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The proceedings contain 115 papers. The topics discussed include: clinical and genetic predictors of sickle cell nephropathy in Malawi;clinicohematological characteristics of iron deficiency anemia and hemoglobinopathies in Pakistan;an experience of non-hospital based laboratory;assessment of hematological parameters of petrol filling workers at petrol stations in Ethiopia: a comparative cross-sectional study;burden and risk factor to acute myocardial ischemia in children with sickle cell anemia;dyslipidemia in transfusion-dependent-thalassemia patients and its correlation with serum vitamin D level;impact of COVID-19 pandemic to pre-transfusion hemoglobin level and frequency of transfusion in transfusion-dependent thalassemia patients in Indonesia;retinopathy in Egyptian patients with sickle cell disease;and dietary pattern, socio-demographic characteristics and nutritional status of pregnant women attending Barau Dikko teaching hospital and the need to develop recommended dietary allowance and dietary reference intakes for sickle cell disease patients.
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Objectives: The aim of this study is to evaluate the effect of the COVID-19 pandemic on myocardial perfusion scans (MPS) during the COVID-19 pandemic period. Method(s): We respectively reviewed single photon emission computed tomography myocardial perfusion scans (SPECT-MPS) performed between June and September 2020 during the COVID-19 pandemic at the Nuclear Medicine Research Center at Mashhad University of Medical Sciences. The findings of stress SPECT-MPS studies acquired in the corresponding months of 2019 were also evaluated for direct comparison. Result(s): In COVID-19 pandemic compared to period prior to the pandemic, no difference was observed in terms of age range of patients under study or their cardiovascular risk factors, except smoking which underwent a significant increase during the COVID-19 pandemic ( 19% vs. 13% , p = 0.009). While the number of patients with non-angina (19% vs. 31%, p = 0.000) or typical (11% vs. 19%, p = 0.000) chest pain significantly decreased during the COVID-19 pandemic, atypical (42% vs. 25%, p = 0.000) chest pain cases showed an increasing number. By considering pretest probability of the patients (high, intermediate and low/very low), during the COVID-19 period, cases of high pretest probability decreased (6% vs. 18%, p = 0.000) and intermediate pretest probability patients also increased (64% vs. 55%, p = 0.005) while low/very low pretest probability cases showed no changes between the two periods. All types of MPS stress tests in the COVID-19 period were pharmacological compared to exercise stress test. No statistically significant difference on the myocardial ischemia or cardiomyopathy between patients between the two periods was observed. Summed stress score (SSS) and summed rest score (SRS) was similar over the two periods,while summed difference score (SDS) significantly increased over the course of COVID-19, confirming a non- increasing pattern of myocardial ischemia. Conclusion(s): Previous research underscores the fact that the number of stress SPECT-MPS studies was significantly reduced during the COVID-19 pandemic compared to the corresponding months prior to the pandemic [1, 2]. Our study concluded that all types of MPS stress tests in the COVID-19 period were pharmacological. This is due to the fact that all related recommendations published in the literature [3] highlighted the avoidance of exercise stress tests during the COVID-19 pandemic to reduce the risk of droplet exposure. During the COVID-19 pandemic, patients in two ends of the spectrum (e.g., non-angina & typical chest pain) were referred less for MPS. However, patients in the middle of the spectrum (e.g., atypical chest pain) underwentMPS less frequently. Myocardial ischemia and cardiomyopathy were not decreased or increased in patients over the COVID-19 period.
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Background. Mortality risk of the COVID-19 is marked elevated in high-risk patients. In our series of 78 patients with inflammatory myopathies (IIM), we documented two patients who died after being infected with SARS-CoV2: we here describe our experience in these unfortunate cases. Case 1: A 45-years-old Caucasian man was diagnosed with PM in 2012 and was treated with prednisone (PDN) associated with intravenous (IVIg) and subcutaneous (SCIg) immunoglobulin. In January 2020, when in remission with a low-dose PDN, he performed a routine control, including a completely negative echocardiogram. In March 2020, he presented with fever and headache from occult SARS-CoV2 infection. Although myositis was in remission, and home treatment had given him with paracetamol and NSAIDs, after two days he had a sudden death. The cause was an acute myocardial ischemia in COVID-19 interstitial pneumonia revealed by autopsy investigation. Case 2: An 87-years-old Caucasian woman came to our attention with severeonset PM in 2017. She responded well at treatment with high-dose IVIg, PDN and methotrexate. In April 2020, she presented with SARS-CoV2 infection, who slowly complicated with an interstitial lung disease until the death due to respiratory failure 25 days after the COVID-19 infection. Conclusions. The two cases are opposite: the man, who had an acute thrombotic event during SARS-CoV2 infection, was in remission since 2012 and he did not have comorbidities. Unlikely, the woman, who had respiratory failure, was a high-risk patient due to old age, high cardiovascular risk, chronic obstructive pulmonary disease (COPD) and intraductal papillary mucinous neoplasms.
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Myocarditis can lead to myocardial infarction in the absence of coronary artery obstruction. We report a case of probable myocarditis, complicated by myocardial infarction with non-obstructive coronary arteries. A 19-year-old man presented with chest pain typical of myocarditis. He was a smoker but was otherwise well. Electrocardiogram revealed diffuse ST-elevation and echocardiography revealed a thin, akinetic apex. Troponin-T levels on admission were raised leading to an initial diagnosis of myocarditis being made. However, late gadolinium enhancement study on cardiac magnetic resonance imaging demonstrated transmural enhancement typical of ischaemia. Coronary angiogram was normal, leading to a likely diagnosis of myocardial infarction with non-obstructive coronary arteries. It is important to highlight that coronary assessment remains important when working up for myocarditis, as myocardial infarction with non-obstructive coronary arteries can often complicate myocarditis in cases of normal angiography. Another important lesson was on how cardiac magnetic resonance imaging provided vital evidence to support underlying ischaemia despite normal coronary angiogram, leading to a diagnosis of myocardial infarction with non-obstructive coronary arteries. Myocardial infarction with non-obstructive coronary arteries remains a broad 'umbrella' term and cardiac magnetic resonance imaging, as well as more invasive coronary imaging techniques during angiography, can further assist in its diagnosis. Our case provides a reminder that myocardial infarction with non-obstructive coronary arteries, although increasingly recognised, remains under-diagnosed and can often overlap with peri-myocarditis, highlighting the need to employ multi-modality imaging in guiding management.Copyright © The Author(s) 2021.
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Introduction: COVID-19 is a disease caused by the SARS-CoV-2 virus. Healthcare-associated infections (HCAI) are infections acquired during a stay in a hospital or other healthcare setting that were not incubating at the time of admission. Objective(s): To describe the impact of HCAI in hospitalised patients with COVID-19. Method(s): A retrospective and descriptive study of hospitalised patients with COVID-19 in a Portuguese hospital in 2020 was conducted. Result(s): The sample consisted of 1110 patients of whom 229 acquired HCAI. The main comorbidities were hypertension 62.45% (n=143), obesity 24.01% (n=55), arrhythmias 20.52% (n=47), ischaemic heart 11.35% (n=26) and heart failure 16.16%. Infectious agents were isolated in 27.95% (n=64), with Escherichia coli and Klebsiella pneumoniae being the most frequent. HCAI's classification were: 5.68% (n=13) nosocomial bacteraemia 31.89% (n=73);urinary tract infection 54.15% (n=124);hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia 8.28% (n=19). Ventilatory support required: 14.85% (n=34) didn't require, 49.34% (n=113) conventional oxygen therapy (COT);2.62% (n=6) high flow therapy, 3.06% (n=7) non-invasive ventilation, 16.16% (n=37) HelmetCPAP, 12.66% (n=29) invasive mechanical ventilation (IMV) and 1.31% (n=3) ECMO. The mean number of days of admission was 14.84 (+/-13.67). The probability of death HCAI's patients was OR 1.63, 95% CI 1.154-2.304. Conclusion(s): The sample shows a high incidence of nosocomial infections. The most frequent HCAI were HAP mainly with clinical diagnosis. Clinical stabilisation of comorbidities and COT were effective for most patients but IMV and Helmet-CPAP for the most severe. HCAI are a high risk factor for mortality.
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Case report - Introduction: Catastrophic antiphospholipid syndrome (CAPS) is a rare, life-threatening disease occurring in up to 1% of antiphospholipid syndrome (APS) cases. It was first defined in 1992 and remains a difficult to treat entity with a mortality rate of 37%. We describe a patient with systemic lupus erythematosus (SLE) and CAPS presenting with simultaneous multi-organ injuries who was successfully managed with 'triple' therapy including cyclophosphamide. Case report - Case description: A 42-year-old female presented to her local hospital with chest pain and worsening vision. She had a background of SLE, triple antibody-positive APS (previous DVT, pregnancy loss and strokes), hypertension, a metallic mitral valve, a previous myocardial infarction and pre-existing visual impairment due to a prior intra-cerebral bleed related to anticoagulation. Examination revealed a faint malar rash, cortical blindness and long tract neurological signs. Her ECG showed ischaemic changes and the admission troponin was significantly raised (3773ng/L). An echocardiogram showed new left ventricular dysfunction and a subsequent cardiac MRI was in keeping with coronary artery disease. Investigations showed an acute kidney injury, newly deranged liver function tests and a raised INR (>11, with no bleeding). Complement was normal with a low dsDNA titre. Urinalysis revealed proteinuria and a protein creatinine ratio measured 176mg/mmol. MRI diffusion weighted brain imaging showed acute bilateral occipital and left fronto-parietal infarcts. She had symptoms of a lupus flare with arthralgia and a butterfly facial rash. COVID-19 PCR tests were negative and she had not been recently vaccinated. She was diagnosed with CAPS and transferred to St Thomas' hospital intensive care. On arrival, she received 1mg intravenous vitamin K followed by triple therapy for CAPS: an unfractionated heparin infusion, oral prednisolone 40mg daily, 5 days of plasma exchange and, given her background of SLE, she was treated with intravenous cyclophosphamide (according to the EUROLUPUS regimen). Intravenous methylprednisolone was avoided due to a previous hypertensive encephalopathy reaction. She responded rapidly. Her troponin fell from a peak of 5054 to 294ng/ L, her creatinine settled at a new baseline (232umol/L) and her liver function normalised. She was switched back to warfarin due to her metallic valve and started on aspirin for cardiovascular secondary prevention. She required physical and occupational therapy due to her strokes but recovered well. Case report - Discussion: According to the 2003 criteria, CAPS can be classified as definite when there is evidence of: -3 organs involved, development of manifestations simultaneously or within a week, confirmation by imaging and/or histopathology of small vessel occlusion and positive antiphospholipid antibodies. Probable CAPS is when 3 out of the 4 criteria are present. In this case, three organs were confirmed to be involved with imaging showing cerebral and cardiac ischaemia. Her creatinine rose from a base of 190 to 289umol/L coupled with a high protein creatinine ratio confirming renal involvement. A Budd-Chiari syndrome was also suspected due to deranged liver function tests and INR, though imaging performed after therapy did not confirm this. A biopsy of any of these four organs was not feasible given the severity of her presentation and coagulopathy. There are no randomised controlled trials but data from the CAPS registry guides treatment and management follows a logical approach: anticoagulation to treat thrombosis, glucocorticoids for inflammation and plasma exchange (or IVIG) to remove the circulating autoantibodies. Triple therapy was associated with a reduced mortality compared to no treatment (28.6% versus 75%, respectively). Following analyses from the CAPS registry we also chose to treat with cyclophosphamide, which is associated with improved survival in patients with SLE. This decision was based on the clinical features of an SLE flare as opposed to serological grounds. There have b en reports of rituximab and eculizumab being used successfully in CAPS, though generally as a last resort. As complement activation is seen in animal models of antiphospholipid syndrome thrombosis and rituximab is often used in refractory SLE, they may prove to be promising agents for refractory CAPS. Case report - Key learning points: 1. Prompt recognition and early treatment is vital in managing CAPS 2. Triple therapy with anticoagulation, glucocorticoids and plasma exchange / IVIG is associated with better survival in CAPS 3. Cyclophosphamide is associated with better survival in patients with CAPS and concomitant SLE.
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Aim/Introduction: COVID-19 pandemic has introduced significant new challenges in everyday medical practice, as history of COVID-19 infection becomes increasingly prevalent and its potential long-term effects and interactions with other known or unknown health problems have not been fully clarified. Here, we aimed to characterize patients with a history of COVID-19 infection who underwent myocardial perfusion imaging at the department of nuclear medicine of a tertiary cardiovascular medicine center. Material(s) and Method(s): Records of all patients with a history of COVID-19 infection with/without need for hospitalization who underwent scintigraphy from April, 1, 2021 to March, 31, 2022 at our department were obtained. Patients undergoing scintigraphy for indications other than myocardial ischemia/viability detection (for example lung perfusion scans, bone scans) were excluded. Regarding myocardial perfusion studies, the presence of scar or ischemia was determined, together with basic hemodynamic parameters (blood pressure, systolic-SBP, diastolic-DBP, pulse-PP) and the respective changes from rest to maximal stress, according to stress test applied. Result(s): In total, 152 patients undergoing myocardial perfusion imaging reported previous COVID-19 infection. For 3 patients, data were incomplete, so the remaining 149 formed our study group (94 male, 55 female, age 67>10years, 5>4 months after COVID-19 infection). In 48 of them (32.2%), treadmill stress test according to Bruce protocol was applied. Another 60 received intravenous adenosine infusion (40.3%), the remaining 41 undergoing regadenoson test (27.5%). Patient age differed significantly according to stress test type (treadmill: 63>10 years, adenosine 70>8 years, regadenoson: 66>10 years, p=0.0001). Forty five patients (30.2%) had reversible perfusion defects compatible with ischemia, while 21 (14.1%) showed permanent perfusion defects (myocardial scar). Both ischemia and scar were more common among patients who needed hospitalization due to COVID-19 compared to those with milder symptoms (ischemia: 17/40 among patients with history of hospitalization, 28/109 among those with no hospitalization due to COVID-19, p=0.048;scar: 11/40 among patients with history of hospitalization, 10/109 among those with no hospitalization, p=0.004). Among those undergoing treadmill test, the ones with history of COVID-19 hospitalization showed higher SBP and PP increase during exercise (86>17 versus 60>24mmHg for SBP, 65>18 versus 45>24mmHg for PP, p=0.009 and p=0.048 respectively), while DBP differences were insignificant. Conclusion(s): Abnormal myocardial perfusion findings in the form of both fixed and reversible perfusion defects are more common among patients needing hospitalization for COVID-19 infection. Altered hemodynamic response to exercise is also present in this patient population.
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Introduction: Data on temporal and gender differences in referral patterns and clinical characteristics of patients referred for myocardial scintigraphy for suspected coronary artery disease (CAD), is lacking. Furthermore, the differential impact of COVID-19 pandemic on gender differences in referrals and clinical risk profile of referred patients is not known. Method(s): This is a cross-sectional observational single center study of patients evaluated across 3 yearly time intervals in 2000, 2010 and 2020. We evaluated 2,615 patients (68% women) with mean age 65.9 years, who were referred for stress/rest myocardial scintigraphy. Trends in clinical characteristics and test results were compared in women and men across these intervals. Result(s): Men were more likely to be referred for testing than women, however there was a consistent increase in proportion of women referred over time, including the time of COVID pandemic in 2020. Men were more likely to present with typical symptoms, compared to women. Among women, there is a significant increase in prevalence of active smoking and a decrease in age at presentation and hypertension, over time (p<0.05). Among men, there was a significant decrease in history of previous MI, with no change in other risk factors over time. Across time intervals, in both men and women, there was a significant increase in EF (Ejection Fraction) and decrease in presence of ischemic myocardium at risk, identified by semi-quantitative scores including summed rest score (SRS), summed stress score (SSS) at rest (p<0.05). Conclusion(s): There are gender differences in proportion of men and women who are referred for stress testing, for evaluation of stable CAD. There was a substantial change in risk of inducible myocardial ischemia among male and female patients with known or suspected CAD. Our findings are relevant to understand the implications of gender differences on risk assessment and diagnostic accuracy in known or suspected CAD, over time.
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Background Objective: What is the association between COVID-19 infection and QTc changes? Coronavirus SARS-COV2 uses angiotensin-converting enzyme receptors 2 (ACE2) on host cells to enter into human cells. These receptors are expressed on the heart cells among other major cells. This is one of the most accepted theories for direct cardiac cell injury of COVID-19disease and associated cardiorespiratory manifestations. COVID-19 infection leads to unstable myocardial cell membranes, by causing hypoxia, myocarditis, myocardial ischemia, and abnormal host immune response. This is the main reason behind Arrhythmia and EKG changes during COVID19 infection. But the specific effect on QTc has not been studied well so far, so our research try to study this connection. Method(s): This is an observational retrospective hospital chart review involving 320 adult participants diagnosed with COVID-19 infection at our facility. After applying the exclusion criteria, 130 participants remained, who were distributed into two groups. One group with long QTc and one group with normal QTc. Data was collected and demographics were recorded using Excel and SPSS, then compared using a student's t-test for independent groups. The quantitative data are summarized by the mean and standard deviation (SD). Statistical significance was taken as P <0.05. Result(s): A total of 63 participants (48.4% of total 130 participants) met the criteria for long QTc, and a total of 67 participants(51.5%) had normal QTc (P < 0.001). There was no statistically significant mortality outcome (0.8% vs. 3.8%, P = 0.21). Conclusion(s): Our study showed 48.4% participants having an increase in QTc during COVID-19 infection, (20% of 320 total admissions). This observation is very important to help healthcare providers to gaina better understanding of this disease.
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Background and Aim: A 15 year old young man with symptoms and signs consistent with MIS-C was admitted to the Intensive Care Unit for inotropic support as he was exhibiting signs of cardiogenic shock. He was previously fit and healthy and he had been exposed to Covid 19 confirmed cases 6-8 weeks prior to becoming unwell. Method(s): The patient received IVIG and steroids as an immuno-modulating regime. On the admission echocardiogram there was a structurally normal heart with large LV thrombuses. The D-Dimers were extremely elevated on admission and the patient received therapeutic heparin infusion. Other prothrombotic causes were excluded. Result(s): The surveillance echocardiogram 24h post admission showed resolution of the thrombuses. The patient never exhibited any signs or symptoms of cardiac ischaemia on the electrocardio-gram or regional wall motion abnormality on the echocardiogram or neurologic impairment and the brain MRI-MRA one week post admission was normal. The patient was discharged home 5 days post admission and on follow ups up to a year after the acute phase remains very well physically and clinically. Conclusion(s): Thromboembolic events are frequently described in COVID-19 patients and in some patients with MIS-C and are the consequence of a hyperinflammatory response and endothelial dysfunction. There might be a potential role of an antiphospholi-pid syndrome secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as has been proposed. An increase in D-dimer level has been shown to be associated with thromboembolic events, including arterial thrombosis especially in the older population and should be investigated promptly. With the appropriate immunomodulation and antithrombotic treat-ment adverse events are prevented. More studies to assess endothelial function and its role in the MIS-C prothrombotic state are necessary.
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SESSION TITLE: Etiologies of Cardiovascular Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Troponin level (Tnl) is usually used as confirmation of acute myocardial infarction (AMI) and is a sensitive marker. It is usually increased within 2-3 hours after AMI. In most cases, increased in Tnl is associated with symptomatic chest pain, cardiac ischemia, chronic coronary syndromes, etc. It can also be elevated in other conditions without cardiac injuries, like critical illness: COVID infection, septic shock, acute stroke and burns. CASE PRESENTATION: A 72 y/o man with history of b/l internal carotid artery (ICA) stenosis (70% in R-ICA and 80-90% in L-ICA) underwent elective left trans-carotid artery revascularization (TCAR). He was transferred to ICU after an uneventful procedure, for monitoring. His history was significant for HTN, HLD, Meniere's disease, gout, prior CVA of L-frontal lacunar and R-PICA (posterior inferior cerebellar artery). Postop vitals: BP 114/60 mmHg, HR 65, RR 16, O2 sat 98%. Tnl increased to 1.95 and then declined (normal 0 - 0.4 ng/ml). He was AAOx4, and asymptomatic. Post-op serial EKGs: normal sinus rhythm with no ST/T wave changes. Echo: EF 60%, normal biventricular size and function. LDL <70, A1C 5.9, normal TSH, no CPK elevation. Other labs: normal, No new neurological deficits. He was continued on ASA, clopidogrel, metoprolol, amlodipine and lisinopril. His hospital stay was uneventful, and he was discharged on post-op day 3. DISCUSSION: Cardiac troponin complex has its distinct subunits according to their functions: highly conserved Ca2+ binding subunit (cTnC);actomyosin ATPase inhibitory subunit and tropomyosin binding subunit. They play the pivotal role in regulating myocardial muscle contraction and relaxation and demonstrate as sensitive biomarkers for the myocardial injuries. Interestingly, there are many other causes that lead to increased cardiac troponin level without remarkable myocardial injuries or ischemia. Elevated Tnl after TCAR procedure can also be due to its surgical complication of a chance of hypoperfusion during the procedure. Our patient's surgery was uneventful. In one randomized controlled trial, it is stated that the risk of having CVA and AMI is higher in carotid endarterectomy compared to revascularization in patients with carotid artery stenosis. Our patient did not have any post-op complication, and only had an idiopathic elevation of troponin. CONCLUSIONS: The role of Tnl plays an important role in confirmation of myocardial infarction or ischemia but it can be idiopathic. Unpublished data from our institution revealed no increase in troponin s/p TCAR after uneventful procedures. This is the first reported case presenting with elevated troponin level without any pertinent positive findings (EKG changes/symptoms). Maybe in uneventful TCAR procedure troponin should not be ordered? Reference #1: Defilippi, C.R., Tocchi, M., Parmar, R.J., Rosanio, S., Abreo, G., Potter, M.A., Runge, M.S., & Uretsky, B.F. (2000). Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes. Journal of the American College of Cardiology, 35 7, 1827-34. Reference #2: Gordon AM, Homsher E, Regnier M. Regulation of contraction in striated muscle. Physiol Rev. 2000 Apr;80(2):853-924. doi: 10.1152/physrev.2000.80.2.853. PMID: 10747208. Reference #3: Brott, T.G., Hobson, R.W., Howard, G., Roubin, G.S., Clark, W.M., Brooks, W., Mackey, A., Hill, M.D., Leimgruber, P.P., Sheffet, A.J., Howard, V.J., Moore, W.S., Voeks, J., Hopkins, L.N., Cutlip, D.E., Cohen, D.J., Popma, J.J., Ferguson, R.D., Cohen, S.N., Blackshear, J.L., Silver, F.L., Mohr, J.P., Lal, B.K., & Meschia, J.F. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. The New England journal of medicine, 363 1, 11-23. DISCLOSURES: No relevant relationships by Moses Bachan No relevant relationships by Zin Min Htet No relevant relationships by Z nobia Khan No relevant relationships by Zin Oo
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Cardiac involvement is an observable issue in multisystem inflammatory syndrome in children (MIS-C) associ20 ated with COVID-19. The most common echocardiographic findings in MIS-C are abnormal coronary arteries, decreased left ventricular function, mitral regurgitation, and pericardial effusion. Abnormalities in the coronary arteries were seen in less than 20% of MIS-C patients. These abnormalities include dilatation or aneurysms in the coronary arteries;however, giant or large aneurysms are rare. On the other hand, transient coronary artery dilatation (which can occur secondary to viral myocarditis) may also mean that the coronary artery Z-scores never exceed 2.5. Reviewing large case series revealed that approximately 30 - 40% of MIS-C patients had decreased left ventricular function. In most cases, left ventricular function is mildly depressed, and severe left ventricular dysfunction was observed in only one-fifth of cases. Hypoxia, myocardial ischemia secondary to coronary involvement, stress-induced cardiomyopathy, injury caused by systemic inflammation, and viral myocarditis are the possible etiologies for the myocardial injury in MIS-C. It is now clear that myocardial strain imaging indices such as a global longitudinal strain (GLS), end-diastolic strain rate (EDSR), and peak left atrial strain (LAS) can demonstrate systolic or diastolic dysfunction in myocarditis patients with preserved left ventricular ejection fraction. Furthermore, right-sided ventricular deformation imaging abnormalities have been reported in adult patients with MIS-C. Less information is currently available on mitral regurgitation and pericardial effusion in pediatric patients with MIS-C;however, in an extensive study on 286 pediatric patients with MIS-C, 28% had pericardial effusion, and 42.7% had mitral regurgitation;both were mild in most patients.
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Myocarditis is usually diagnosed clinically by electrocardiograms, echocardiography, and increased cardiac enzymes since troponin is also defined as a marker of cardiac injury in children and adolescents. Myocarditis and pericarditis have been found in up to 40% and 25% of patients, respectively. Pericardial effusion occurred in up to 32% of patients. Together with the myocardial dysfunction findings, these characterize the pancarditis associated with COVID-19. Myocardial involvement may also be related to the presence of arrhythmias. In COVID-19, hypoxia, neurohormonal or inflammatory stress, and metabolic disorders contribute to changes in the cardiac rhythm. Some of the current drug therapies used in this disease can also induce arrhythmia, adversely affecting cardiac electrophysiology. Patients with COVID-19 have an increased risk of developing venous thrombosis, reaching 25%, with the highest risk in those with increased Ddimer and inflammatory markers, decreased fibrinogen, and those with the severe acute respiratory syndrome. There is suspicion mainly in patients who develop refractory hypoxemia or asymmetric edema of the lower limbs. Coronary thrombosis, in addition to the one being characterized, may correspond to one of the pathophysiological mechanisms of cardiovascular complications. Because of the systemic inflammatory response and imbalance in the oxygen supply, there is also an increased risk of coronary ischemia.
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Introduction: The COVID-19 vaccine was approved for use in adolescents ages 12-17 on May 10, 2021. There have since been case reports of myocarditis shortly after the COVID-19 vaccine, mostly in adolescent males. Among these cases, coronary vasospasm has not been described. Case Description: A 16 year old previously healthy male presented with two days of chest pain and subjective fevers three days after receiving the second dose of the Pfizer COVID-19 vaccine. High-sensitivity troponin I was 10,819 ng/L (reference range: 3-57), and ECG showed mild diffuse ST segment elevations (Image 1). He was admitted for suspected myopericarditis and treated with ketorolac, prednisone, and IVIG. Shortly after admission, he experienced sudden crushing, substernal chest pain. An ECG obtained during the episode showed striking ST segment elevation in the inferolateral leads (Image 2). He was started on a nitroglycerin drip, supplemental oxygen, low dose aspirin and received 3 doses of morphine. The acute chest pain responded rapidly to these measures, and the nitroglycerin drip was stopped after 24 hours without recurrence of symptoms. An echocardiogram was normal. Cardiac MRI showed subepicardial enhancement without evidence of acute infarction. He was discharged on hospital day #4, chest pain free for 24 hours with downtrending troponin. Discussion: Our patient's initial presentation of chest pain with elevated troponin and mild diffuse ST segment elevation is consistent with myopericarditis, similar to described cases occurring after the COVID-19 vaccine. During an acute, more severe, episode of chest pain, there was further localized ST segment elevation consistent with myocardial ischemia. Serial ECGs demonstrated improvement as the chest pain resolved, suggesting acute coronary artery vasospasm. Intravenous nitroglycerin, the mainstay of treatment for coronary vasospasm, was therapeutic with no recurrence of chest pain. Interestingly, our patient's acute inferolateral ST segment elevations during the episode of severe chest pain correlated with the distribution of myocardial enhancement noted on cardiac MRI, implicating subepicardial myocarditis as the likely cause. This complication has been reported in adults with viral myocarditis. Conclusion: This case highlights the importance of recognizing coronary vasospasm as a potential complication of COVID vaccine-induced myopericarditis.
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Introduction: Cardiac disease is the leading cause of maternal death in the UK [1].We present the case of awoman with late intrauterine fetal death (IUFD) and intrapartum cardiac ischaemia. A family history of limb girdle muscular dystrophy (LGMD) may be relevant. Case Report: A 23-year-old nulliparous woman at 39 weeks of gestation presented with reduced fetal movements and IUFD was confirmed. She had no medical history, and despite two first degree relatives with LGMD, she was asymptomatic and had not been tested. Uterine contractions started and epidural analgesia was initiated. Shortly thereafter, the woman was found to be bradycardic at 35– 40 beats/min. All other observations were normal and she was asymptomatic with no detectable sensory or motor block. A 12 -lead ECG showed inferior T-wave inversion and serial troponins were markedly elevated. Caesarean section (CS) under general anaesthesia was performed at maternal request and was uneventful. Postpartum echocardiogram demonstrated a dilated left atrium, left ventricular akinesis and an ejection fraction of 45–50%. The next day the woman developed chest pain and desaturated. CTPA and CT coronary angiogram were normal. Oxygenation improved and other than sporadic chest heaviness she remained well and was discharged 4 days post CS. Cardiology follow-up did not occur due to a communication breakdown. Post-mortem of the fetus found no cause for the IUFD and no features of LGMD. Thewoman suffered a miscarriage four months after this but delivered a healthy baby at elective CS two years later. During the latter pregnancy cardiology input from a tertiary centrewas requested but did not occur due to the COVID-19 pandemic. An echocardiogram in the third trimester was normal and the woman has been well since. Discussion: Troponin rise is abnormal in pregnancy and requires investigation. IUFD in itself can lead to sequelae requiring a low threshold for investigation. The family history in this case is autosomal dominant type 1B LGMD, associated with cardiomyopathy and arrhythmias [2]. The woman has declined testing and the cause for the peripartum cardiac disease remains unknown. The recovery and recent uneventful pregnancy suggest Takotsubo’s cardiomyopathy or coronary vasospasm as additional possible diagnoses. This case also underlines the importance in sensitive communication in cases of IUFD to ensure women are investigated and not lost to follow-up.
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Background: Water retention leading to worsening congestion is a common reason for heart failure (HF) hospitalisation. Increases in aldosterone, due to increased secretion (driven by angiotensin and hyperkalaemia) and reduced degradation (due to hepatic dysfunction), contribute to congestion. Mineralocorticoid receptor antagonists (MRA) reduce morbidity and mortality in advanced HF. However, use of MRA is often limited by hyperkalaemia, renal dysfunction and hypotension. Hyperkalaemia can be corrected by potassium binding agents. Methods: An open-label, randomised, multi-centre (up to 100 UK sites) trial investigating the use of a potassium binding agent, patiromer, to facilitate higher doses of MRA for HF with worsening congestion requiring treatment with ≥80mg/day of furosemide (or equivalent). Patients are first entered on an unconsented screening-log (approved by the UK Health Research Authority) and then asked to consent to a registry (no exclusion criteria). If they agree, and are eligible (systolic blood pressure ≥90mmHg, eGFR ≥30mL/min/1.73 m2, no other terminal disease, no active infection or myocardial ischaemia), they are invited to participate in a randomised trial. Patients who consent for the trial enter a run-in phase of ≤35 days, when they receive ≤100mg/day of spironolactone. If serum potassium rises to >5.0mmol/L, the patient is randomised either to receive an MRA at guideline recommended doses or to have spironolactone increased ≤200mg/day, using patiromer to manage hyperkalaemia, providing eGFR remains ≥30mL/min and the patient does not become hypotensive. The primary outcome of the first phase of the trial (n = 400) is severity of congestion at 60-days but patients will be followed The RELIEHF Registry & Randomised Trial long-term for morbidity and mortality. An adaptive trial design allows recruitment to be increased up to 2.000 patients. Results: The conduct of the trial has been disrupted by COVID. As of January 2022, from 10 sites, >300 patients (40% women;median age 76 (65-83) years have been screened, >100 (37% women;median age 72 (62-80) years) have consented for the registry and >25 for the randomised trial. Of patients screened, about 50% were asked for registry-consent, of whom one third refused. The main reason for not asking was that the care-team considered it inappropriate due to patient frailty and/or cognitive dysfunction. Most patients who consented for the registry agreed, in principle, to participate in a randomised trial. Most patients have tolerated 100mg of spironolactone during the run-in period. Conclusions: For a high proportion of patients admitted to hospital with worsening HF, research staff do not deem it appropriate to approach them to ask for research consent. Most patients with HF who were asked to participate in research were willing to do so and to participate in a randomised trial, although a substantial proportion were not eligible for this trial. Of those who were, the majority tolerated spironolactone at a dose of 100mg/day.
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Background: Vaccination efforts worldwide continue in the face of the ongoing pandemic of COVID-19. More than 6.65 billion doses of the COVID-19 vaccine have been administered thus far. Adverse events after receiving the vaccine are being reported and monitored closely. Recently, there have been increasing reports of myocarditis/pericarditis in young men after receiving a second dose of the mRNA vaccine. Rare complications such as vaccine-induced immune thrombotic thrombocytopenia and thrombotic thrombocytopenic syndrome have been identified after the administration of viral vector vaccines. We present here three STEMI cases in young, healthy males three days after receiving the second dose of an mRNA vaccine. Methods: Three males aged 19-34 years old with no past medical history presented to the emergency department with ST elevations on EKG and increased troponin I. They were each taken to the cardiac catheterization lab. All patients had received a second dose of mRNA vaccine within four days prior to presentation. Results: All three patients had no evidence of coronary obstruction on cardiac catheterization. They were admitted overnight, and their troponin I levels trended downwards without further intervention. Conclusion: With the relatively new advent of mRNA vaccines against the COVID-19 virus, there are still many potential short and long-term complications that have yet to be identified. The patient presentations herein were suspicious for acute coronary syndrome given their typical anginal chest pain, acute troponin I rise and fall, and EKG changes indicative of myocardial ischemia. However, there was no evidence of obstruction on left heart catheterization in any of these cases. Given these findings, it is possible that cardiac inflammation or coronary vasospasm are correlated with having received a second dose of the mRNA vaccine. Further studies are needed to determine if these occurrences are merely coincidental or if they can be directly attributed to such vaccines. Going forward, it is imperative to obtain COVID-19 vaccination history whenever a patient presents to a healthcare setting, as we continue to learn about the possible and varied sequelae of such vaccines.
ABSTRACT
Background. COVID 19 is associated with a hypercoagulable state with cytokine storm syndrome and thrombocytopenia leading to complications across various systems. COVID-19 infection, its treatment, resultant immunosuppression, and pre-existing comorbidities have made patients vulnerable to secondary infections Methods. We systematically reviewed COVID-19 cases between Jan to May 2021 for pulmonary and extrapulmonary complications. Patients with recent COVID-19 vaccination and neurological symptoms were also included. Results. Neurological complications: Neurological complications include ischemic and haemorrhagic strokes. Other complications are encephalopathy, encephalitis, Guillain-Barré syndrome, acute hemorrhagic necrotizing encephalopathy. Demyelination and radiculopathies are seen as post vaccination complications. Mucormycosis: Unprecedented high rate of invasive fungal sinusitis in association with COVID -19 is reported from the Indian subcontinent. This has a propensity for intra orbital and intracranial extension. COVID -19 associated coagulopathy: COVID -19 is a pro-inflammatory hypercoagulable state. Pulmonary thromboembolism, deep venous thrombosis and catheter related thrombosis are well documented. Cardiac complications: Cardiac manifestations include Myocardial Injury with non-obstructed coronary arteries (MINOCA), myocarditis, myocardial ischemia, cardiomyopathy. Pulmonary complications and sequelae of COVID -19: Progression of lung injury to ARDS during the initial phase and fibrosis of parenchyma in the recovery phase. Spontaneous pneumomediastinum, pneumatoceles and pneumothorax and secondary infections are identified in our study. COVID- 19 associated gastrointestinal complications: Patients evaluated for renal colic, pancreatitis, cholecystitis showed, ground glass opacities or subpleural bands in typical Covid-19 distribution. COVID-19 may lead of acute kidney and bowel injury due to arterial thrombosis. COVID - 19 associated myonecrosis: Ischemia of the small caliber vessels may result in myonecrosis. Conclusion. Awareness of these unusual manifestations will facilitate an early diagnosis, improve management and help reduce morbidity and mortality.
ABSTRACT
Ischemic preconditioning (IPC) is an innate mechanism of tissue protection from ischemia, which is easily replicable in clinical settings in the form of remote IPC. The final protective effect of IPC comprises the induction of favorable anti-inflammatory and anti-thrombotic molecular pathways. Recent studies on humans have confirmed that IPC protocols may exert cardioprotective actions. Moreover, IPC was also found to be capable of reducing surgical lung injury through the contrast of inflammatory response. Hence, IPC seems an ideal candidate to be tested as an innovative therapeutic weapon against a disease as coronavirus disease 19 (COVID-19), in which inflammation plays a key role. Interestingly, the use of IPC protocols for COVID-19 patients, beyond the potentiality of reducing the cardiologic complications, could also prove useful for the attenuation of inflammatory phenomena that characterize the course of coronavirus disease.