cohort of COVID- 19 patients admitted to our centre during the Delta variant wave of COVID-19 in NSW, Australia underwent a CT of the thorax. In 23% of these patients, chest CT resulted in a change in management. 72.8% of chest CT scans were for the evaluation of possible pulmonary emboli. CT was not used for diagnosis or follow-up of COVID-19 in any of our patients.
ABSTRACT
Background: COVID-19 disease arises from infection with severe acute respiratory cornonavirus-2 (SARS-CoV- 2). Severe disease is associated with a coagulopathy characterised by elevated D-dimer levels, fibrin deposition in the lung, and a thrombotic incidence of approximately 30%, indicating catastrophic derailment of the haemostatic system. Aim(s): To investigate whether SARS-CoV- 2- induced coagulopathy arises due to an imbalance in the fibrinolysis. Method(s): Citrated plasma was collected from 139 patients presenting with symptomatic COVID-19, 24 patients with non-COVID- 19 respiratory infection and 30 healthy controls in a dual-centre study. Fibrinolytic biomarkers were evaluated including plasminogen activator inhibitor 1 (PAI-1), tissue plasminogen activator (tPA), plasminogen, vitronectin and thrombin activatable fibrinolysis inhibitor (TAFI). Furthermore, diagnostic biomarkers including, fibrinogen, C-reactive protein (CRP), D-dimer and inflammatory cytokines were quantified. Clot lysis was evaluated using turbidity assays, plasma clot structure visualised by confocal microscopy and plasmin generation quantified by chromogenic substrate. Result(s): PAI-1 antigen, activity, and the cofactor for this serpin, vitronectin, were significantly elevated in patients with COVID-19 compared to healthy controls and non-COVID- 19 respiratory infection. Patients with COVID-19 exhibit attenuated plasmin generation compared to healthy volunteers despite significant elevation in tPA. PAI-1 correlated with inflammatory cytokines (IL-1beta, IL-8 and TNF-alpha). In line with this acute phase proteins, fibrinogen and CRP were high in patients with COVID-19 but only CRP was increased compared to non-COVID- 19 respiratory infections. Levels of PAI-1 and vitronectin were associated with escalating oxygen support and a corresponding decrease in plasminogen. Importantly, patients with COVID-19 disease exhibit resistance to fibrinolytic degradation by Actilyse, however, this could be overcome by the PAI-1 resistant form of tPA, Metalyse. Conclusion(s): We reveal that COVID-19 disease promotes a hypofibrinolytic state due to elevated PAI-1 and its stabilizing cofactor vitronectin. PAI-1 correlates with inflammatory cytokines and disease severity thereby highlighting its potential prognostic power in the development of severe COVID-19 disease.