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Objectives: COVID 19 and increasing unmet needs of health technology had accelerated an adoption of digital health globally and the major categories are mobile-health, health information technology, telemedicine. Digital health interventions have various benefit on clinical efficacy, quality of care and reducing healthcare costs. The objective of the study is to identify new reimbursement policy trend of digital health medical devices in South Korea. Method(s): Official announcements published in national bodies and supplementary secondary research were used to capture policies, frameworks and currently approved products since 2019. Result(s): With policy development, several digital health devices and AI software have been introduced as non-reimbursement by utilizing new Health Technology Assessment (nHTA) pathway including grace period of nHTA and innovative medical devices integrated assessment pathway. AI based cardiac arrest risk management software (DeepCARS) and electroceutical device for major depressive disorders (MINDD STIM) have been approved as non-reimbursement use for about 3 years. Two digital therapeutics for insomnia and AI software for diagnosis of cerebral infarction were approved as the first innovative medical devices under new integrated assessment system, and they could be treated in the market. In addition, there is remote patient monitoring (RPM) reimbursement service fee. Continuous glucose monitoring devices have been reimbursed for type 1 diabetes patients by the National Health Insurance Service (NHIS) since January 2019. Homecare RPM service for peritoneal dialysis patients with cloud platform (Sharesource) has been reimbursed since December 2019, and long-term continuous ECG monitoring service fee for wearable ECG monitoring devices (ATpatch, MEMO) became reimbursement since January 2022. Conclusion(s): Although Korean government has been developed guidelines for digital health actively, only few products had been reimbursed. To introduce new technologies for improved patient centric treatment, novel value-based assessment and new pricing guideline of digital health medical devices are quite required.Copyright © 2023
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Bruton tyrosine kinase inhibitors (BTKis) were approved for use at the end of 2013 and have since been used for indications including chronic lymphocytic leukaemia (CLL), Waldenstrom's macroglobulinaemia and mantle cell lymphoma. The use of BTKis has increased significantly in the UK since they achieved NICE (National Institute for Health and Care Excellence) approval for frontline treatment of CLL in 2021. However, they are associated with significant adverse cardiovascular events. In September 2021 the British Journal of Haematology published good practice guidelines for the management of cardiovascular complications of BTKis. Our aim was to see whether these guidelines had been adhered to for patients taking BTKis. Method(s): Data was collected for all patients being prescribed BTKis (ibrutinib and acalabrutinib) in the South Tees NHS Trust in July 2022. Patients' medical records were used to assess whether their management adhered to the good practice guidelines. Data was collated for 67 patients in total. Result(s): The data showed that although all patients were consented for the risk of atrial fibrillation only 6% were consented for hypertension and only 1.5% for ventricular arrhythmias and sudden cardiac death. The guidelines recommend a baseline ECG (electrocardiogram) on commencement of treatment;however, only 7% had this completed and 0% had the minimum monitoring recommendation of 6-monthly ECGs. Thirty patients (45%) had an indication for a baseline echocardiogram;however, only one had this completed. For patients reporting symptoms of syncope, dizziness or palpitations only 50% had an ECG completed. Three patients developed worsening heart failure. The recommendations suggest referral to a cardio-oncologist;however, due to lack of availability of this service the referrals were instead made to the usual cardiologist. Conclusion(s): Although there was a lack of compliance with guideline recommendations, it should be considered that most usual checks were affected by COVID-19 outbreaks and a drop in face-to- face clinics, which were replaced by phone clinics and home delivery of medications. However, the premade consent forms for BTKis need to be updated to include consent for ventricular arrhythmias and sudden cardiac death. There also needs to be routine procedures in place to ensure that regular blood pressure testing and ECG monitoring occurs and that there is prompt recognition of cardiovascular complications. Action and implementation: To ensure improved compliance with these guidelines we plan to update our consent forms and create a proforma for clinic use to ensure that clinicians are aware of the various monitoring criteria required.
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The aim of the research. To study the features of cardiovascular system disorders in post-covid syndrome (PCS) in children and adolescents after a mild form of coronavirus infection (COVID-19). Material and methods. From 260 children and adolescents after a mild form of COVID-19, a total of 30 patients aged 7-17 years with cardiac manifestations of PCS were selected. Therewith, 32 patients with an uncomplicated form of the disease were selected to form a comparison group. In 3 and 6 months after disease onset, a comprehensive examination of patients was performed with a questionnaire on the subjective scale for MFI-20 assessment asthenia (Multidimensional Fatigue Inventory-20), electrocardiography (ECG), echocardiography;daily monitoring of ECG and blood pressure. The biochemical blood test included assay of creatine phosphokinase-MB (CPK-MB), troponin I and lactate dehydrogenase (LDH). Results. The incidence of PCS with cardiac manifestations amounted to 11.5 %. After 3 months from the disease onset, complaints of pain and discomfort in the chest, palpitations, fatigue, and poor exercise tolerance persisted. Asthenic syndrome was diagnosed in 70 % of patients. The "general asthenia" indicator totalled14 [12;16] points (p<0.001) and was associated with the age of patients (r=+0.5;p<0.05). Arrhythmic syndrome and conduction disorders were detected in 67% of children. Labile arterial hypertension and hypotension occurred in 23 % of the adolescents. The increase in CPK-MB remained in 17% of the children, LDH - in 10%. In the sixth month after the onset of the disease, there were no significant differences in the results of the examination in the observation groups. However, a decrease in the level of resistance within 6 months was recorded in 43.3% of the schoolchildren with PCS (p<0.001). Conclusion. The data obtained indicate the need for early verification of cardiopathies in children with COVID-19, determination of a set of therapeutic and rehabilitation measures as well as ECG monitoring.Copyright © 2022, Krasnoyarsk State Medical University. All rights reserved.
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Case Report: It is well documented that Coronavirus Disease 19 (COVID-19) patients who suffer cardiac injury have a higher mortality rate, however the exact mechanism of cardiac injury and potential complications are still unknown. Takotsubo Cardiomyopathy (TCM), which was first described in 1990 in Japan, is characterized by a transient systolic and diastolic left ventricular dysfunction with a range of wall motion abnormalities predominantly affecting women often following an emotional or physical trigger. Though TCM is seen less commonly as a cardiac complication of COVID-19, with increasing rates of cardiovascular events due to COVID-19, TCM should be taken into consideration as a potential diagnosis for a COVID-19 positive patient. Case Description: The case of a 75-year old female with a history significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and gastroesophageal reflux disease presented to the Emergency Department after a ground level fall and subsequent left hip pain. Upon primary survey, EKG showed persistent sinus tachycardia in the 130-150s, with intermittent borderline dynamic changes and a troponin that was mildly elevated at 0.10, and an initial false negative COVID-19 test. Preoperative echocardiogram showed normal left ventricle size, no regional wall abnormalities, and a left ventricular ejection fraction (LVEF) of 60-65%. In post-operative care, EKG illustrated dynamic changes in the form of ST elevation in the lateral precordial leads, as well as an increase in the cardiac troponins, from 0.07 to 3.51. A subsequent echocardiogram illustrated a drop in her ejection fraction from 60-65% to 30-35%, with evidence of left ventricular systolic dysfunction that was not noted on previous echocardiograms. Following the Mayo clinic diagnostic criteria, this patient met the diagnostic criteria for TCM, as evident by new electrocardiograph findings, non-obstructive cardiac catherization findings, echocardiogram findings illustrating transient left ventricular systolic dysfunction, modest elevations in cardiac troponins as well as the patient being a post-menopausal female. Subsequent echocardiogram on 2 week follow up showed a rebound in her ejection fraction to 50-55%. Discussion(s): Possible outcomes of TCM include cardiogenic shock, respiratory failure, and death. It is imperative that clinicians consider TCM as a possible diagnosis when treating COVID-19 patients that may be exhibiting cardiac complications. Frequent ECG monitoring and a vigilant differential should include TCM in patients presenting with COVID-19.
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Background: COVID-19 infection has been shown to have an adverse impact on the cardiovascular system. Cardiac injury, as indicated by elevated cardiac troponin and NT-proBNP levels have been confirmed in COVID-19 cases. There is still ambivalent data on the effect of left ventricular function. Cases of left ventricular impairment, persistent hypotension, acute myopericarditis, myocarditis, arrhythmia and heart failure have been reported in the short term, but there is a significant lacuna when it comes to medium and long-term follow-up of subjects previously infected with COVID-19. Purpose(s): To assess any residual myocardial and autonomic injury in subjects previously infected with COVID-19 at a median follow-up of 5 months. Method(s): A case-control study was performed. Cases were randomly selected subjects who were previously diagnosed with COVID-19 infection following nasopharyngeal swabbing. Controls were subjects who had not been found to be infected with COVID-19 following swabbing and were negative for COVID-19 IgG antibodies. All participants were submitted a standardised questionnaire regarding past medical history. Blood investigations were taken including NT-proBNP and troponin I levels. In addition, all participants underwent 24-hour ambulatory blood pressure monitoring (ABPM) and 24-hour ECG monitoring. The latter was used to assess both for underlying arrhythmias as well as heart rate variability (HRV), a measure of autonomic regulation of the heart. All data was analysed using SPSS version 23.0. Result(s): The study comprised 259 subjects, whereby cases included 174 participants while 75 subjects were age- and gender-matched controls. The study cohort was relatively young with a mean age of 46.1+/-13.8 years. The median follow-up was of approximately 5 months (median 173.5 days, IQR 129-193.25 days). There was no statistically significant difference between cases and controls with regards cardiovascular risk factors and underlying medical conditions. Likewise, there was no difference in blood investigations, including troponin I and NT-proBNP levels at 5-months followup. No difference was noted between the two groups in both awake and asleep blood pressure (BP) readings, as well as dipping BP status. No significant arrhythmias were noted in both groups on 24-hour ECG monitoring. However, when assessing for heart rate variability, it was shown that subjects who had been previously infected with COVID-19 exhibited lower root-mean square differences of successive R-R intervals (RMSSD), p=0.028. This indicates poor vagus nerve-mediated autonomic control of the heart. Conclusion(s): Subjects previously infected with COVID-19 exhibited lower HRV as exhibited by low RMSSD as compared to controls. Reduced HRV is a known biomarker for mortality and sudden death in cardiac disease. The possible long-term implications of reduced HRV in subjects previously infected with COVID-19 merits further investigation.
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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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Objective: To evaluate the need for cardiac monitoring of unselected patients recovered from COVID-19 and to estimate the risk of development of arrhythmias after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Result(s): Presence of significant pathology detected was rare (one paroxysmal atrial fibrillation in 73-year-old woman with dilated left atrium;71-year-old man with atrioventricular blockade with indication for implantation of the pacemaker, when cardiac MRI didn't find any signs of myocardial inflammation. After evaluation both were not related to previous SARS-CoV-2 infection. During one-year follow-up after COVID-19 infection there was no change in heart rate variability evaluated by SDNN (V1 vs V3 156.6+/-40.6 vs 156,0+/-38.0;p = 0.855), rMSSD (V1: 33+/-13.95 to 30.6+/-12.89;p = 0.175) and triangle (V1: 28.5+/-7.8 to 29.5+/-8.8;p = 0.488). Dividing heart rate oscillations into low-frequency (LF), and high-frequency (HF) bands, we have found statistically significant changes between V1 a V3 for LF (718+/-433.7 to 646+/-361;p = 0.024) and HF (341.5+/-335 to 268.0+/-266;p = 0.032). These parameters are mostly affected by breathing rate and are representing possible autonomic dys-regulation (HF/LF ratio). Conclusion(s): Despite many information regarding cardiac impairment of SARS-CoV2 our study does not suggest an increased risk of development of arrhythmias after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) even in a population with high proportion of ongoing symptomatology. Some findings may suggest autonomic dysfunction after COVID-19. Based on our results the routine ECG monitoring is currently not recommended after COVID-19 recovery.
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Background and aims: Relative Bradycardia (RB) is a poorly understood condition that refers to inappropriately low heart rate response to a given increase in body temperature. Dysfunctional crosstalk between the immune system and the autonomous nervous system has been advocated. It is most often observed in intracellular gram negative and parasitic infections, with a prevalence ranging between 15% and 20%. The aim of this study was to identify the prevalence, clinical determinants and significance of RB in patients hospitalized for SARS-CoV-2 infection and to evaluate its prognostic value for long-covid syndrome during follow-up. Method(s): We enrolled consecutive patients hospitalized for SARS-CoV-2 infection from March 2020 to April 2021. We collected clinical parameters including clinostatic and orthostatic blood pressure (BP) and heart rate (HR) at 1,3 and 5 minutes, oxygen saturation, body temperature (BT), routine blood tests, 12-lead ECG, and 48-h Holter ECG. At follow up, clinical symptoms were investigated by novel Malmo POTS Symptoms (MAPS) questionnaire. Result(s): Total population included 269 inpatients (mean age 67+/-17 years, 59% male).Of these, 30 (11%) presented with sinus bradycardia and 37 (14%) RB. RB was more frequently observed in younger male patients with higher BT and heightened CRP levels. There were no significant correlations between BP and HR orthostatic changes and BR during hospital admission or during follow-up. No clinically relevant arrhythmias were revealed during 48-hour ECG monitoring. After mean16-month follow-up, MAPS score was higher in patients with RB (30+/-19) compared to those without RB (18+/-21, p=0.001) during index hospital admission. Dizziness, palpitations and fatigue were more frequently reported in patients with RB(p<0.001). Conclusion(s): RB is not an uncommon condition during acute COVID-19. SARS-CoV-2 inpatients who presented RB during index hospitalization showed a higher symptom burden during follow-up, as recorded by MAPS score. Further studies are needed to clarify the clinical significance of RB and its value to predict post-acute sequelae of COVID-19. (Figure Presented).
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Background: The COVID-19 pandemic resulted in a necessary transition from centre-based cardiac rehabilitation to virtual cardiac rehabilitation (VCR) to continue delivery of effective and high-quality care. To enhance risk stratification, an extended duration electrocardiographic (ECG) patch monitor was added to the intake protocol for patient's enrolled in a virtual only cardiac rehabilitation program. Method(s): The objectives of this study were to assess the diagnostic yield of extended ECG patch monitoring (DR400 3-channel monitor, NorthEast Monitoring, Inc., Maynard MA;5-day duration) and the effect on clinical management in a tertiary cardiac rehabilitation population. A retrospective analysis of consecutive patients enrolled in VCR at a single site was performed. All patients who were enrolled in VCR and underwent extended ECG patch monitoring as part of their intake assessment were included. Risk was defined by the AACVPR 2020 risk categorization. Extended patch monitor diagnoses were reviewed for accuracy and classified as a new or known diagnosis. Impact on clinical management was defined as any medication adjustment, procedure requirement/recommendation, or exercise prescription modification. Patient characteristics, cardiac testing results, and risk categorization were described using basic descriptive methods including frequency distributions, and means and SDs. Result(s): Two-hundred and sixty-nine patients [mean age 61.7 years (SD 12.0) 63% male] out of 286 patients enrolled in VCR between August 13, 2020 and October 26, 2021 met inclusion criteria (Table 1). Two percent of patients were classified as high risk, 41% as moderate risk, and 57% as low risk. Thirty (11%) new arrythmia diagnoses were obtained from extended ECG patch monitoring. Diagnoses included one patient with atrial flutter and high-grade AV block, one patient with paroxysmal atrial fibrillation, and 28 patients with non-sustained ventricular tachycardia (NSVT) (4-48 beats;11% symptomatic). Fifty-seven percent (n=17) of diagnoses were evident on the first 24-hours of monitoring and 43% (n=13) required extended duration monitoring for diagnosis. Thirteen patients with known atrial fibrillation or flutter were noted to have this arrhythmia present. Of those with a new diagnosis, 6 (20%) resulted in a change in clinical management (Figure 1). Conclusion(s): Extended duration ECG patch monitoring appears diagnostically and clinically useful when utilized as a component of intake evaluation for VCR. Furthermore, added benefit of extended (i.e., 5 day) versus the initial 24-hour period of monitoring was observed. Further evaluation is required to determine the optimal duration and clinical utility of asynchronous ECG monitoring as a component of risk stratification for VCR programs.
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The proceedings contain 14 papers. The topics discussed include: sex differences in post-stroke depressive symptoms at entry to cardiac rehabilitation: a retrospective study;the diagnostic and clinical utility of extended ECG monitoring for risk stratification in virtual cardiac rehabilitation;exploring the challenges of implementing guidelines. a protocol for a systematic review of systematic reviews using the theoretical domains framework;cardiac rehabilitation and frailty: a systematic review;vascular response to a cardiac rehabilitation program adapted for COVID-19;qualitative and mixed methods research in the cardiovascular sciences: a trend analysis of Canadian federal funding from 2001-2021;validation of digital educational materials for cardiac rehabilitation patients;the impact of frailty at admission of cardiac rehabilitation on long-term adverse outcomes;and the complex roles of acculturation and religious coping in shaping recovery experiences after cardiac events among Arab individuals in Ottawa.
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Background: Conflicting results on the cardiovascular involvement after SARS-CoV-2 infection generated concerns on the safety of return-to-play (RTP) in the athletic population. However, data are limited to the approached based on Troponine, ECG and echocardiogram while the data on exercise test are scarce. Purpose: Aim of the study was to evaluate the prevalence of cardiac involvement after COVID-19 in competitive athletes for the RTP applying a comprehensive cardiovascular evaluation. Methods: Since October 2020, all consecutive competitive athletes (age≥14 years) presented to our Institute after COVID-19 prior RTP were enrolled. The protocol was dictated by the Italian governing bodies and comprised: 12-lead ECG, blood test, cardiopulmonary exercise test (CPET), 24-hours ECG monitoring, spirometry. Cardiovascular Magnetic Resonance (CMR) was performed based on clinical indication. Results: 219 competitive athletes were enrolled (59% male), age 23 years (19,27): 20% asymptomatic, 77% mildly asymptomatic, 2% had pneumonia. The evaluation was performed after a median of 10 days (6-17 days) from negative SARS-CoV-2 swab. All athletes had a good performance at CPET. Uncommon premature ventricular contractions (PVCs) were found in 10% (n=21) and were detected by CPET. Two athletes (1%) were finally diagnosed with acute myocarditis (confirmed by CMR) and another had newly diagnosed mild pericardial effusion (Figure). All the three athletes were temporally refrain from sport participation. Conclusions: Cardiac abnormalities in competitive athletes screened after COVID-19 resolution were detected in a minority of the cases (1.4%). No one of the remaining athletes had abnormalities by imaging or laboratory test neither reduction in cardiopulmonary fitness. Our data are in line with those reporting low prevalence of cardiovascular complication in mildly symptomatic or symptomatic athletes. (Figure Presented).
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Background: Conflicting results on the cardiovascular involvement after SARS-CoV-2 infection generated concerns on the safety of return-to-play (RTP) in the athletic population. However, these data are mainly based on Troponin and imaging findings. Purpose: Aim of the study was to evaluate the prevalence of cardiac involvement after COVID-19 in Olympic athletes, who had previously been screened in our pre-participation program. Methods: Since November 2020, all consecutive Olympic athletes presented to our Institute after COVID-19 prior RTP were enrolled. The protocol was dictated by the Italian governing bodies and comprised: 12-lead ECG, blood test, cardiopulmonary exercise test (CPET), 24-hours ECG monitoring, spirometry. Cardiovascular Magnetic Resonance (CMR) was also performed. All Athletes were previously screened in our Institute as part of their periodical pre-participation evaluation. Results: Forty-seven Italian Olympic athletes were enrolled: 83% asymptomatic, 13% mildly asymptomatic, 4% had pneumonia. The evaluation was performed after a median of 9 days from negative SARS-CoV-2 swab. Uncommon premature ventricular contractions (PVCs) were found in 13% athletes, however, only 6% (n=3) were newly detected. All newly diagnosed uncommon PVCs were detected by CPET. One of these three athletes had evidence for acute myocarditis by CMR, along with Troponin raise;another had mild pericardial effusion. No one of the remaining athletes had abnormalities detected by CMR (Figure). Conclusions: Cardiac abnormalities in Olympic athletes screened after COVID-19 resolution were detected in a minority and were associated with new ventricular arrhythmias. Only one had evidence for acute myocarditis (in presence of symptoms and elevated biomarkers). No one of the remaining athletes had abnormalities by imaging or laboratory test. Our data support the efficacy of the clinical assessment including exercise-ECG to raise suspicion for cardiovascular abnormalities after COVID-19. Instead, the routine use of CMR as a screening tool appears not justified. (Figure Presented).
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Introduction: Prior to COVID-19, ECG patches (ECGp) were applied almost exclusively in-clinic (CA) by technicians which required an office visit and fee. Since the pandemic, direct-to-patient, self-applied patch use (SA) has substantially increased, though the metrics surrounding SA are unknown. This study compares monitoring completion rates and data quality between CA and SA ECGp prior to and during COVID-19. Hypothesis: CA and SA ECGp have similar data quality and monitoring completion metrics. Methods: We performed a retrospective cohort analysis of patients prescribed an iRhythm Zio XT patch at Northwestern Memorial Hospital during the “pre-COVID” (3/1/2019-3/1/2020) and “COVID” (4/1/2020-4/1/2021) timeframes. Differences in ECGp with data available, actual vs prescribed wear time, and analyzable data between groups were assessed. ECGp without data was defined as devices which were not returned or not activated. Results: The cohort included 29,118 ECGp prescriptions;13,180 pre-COVID (45%). The cohort was 56% female with mean age of 59.3 + 17.7 years. Palpitations (29%) and atrial fibrillation (19%) were the most common indications. In the pre-COVID cohort, there were no (0%) SA ECGp and data were available for 12,932 CA patches. In the COVID cohort, 34% of ECGp were SA;data were available for 10,231 CA ECGp and 4,902 SA ECGp. Average delay between prescription and SA ECGp activation was 8.1 ± 12.2 days. Comparisons between percent analyzable data, wear times, and ECGp with data available are shown in figure 1. Conclusions: COVID-19 resulted in a rapid adoption of SA ECGp use. Compared to CA, SA was associated with an inherent delay in ECGp application and a higher proportion of ECGp without data. However, there was no difference in actual vs prescribed wear time and a small but statistically significant decrease in percent analyzable data. These differences must be balanced with the additional cost and need for in-person visit for CA vs SA. (Figure Presented).
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Introduction: Multisystem inflammatory syndrome in children (MIS-C) is a severe complication of COVID-19 infection, typically evidenced 4-6 weeks after the infection. The debated pathogenesis is a dysregulation of inflammatory response to SARS-CoV-2 infection ad a cytokine hyperexpression. Persistent fever, respiratory and gastrointestinal symptoms are the most common manifestations, associated with typical clinical signs described in Kawasaki Disease (KD). Furthermore, pleiomorphic cardiac manifestations are described, including ventricular dysfunction, coronary artery dilation and aneurysms, arrhythmia, conduction abnormalities and pericardial effusion. These manifestations are a strong link with KD, even if in MIS-C they are more frequently documented. Severe cases can present as Toxyc Shock Syndrome (TSS) with vasodilatory or cardiogenic shock, requiring treatment with plasma expanders, inotropic drugs, diuretics, albumin and -in the more severe patients- extracorporeal membrane oxygenation and mechanical ventilation. KD experience guided the clinicians to treat these children with intravenous immunoglobulin (IVIG), steroids, aspirin (ASA) and, in refractory cases, anti-IL-1 monoclonal antibodies. Objectives: Most patients recover within days to a couple of weeks and mortality is rare, although the medium- and long-term sequelae, particularly cardiovascular complications, are not yet known. Methods: We describe the short-term outcome in a case series of 12 Sicilian children (4M;8F;age: 1.4-14 years) with MIS-C and a documented recent or actual infection by SARS-CoV-2 who showed cardiac involvement. Results: The cardiac features were: 3 patients showed pericardial effusion;1 coronaritis;6 transient mitral valve regurgitation;1 Brugada pattern, evidenced when he was febrile;2 showed associated mitral and aortic valve regurgitation). 7/8 patients with valve regurgitation showed a significant increase of pro-BNP, normalized during the follow-up. TSS was described in 2 patients, showing a significant increase of troponin, promptly treated with high dose of methylprednisolone, IVIG, vasoactive drugs, albumin and diuretics. 3 patients (21%), after the resolution of the acute phase, showed bradycardia (heart rate < 50/min), persisting for 7-10 days. The bradycardia was not associated with first-degree AVB, or a pathological PR. 6 patients (42%) showed an altered ventricular repolarization phase, in association with an increase of pro-BNP (129-3980 pg/ml). 4/12 (33%) had increased troponin levels (27.3-246 ng/ml) in the acute phase, with the normalization of troponin after IVIG and steroids treatment. Pro-BNP persisted increased for a longer time, besides the clinical improvement and the normalization of blood chemistry parameters. Conclusion: Generally, pro-BNP and troponin levels in MIS-C are higher than in KD, reflecting vasculopathy and cardiomyocytes damage extent. Persistence of increased levels of pro-BNP, in patients with a normalization of inflammatory parameters, suggests a mechanism of myocardial oedema, persisting besides the intensive care approach useful, however, to limit effects on cardiac function and normalize inflammatory parameters. Patients admitted with MIS-C require close electrocardiogram monitoring during the acute phase and the recovery, even if they do not manifest dyselectroliteemia, coronary lesions, pericardial effusion, myocarditis, shock. This approach can avoid severe arrythmia.
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Background and Aims: Subclinical atrial fibrillation (SCAF) is an asymptomatic, short and fast atrial arrhythmia observed during long-term monitoring. SCAF incidence ranges between 5-15% in critical illness and is associated to an increased risk of one-yeardeath, while its role in thromboembolism is debated. With this pilot study, we assessed SCAF incidence in a longitudinal cohort of moderate-to-severe CoViD-19, evaluating its association with inhospital death, major bleeding or thromboembolism. Methods: We considered all the subjects admitted to our subintensive medicine department for moderate-to-severe CoViD-19 undergoing to continuous ECG monitoring for at least seven consecutive days, evaluating the occurrence of SCAF daily. We also collected history, ECG, age, sex, occurrence of in-hospital death, thromboembolism and major bleeding. Results: Of 34 consecutive patients, 4 were excluded for pre-existing atrial fibrillation. We analysed 30 subjects who completed ECG monitoring: mean age was 66±14.8 years, 47% were females. SCAF incidence was 20% in 7 days. During the admission we observed 6(20%) deaths, 2(6%) thromboembolic events and 2(6%) major bleedings, with no relationship with SCAF occurrence. SCAF was more frequently observed in severe than in moderate CoViD-19 (p=0.0001). Conclusions: SCAF shows high incidence in CoViD-19, especially within a severe disease. This pilot study did not underline an association with short-term events: we are expanding our cohort and performing a longer follow-up to validate our data and to assess associations with post-CoViD events.
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Background and Aims: Subclinical atrial fibrillation (SCAF) is defined as a fast, asymptomatic and self-terminating arrhythmic event, often diagnosed by long-term monitoring. We observed a high SCAF prevalence in moderate-to-severe CoViD-19. We aimed to assess the determinants of SCAF in this cohort. Methods: All the consecutive patients affected by moderate-tosevere CoViD-19 admitted in a subintensive CoViD-19 unit were enrolled;each patient was submitted to continuous ECG monitoring for 7 days;for each subject, we collected - at the admission - age, sex, BMI, history of heart failure, history of hypertension, history of COPD, LUSS score, 12-leads ECG (calculating intervals and assessing the most common alterations), BNP, Troponin I and PaO2/FiO2. Results: We obtained 34 consecutive patients;4 patients were excluded for pre-existing atrial fibrillation;SCAF was observed in 20% of the sample;age, sex, BMI, history of heart failure, hypertension and COPD, all the ECG intervals (PR, QRS and ST), ECG alterations (atrioventricular blocks, intraventricular blocks, hypertrophy or ischemia), BNP, Troponin I and PaO2/FiO2 did not result statistically associated with SCAF. Patient developing SCAF had a higher LUSS score resulted significantly associated to SCAF (LUSS in no-SCAF: 15.36±5,38;LUSS in SCAF: 20,0±4,27;p=0,027), even after Bonferroni correction. Conclusions: SCAF has a high prevalence in CoViD-19 and seems to be correlated more to the disease severity than to the classical risk factors for atrial fibrillation. Larger cohorts are required to validate our observations.
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Objective: To evaluate the need for cardiac evaluation of unselected patients recovered from COVID-19. Methods: Prospective observational cohort study, which included 105 patients recently recovered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The diagnosis was established by reverse transcription polymerase chain reaction on swab test of the upper respiratory tract. Demographic parameters, patient history, clinical evaluation, cardiac blood markers, ambulatory 7-day ECG monitoring and echocardiography have been performed to determine possible cardiac injury. Results: The study group (n=105) included 58% women, mean age was 46 years (range 18-77 years). Mean time interval between the onset of the infection and the follow-up visit was 107 days. One quarter of the patients required hospitalisation during the acute phase of the disease, the rest recovered at home. 74% suffered from mild form, 3.8% moderate, 18.3% severe and 2.9% of critical form of the disease. At the time of evaluation 63.5% of the patients were referring the ongoing symptoms, fulfilling the criteria of postcovid syndrome, while more than half of the whole group mentioned at least one symptom of possible cardiac origin (breathing problems, palpitations, exercise intolerance, fatigue). One patient was diagnosed with paroxysmal atrial fibrillation (woman, 73 years old, dilated left atrium), one patient with atrioventricular block with indication for implantation of the pacemaker (man, 71 years, cardiac MRI didn't found any signs of myocardial inflammation);in one subject (man, 69 years) was diagnosed coronary artery disease due to atherosclerosis with the necessity of revascularization by percutaneous coronary intervention;one woman was prescribed beta-blocker for inadequate sinus tachycardia and palpitations. All these findings are not suspected to be the result of SARS-CoV-2 infection. In three patients mild pericardial effusion was found with no intervention necessary. There was not found any left or right ventricle dysfunction on echocardiography. Only three findings on ECG monitoring mentioned above need a therapeutic intervention. Conclusion: Despite the significant proportion of the patients with ongoing symptoms beyond the 12 weeks after the onset of the infection SARS-CoV-2, confirmed cardiac impairment is quite rare and distributed mostly among older patients and those with other risk factors.