Post-COVID-19 cardiovascular complications and their association with clinical characteristics, symptoms and comorbidities - the LATE-COVID study

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.

Risk factors, thromboembolic events, and clinical course of New-Onset Atrial Fibrillation among COVID-19 hospitalized patients: A multicenter cross-sectional analysis in Iran.

Background and Aims: We focused on determining the risk factors, thromboembolic events, and clinical course of New-Onset Atrial Fibrillation (NOAF) among hospitalized coronavirus disease (COVID-19) patients. Methods: This retrospective study was conducted in the major referral centers in Tehran, Iran. Of 1764 patients enrolled in the study from January 2020 until July 2021, 147 had NOAF, and 1617 had normal sinus rhythm. Univariate and multivariate Logistic regressions were employed accordingly to evaluate NOAF risk factors. The statistical assessments have been run utilizing SPSS 25.0 (SPSS) or R 3.6.3 software. Results: For the NOAF patients, the age was significantly higher, and the more prevalent comorbidities were metabolic syndrome, heart failure (HF), peripheral vascular disease, coronary artery disease, and liver cirrhosis. The multivariate analysis showed the established independent risk factors were; Troponin-I (hazard ratio [HR] = 3.86; 95% confidence interval [CI] = 1.89-7.87; p < 0.001), HF (HR = 2.54; 95% CI = 1.61-4.02; p < 0.001), bilateral grand-glass opacification (HR = 2.26; 95% CI = 1.68-3.05; p = 0.002). For cases with thromboembolic events, NOAF was the most important prognostic factor (odds ratio [OR] = 2.97; 95% CI = 2.03-4.33; p < 0.001). While evaluating the diagnostic ability of prognostic factors in detecting NOAF, Troponin-I (Area under the curve [AUC] = 0.85), C-Reactive Protein (AUC = 0.72), and d-dimer (AUC = 0.65) had the most accurate sensitivity. Furthermore, the Kaplan-Meier curves demonstrated that the survival rates diminished more steeply for patients with NOAF history. Conclusion: In hospitalized COVID-19 patients with NOAF, the risk of thromboembolic events, hospital stay, and fatality are significantly higher. The established risk factors showed that patients with older age, higher inflammation states, and more severe clinical conditions based on CHADS2VASC-score potentially need subsequent preventive strategies. Appropriate prophylactic anticoagulants, Initial management of cytokine storm, sufficient oxygen support, and reducing viral shedding could be of assistance in such patients.

NEW-ONSET SYSTEMIC LUPUS ERYTHEMATOSUS AND STEVEN JOHNSONS SYNDROME WITH SEVERE ARDS HERALDED BY POST-COVID-19 INFECTION MULTISYSTEM INFLAMMATORY SYNDROME IN AN ADULT (MIS-A)

SESSION TITLE: Autoimmune Diseases Gone Wild: Rare Cases of Pulmonary Manifestations SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Post-Covid-19 Multisystem Inflammatory Syndrome (MIS) is a severe hyperinflammatory syndrome associated with either the acute or recovery phase of covid-19 infection affecting multiple organ systems requiring hospitalization. This syndrome has been described in both children (MIS-C) and adults (MIS-A). Several case reports and systematic reviews have reported an association between post-covid-19 MIS-A and several autoimmune diseases. CASE PRESENTATION: We herein report a case of a 27-year-old female with no known chronic medical condition and a non-contributory family history who was diagnosed with post-covid-19 multisystem inflammatory syndrome in adults (MIS-A). She presented with generalized partial thickness erythematous skin ulcerations with tender blistering and painful erosion of her mucus membranes (oral and vaginal mucosa). This was diagnosed as Steven Johnsons syndrome. She was pulsed with intravenous methylprednisone. During this therapy, she progressed to severe acute respiratory distress syndrome (ARDS) requiring mechanical ventilation (fig 1). Bronchoscopy revealed mild pulmonary hemorrhage fig 2a&b). Serological testing heralded a new onset systemic lupus erythematosus in light of positive antinuclear antibodies, anti Ds DNA and anti Smith antibodies. Her course was complicated by significant proteinuria and an active renal cast suggestive of lupus nephritis. This necessitated further treatment for active lupus. She was successfully extubated and discharged home. DISCUSSION: We arrived at the diagnosis of post-covid-19 multisystem inflammatory syndrome in adults (MIS-A) in light of her presenting with fever, hypotension, persistent sinus tachycardia and new onset atrial fibrillation), acute pancreatitis, acute kidney injury, elevation in transaminases, new onset skin rash, elevated inflammatory markers and a recent history of positive SARS-CoV-2 infection. Covid-19 has been reported to induce wide spread vasculitis resulting in MIS-A or MIS-C by triggering type 3 hypersensitivity (1). Also, multiple case reports and systemic reviews have reported a direct association between MIS-A and several autoimmune diseases including SLE, SJS (2). The patient recovered with high dose corticosteroid and supportive therapy indicating her severe ARDS was most likely due associated to SJS, SLE and MIS-A. Clinicians should also keep in mind that SARS-CoV-2 PCR swab may be negative at the time patient presents with symptoms of MIS-A as the infection might have occurred about 4-5weeks prior just as in our patient(3) CONCLUSIONS: We cannot underscore enough the importance of clinicians having a high index of suspicion for this syndrome in patients with acute or recent covid-19 infection, with or without a positive PCR covid-19 test. Early involvement of a multidisciplinary approach and appropriate management is essential to mitigate morbidity and mortality in these patients. Reference #1: Roncati L, Ligabue G, Fabbiani L, Malagoli C, Gallo G, Lusenti B, et al. Type 3 hypersensitivity in COVID-19 vasculitis. Clin Immunol Orlando Fla. 2020 Aug;217:108487. Reference #2: Gracia-Ramos AE, Martin-Nares E, Hernández-Molina G. New Onset of Autoimmune Diseases Following COVID-19 Diagnosis. Cells [Internet]. 2021 Dec 20 [cited 2022 Mar 22];10(12):3592. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8700122/ Reference #3: Morris SB. Case Series of Multisystem Inflammatory Syndrome in Adults Associated with SARS-CoV-2 Infection — United Kingdom and United States, March–August 2020. MMWR Morb Mortal Wkly Rep [Internet]. 2020 [cited 2022 Mar 22];69. Available from: https://www.cdc.gov/mmwr/volumes/69/wr/mm6940e1.htm DISCLOSURES: No relevant relationships by Isaac Ikwu No relevant relationships by Anthony Lyonga Ngonge No relevant relationships by Alem Mehari No relevant relationships by Noordeep Panesar no disclosure on file for Vis al Poddar;No relevant relationships by Emnet Yibeltal

RARE CASE OF SALMONELLA MYOCARDITIS MIMICKING ACUTE INFERIOR ST-ELEVATION MYOCARDIAL INFARCTION (STEMI)

SESSION TITLE: Infections In and Around the Heart Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Acute bacterial myocarditis due to Salmonella bacteremia is a rare cause of ST-segment elevation that can manifest as acute decompensated heart failure, life threatening arrhythmias, and sudden cardiac death. CASE PRESENTATION: A 62-year-old male with a past medical history of HTN, HLD, DM2, and TIA presented with nausea, vomiting, nonbloody diarrhea, and right upper quadrant pain for five days. He quickly decompensated in the ED, becoming increasingly hypotensive, tachycardic, and lethargic concerning for sepsis. Broad spectrum antibiotics and IV fluids were initiated. Chest X-ray revealed multifocal pneumonia. Labs revealed a metabolic acidosis consistent with acute hypoxic respiratory failure warranting emergent intubation. CTA chest showed multifocal pneumonia and Covid-19 antigen testing was negative. Troponin I was elevated at.211 ng/mL (n <.08) and ECG showed new onset atrial fibrillation, for which cardiology was consulted. On admission to the ICU, repeat labs showed acute renal failure and he was anuric warranting hemodialysis initiation. Despite medical optimization, his Troponin I trended up to 1.458 ng/mL, and repeat ECG showed 2:1 atrial flutter with new ST-elevations in leads II, III, and aVF, consistent with an acute inferior STEMI. Labs did not show hyperkalemia nor hypercalcemia. Transthoracic echocardiography revealed normal systolic and diastolic function, with a left ventricle ejection fraction of 65-70%. A heparin infusion was started and he was taken for a cardiac catheterization which showed no evidence of occlusive CAD. His blood cultures revealed Salmonella enteritidis for which he was switched to ciprofloxacin. Abdominal ultrasound appeared benign, but CT abdomen with contrast showed findings of cholecystitis, which was confirmed on HIDA scan. Gastroenterology and Surgery were consulted who recommended a cholecystostomy tube placement, with a delayed laparoscopic cholecystectomy (LC) when stable. Repeat ECG following the LC showed complete resolution of the previous STEMI. He was discharged to a rehabilitation facility where he made a full recovery. DISCUSSION: Acute bacterial myocarditis can mimic acute coronary syndromes and warrants a high index of suspicion in the setting of Salmonella bacteremia. Our patient presented with signs of acute cholecystitis and an ECG concerning for acute STEMI. Bacterial etiologies of myocarditis are less reported in the literature compared to viral infections, and are seen more often in patients with severe sepsis such as our patients. Common findings associated with Salmonella myocarditis include ST-segment elevation on ECG and elevated troponin levels. Serial ECG findings can distinguish myocarditis from acute myocardial infarction. Early diagnosis is essential to improve outcomes and reduce mortality. CONCLUSIONS: Acute bacterial myocarditis can mimic acute coronary syndromes. Reference #1: Villablanca P, Mohananey D, Meier G, Yap JE, Chouksey S, Abegunde AT. Salmonella Berta myocarditis: Case report and systematic review of non-typhoid Salmonella myocarditis. World J Cardiol. 2015;7(12):931-937. doi:10.4330/wjc.v7.i12.931 Reference #2: Sundbom P, Suutari AM, Abdulhadi K, Broda W, Csegedi M. Salmonella enteritidis causing myocarditis in a previously healthy 22-year-old male. Oxf Med Case Reports. 2018;2018(12):omy106. Published 2018 Nov 26. doi:10.1093/omcr/omy106 Reference #3: Majid A, Bin Waqar SH, Rehan A, Kumar S. From Gut to Heart: Havoc in a Young Patient with Typhoid-associated Cardiomyopathy. Cureus. 2019;11(7):e5049. Published 2019 Jul 1. doi:10.7759/cureus.5049 DISCLOSURES: No relevant relationships by Mohamed Faher Almahmoud No relevant relationships by JONATHAN BROWN No relevant relationships by Hytham Rashid No relevant relationships by Syed Raza

Prevalence and impact of dysrhythmias in COVID-19 intensive care patients

Background: The COVID-19 pandemic has had a dramatic impact on clinical practice, amounting to more emergency department and intensive care unit (ICU) admissions. Due to their frequent multiple comorbidities, management in the ICU is challenging. Early studies suggest that cardiac injury is frequent in hospitalized patients with COVID-19, and it is plausible that these patients have a higher risk of cardiac dysrhythmias. Purpose: To determine the prevalence of dysrhythmias in ICU patients with COVID-19 pneumonia, identify major predictors and determine the impact on in-hospital mortality. Methods: A retrospective study of 98 consecutive patients with COVID-19 Pneumonia admitted to the ICU of a tertiary hospital in 2020. The main outcome was dysrhythmias (including significant bradycardia, high/slow ventricular rate or new-onset atrial fibrillation (AF) or atrial flutter, other supraventricular tachycardias, ventricular tachycardia and ventricular fibrillation). Significant bradycardia was defined as heart rate lower than 40 or need of treatment. Sociodemographic variables and clinical data were retrieved for each patient, severity scores at admission (Apache II, SOFA and SAPS II), number of days on mechanical ventilation or high-flow oxygen and placement on Venovenous Extracorporeal Membrane Oxygenation (ECMO) or prone position were recorded. Statistical comparison was made between groups, including logistic regression adjusting for confounding variables. Results: The most frequent arrhythmia was significant sinus bradycardia (28, 28.5%) followed by high ventricular rate AF (14, 14.2%). Patients who had dysrhythmias were older (66.24 ± 10.13 vs 60.85 ± 12.69 years, p 0.024), more severe (SAPS II score 42.55 ± 11.08 vs 35.98 ± 11.26, p 0.006), had more atrial fibrillation (AF) (p 0.022), had higher maximum C-reactive protein (mCRP) (6.56 ± 2.68 vs 6.24 vs 2.86, p 0.009), were mechanically ventilated for a longer time (15.64 ± 13.18 vs 8.92 ± 8.85 days, p 0.004), had longer intubation time (14.52 ± 9.39 vs 8.70 ± 8.21 days, p 0.002) and had higher usage of dexamethasone (p 0.042) and prone position (p 0.016). When adjusted for confounding variables, prone was the most significant predictor (OR 2.800;95% CI 1.203-6.516) followed by use of dexamethasone (OR 2.484;95% CI 1.020-6.050). Days intubated, days on mechanical ventilation, age, mCRP and SAPS II on admission were also predictors of dysrhythmia. Regarding mortality, patients with arrhythmic events had a tendency for greater in-hospital death (OR 2.440;95% CI 0.950-6.310;p 0.065). Conclusions: COVID-19 ICU patients are a subset of patients at risk of cardiac arrhythmias. Use of prone position was the main contributor to these events, but clinical history, severity and treatment may also play an important role. Efforts must be made to optimize ventilatory support and treatment in order to reduce the risk of dysrhythmias. (Figure Presented).

Tachydysrhythmias in patients admitted with COVID-19 pneumonia: prevalence and impact on in-hospital mortality

Background: The COVID-19 pandemic has shifted tremendously the paradigm of hospital care and treatment of cardiovascular (CV) patients. According to most recent evidence, due to its multisystemic impact, COVID-19 may lead to an increased risk of cardiac arrhythmias with subsequently increased morbimortality. Purpose: Determine the prevalence of tachyarrhythmias in patients admitted with COVID-19, possible predictors and impact on in-hospital mortality. Methods: A retrospective study of 3475 consecutive patients with COVID-19 pneumonia admitted to our hospital between February 2020 and November 2021 were included. The main outcome was tachyarrhythmias (high ventricular rate (HVR) or new-onset atrial fibrillation (AF), HVR or new-onset atrial flutter (AFL), other supraventricular tachycardias (SVT), ventricular tachycardia (VT) and ventricular fibrillation (VF)). Secondary outcome was in-hospital mortality. Sociodemographic variables and clinical data were recorded. Statistical comparison was made between groups, including logistic regression to determine odds ratios (OR). Results: A total of 215 patients presented HVR AF (6.31%), 79 of which with new-onset AF (36.74%). 8 patients had HVR AFL (0.23%), 5 VT (0.15%), 4 VF (0.12%) and only 3 patients had a SVT identified (0.09%). Patients with tachyarrhythmias were significantly older (77. 74 ± 11.25 68.94 ± 17.51 years, p <0.001) and had more hypertension (p 0.034), heart failure (HF) (p <0.001), severe valvular heart disease (VHD) (p 0.007), coronary artery disease (CAD) (p 0.031), chronic kidney disease (CKD) (p 0.048) and paroxysmal AF (if previously diagnosed (p 0.001). There were no significant differences regarding gender, dyslipidemia, diabetes, cerebrovascular disease and obstructive sleep apnoea (OSA). Patients with HF had the highest risk of tachyarrhythmia (OR 3.539;95% CI 2.666-4.698;p <0.001), followed by severe VHD (OR 1.990;95% CI 1.192-3.365;p 0.009) and CAD (OR 1.575;95% CI 1.040-2.386;p 0.032). Older patients or patients with hypertension or CKD were also at an increased risk. Also of note, patients previously diagnosed with paroxysmal AF were more likely to have episodes of HVR AF than the ones with persistent or permanent AF (OR 1.819;95% CI 1.272-2.602;p 0.001) Regarding the secondary outcome, patients with tachyarrhythmias during hospital stay had an odd almost 3 times higher of death (OR 2.820;95% CI 2.151-3.695;p <0.001). Conclusions: Tachyarrhythmias is a common complication in COVID-19 patients during hospital stay that is significantly linked to higher in-hospital mortality. Patients presenting with high CV disease burden are at particularly significant risk and should be carefully managed. Odds-ratio of tachyarrhythmias (Figure Presented).

Secondary bacterial infections are a leading factor triggering New Onset Atrial Fibrillation in intubated ICU Covid-19 ARDS patients.

BACKGROUND: Cardiac arrhythmias, mainly atrial fibrillation (AF), is frequently reported in COVID-19 patients, more often in Intensive Care Unit (ICU) patients, yet causality has not been virtually explored. Moreover, non-Covid ICU patients frequently present AF, sepsis being the major trigger. We aimed to examine whether sepsis or other factors-apart from Covid-19 myocardial involvement-contribute to elicit New Onset AF (NOAF) in intubated ICU patients. METHODS: Consecutive intubated, Covid-19ARDS patients, were prospectively studied for factors triggering NOAF. Demographics, data on Covid-19 infection duration, laboratory findings (troponin as well), severity of illness and ARDS were compared between NOAF and control group (no AF) on admission. In NOAF patients, echocardiographic findings, laboratory and secondary infection data on the AF day were compared to the preceding days and/or ICU admission data. RESULTS: Among 105 patients screened, 79 were eligible; nineteen presented NOAF (24%). Baseline characteristics did not differ between the NOAF and control groups. Troponin levels were mildly elevated upon ICU admission in both groups. Left ventricular global longitudinal strain was impaired (<16.5%) in 63% vs 78% in the two groups, respectively. The right ventricle was mildly dilated, and pericardial effusion was present in 52 vs 43%, respectively. NOAF occurred on the 18 ± 4.8 days from Covid-19 symptoms' onset, and the 8.5 ± 2.1 ICUday. A septic secondary infection episode occurred in 89.5% of the patients in the NOAF group ( vs 41.6% in the control group (p < 0.001). In fact, NOAF occurred concurrently with a secondary septic episode in 84.2% of the patients. Sepsis presence was the only factor associated to NOAF occurrence (OR 16.63, p = 0.002). Noradrenaline, lactate and inflammation biomarkers gradually increased in the days before AF (all p < 0.05). Echocardiographic findings did not change on NOAF occurrence. CONCLUSION: Secondary infections seem to be major contributors for NOAF occurrence in Covid-19 patients, probably playing the role of the "second hit" in an affected myocardium from Covid-19.

New-Onset Atrial Fibrillation in COVID-19 Infection: A Case Report and Review of Literature.

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, many cases of arrhythmias have been reported in patients with COVID-19 infection. We present the case of a 66-year-old female with no known cardiovascular history who presented with worsening shortness of breath and productive cough and tested positive for COVID-19 infection in the ED. The patient had a recent hospitalization for COVID-19 infection during which she was treated with dexamethasone and remdesivir therapy and her course remained uncomplicated at that time. Following this, she developed worsening shortness of breath at home for which she presented to the ED. During this hospitalization, she was treated with dexamethasone, remdesivir, and supplemental oxygen. On day six of hospitalization, the patient became tachycardic and had palpitations. Cardiac monitor and EKG showed evidence of new-onset atrial fibrillation (NOAF). Initially patient received metoprolol and diltiazem, both of which failed to achieve adequate rate control. Following this, the patient was started on carvedilol 30 mg every six hours, which attained good rate control. Her CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74, and sex category) score was 4 for which she was started on apixaban 5mg twice daily. The patient was discharged on the same medications. Despite increasing reported incidences of NOAF in COVID-19 infection, only little is known about the optimal management strategies and possible etiopathology. The aim of our review is to highlight the possible mechanisms triggering atrial fibrillation in COVID-19 infection and go over the management strategies while reviewing the available literature.

Risk Factors and Therapeutic Interventions Associated with Mortality in Veterans Diagnosed with SARS-CoV-2 Infection (or COVID-19) Admitted to a Large Academic Medical Center

Background. Patient and treatment-related factors have been used to stratify COVID-19 outcomes;however, studies in the general population and specifically veterans have yielded variable results. This study was designed to assess how baseline characteristics and interventions correlate with clinical outcomes in patients admitted with COVID-19 at a large academic Veterans Affairs hospital. Methods. Retrospective chart review was conducted on veterans admitted to the hospital with COVID-19 between March 1 to December 31, 2020. Veterans without respiratory symptoms attributed to COVID-19 or enrolled in a COVID-19 clinical trial were excluded. Primary outcome was in-hospital mortality up to 28 days. Secondary outcomes were 90-day mortality, discharge to higher level of care or remained in the hospital within 28 days, and discharge with new oxygen requirement within 28 days. Patient characteristics and therapeutic interventions were assessed for correlation with primary and secondary outcomes. Results. Of 497 hospitalized patients reviewed, 293 were included for analysis;94% were male;average age was 68 years with 64.9% of veterans greater than 65 years of age;43.7% were Black;17.4% were Hispanic. In-hospital mortality at 28-days and 90-day mortality were 18.1% and 21.5%, respectively. At discharge, 34.1% had a new oxygen requirement and 17.5% went to a higher level of care. Patients that died in-hospital were more likely to be greater than 65 years of age (p< 0.001), Hispanic (p=0.007), have chronic kidney disease (CKD) (p=0.005), be admitted to ICU (p< 0.001);receive dexamethasone (p< 0.001), convalescent plasma (p< 0.001), or antibiotics (p< 0.001);require mechanical ventilation (p< 0.001);or have new onset atrial fibrillation (p< 0.001). Veterans also had higher levels of inflammatory markers within 48 hours of hospital admission (see Table 2) and longer length of hospital stay (< 0.001). There was a trend for patients that died in the hospital within 28-days to be less likely to be Black (p=0.06). Conclusion. Patients were more likely to die in-hospital within 28-days if they were greater than 65 years of age, Hispanic and had CKD. Veterans that died in-hospital within 28-days had higher inflammatory marker levels and were more likely to receive COVID-19 treatments.

Home-based cardiac tele-rehabilitation during covid-19-early preliminary experience for post cardiac surgery patients in Hong Kong

Objectives: Home-based Cardiac rehabilitation (HBCR) models have been implemented as a potential solution to address access barriers to cardiac rehabilitation (CR). During COVID-19 pandemic peak period in Hong Kong, there is increasing emphasis on social distancing and caregiving strategies to better reach patients (pt) outside hospital. We designed and implemented HBCR amongst cardiac pts recovering from major cardiac surgeries including heart transplantation. We report our early 4 weeks' experience of HBCR during peak COVID-19 outbreak and explore the safety and feasibility of HBCR with telecommunication and tele-monitoring using wearable device (WD). Methods: Twelve pts (8 men (66%);mean age 52.6±9.7) were enrolled in July 2020. There are 5 post-heart transplant pts, 6 post-cardiac surgery pts and 1 post-PCI pt. HBCR includes exercise prescription, nutrition and risk factor modification for 12 weeks. An individualized exercise prescription is determined based on initial standardized assessments in hospital and tailored to fit lifestyle and home environment. Goal is set at 150 minutes of low to moderate-intensity aerobic exercise per week. Exercise is progressed weekly based on daily metrics recorded by WD (exercise log and % target heart rate reserve (THRR) attained), exercise routine and rate of perceived exertion (RPE). These were reported by pts through an online survey after each exercise session which were reviewed daily, with progress follow-up by phone calls or text messages on a weekly basis. Results: All pts participated and uploaded their WD data successfully despite early connectivity issue in 1 pt. 75% pts submitted online survey after each exercise session. Weekly average exercise time was 330 minutes (median). Mean % THRR was 58%. Overall mean reported BP was 118±10 mmHg and mean RPE was 11±1.7. No adverse event or emergency hospitalization reported. Weekly follow-up communications were all successful. One pt with new onset atrial fibrillation was detected with prompt in-hospital consultation. Conclusion: HBCR protocol designed and supervised remotely by dedicated CR team is safe and effective. It is foreseeable that HBCR will continue beyond COVID-19 to serve critical needs of pts with improved utilization of CR.

Corticosteroids and the risk of atrial fibrillation in hospitalized covid-19 patients

Introduction: Some studies suggest an increased incidence of atrial fibrillation (AF) in patients receiving corticosteroids, whereas others suggest a preventive effect of steroids. Data on the impact of steroids on the incidence of new-onset AF in hospitalized COVID-19 patients is lacking. Methods: This retrospective, multicenter cohort study included patients ≥ 18 years admitted to one tertiary care and five community hospitals for treatment of COVID-19 infection between 3/1/2020 and 3/31/2021. Subjects were stratified based on steroid exposure during hospitalization: group 1 (full-dose) received cumulative dosage including dexamethasone ≥ 6 mg/day, methylprednisolone ≥ 80 mg/day or hydrocortisone ≥ 50 mg/day for ≥ 3 days, group 2 (low-dose) did not receive the aforementioned dosage, and group 3 had no steroid usage. Patients with a history of AF and length of stay < 3 days were excluded. Results: Among 4578 (1556 in group 1, 1046 in group 2, 2156 in group 3) patients (mean age 65.4 ± 61 years, 50.4 % females), 542 patients developed new-onset AF. 523 (24.3%) patients in group 1, 97 (9.3%) in group 2, and 125 (8%) in group 3 died during hospitalization. In multivariable logistic regression models adjusted for hypoxia and significant baseline demographics (age, sex, body mass index, hypertension, pulmonary disease, chronic kidney disease, liver disease, and cerebrovascular accident), we found that group 1 had a higher incidence of AF compared to group 3 (adjusted relative risk [aRR] 1.59;95% CI 1.27-1.99;p < 0.001) and group 2 (aRR 1.39;95% CI 1.09-1.77;p = 0.007). The group 2 vs group 3 (aRR 1.14;95% CI 0.87-1.50;p = 0.347) comparison did not reach statistical significance (Figure). Conclusions: Corticosteroids, the mainstay of treatment of hypoxic COVID-19 patients, are associated with an increased risk of developing AF. This suggests that steroids have a potential direct arrhythmogenic effect in COVID-19 patients.

Incidence of cardiac complications during index hospitalisation with covid-19 in Australia: Aus-covid study

Introduction: Cardiac complications of COVID-19 include acute cardiac injury, myopericarditis, cardiomyopathy and arrhythmias. This study aimed to describe the incidence of cardiac complications in patients admitted to hospital with COVID-19 in Australia. Methods: AUS-COVID is a multicentre observational cohort study across 21 Australian hospitals including all index hospitalisations with laboratory-proven COVID-19 in patients aged 18 years or older. All consecutive patients entered in the AUS-COVID Registry by 28 January 2021 were included in the present study. Results: Six hundred and forty-four hospitalised patients (62.5 ± 20.1 years old, 51.1% male) with COVID-19 were enrolled in the study. Overall in-hospital mortality was 14.3%. Twenty (3.6%) patients developed new atrial fibrillation or flutter during admission and 9 (1.6%) patients were diagnosed with new heart failure or cardiomyopathy. Three (0.5%) patients developed high grade atrioventricular (AV) block. Two (0.3%) patients were clinically diagnosed with pericarditis or myopericarditis. Among the 295 (45.8%) patients with at least one troponin measurement, 99 (33.6%) had a peak troponin above the upper limit of normal (ULN). In-hospital mortality was higher in patients with raised troponin (32.3% vs 6.1%, p<.001). New onset atrial fibrillation or flutter (6.4% vs 1.0%, p=.001) and troponin elevation above the ULN (50.3% vs 16.4%, p<.001) were more common in patients 65 years and older. There was no significant difference in the rate of cardiac complications between males and females. Conclusions: Among patients with COVID-19 requiring hospitalisation in Australia, troponin elevation was common but clinical cardiac sequelae were uncommon. The incidence of atrial arrhythmias and troponin elevation was greatest in patients 65 years and older.

Use of commercial outpatient monitoring for near-real-time, acute-and subacute-care telemetry like monitoring in covid-19 pandemic

Introduction: Limited data exist on the role of commercial mobile cardiac telemetry (MCT) monitoring with QT capability as a near-real-time inpatient monitoring tool for COVID-19 stable patients. Our aim was to determine whether outpatient MCT monitoring could be adapted for nearreal-time inpatient arrhythmia and QT monitoring during the COVID-19 pandemic. Methods: We conducted a prospective observational study on patients ≥18 years old with confirmed COVID-19 who required hospitalization between June and December 2020. Data including baseline characteristics and laboratory data were collected. Cardiac rhythms monitored using the MCT monitors (Medilynx Pocket ECG) were analyzed (beat-to-beat analysis). Off-site technicians monitored for arrhythmias 24/7 and notified the physician based on the pre-defined events (QTc ≥500 ms with QRS <120 ms or QTc >520 ms with QRS ≥120 ms or atrial and/or ventricular tachyarrhythmia ≥5 beats). Primary endpoint was the detection of any of the pre-defined events. Results: 29 patients were enrolled in this study. 65.5% were female. There were no significant differences except age in baseline characteristics and laboratory data between those with and without events. Patient age was a significant predictor of events at multivariable analysis [odds ratio 1.08, 95% CI (1.01-1.15);P = 0.023]. Table 1 showed the overall number and events recorded on the MCT monitors. Two patients had new-onset atrial fibrillation (AF) and 5 patients had AF with heart rate >100 bpm. In retrospective analysis, these findings correlated with the 12-lead ECGs performed during their hospital stays. Two patient had significant QTc prolongation noted on the MCT monitor. No adverse events occurred in any of the monitored patients. Conclusions: Our results showed that commercial MCT monitoring can potentially provide a system for detecting clinically relevant arrhythmias and QT prolongation, especially if there is a subsequent shortage of telemetry monitors.

Tachyarrhythmias in covid-19 patients admitted to the intensive care unit

Introduction: The SARS-CoV-2 infection has been associated with new-onset arrhythmias. Newonset tachyarrhythmias including atrial fibrillation, atrial flutter, and ventricular tachycardias (VT) have been reported from different retrospective studies. It is proposed that new-onset arrhythmias are likely associated with systemic illness, and not only triggered by SARS-CoV-2 infection. Hypothesis: We hypothesized that patients who were admitted to the ICU/CCU level of care were more likely to have new-onset tachyarrhythmias vs hospitalized patients who were not admitted to the ICU/CCU. Methods: This is a multi-center retrospective study. The RT-PCR confirmed adult COVID-19 patients consecutively admitted from March 1st to April 30, 2020, were included. Demographic characteristics, comorbidities, and the onset of new arrhythmias were manually extracted from EMR. Categorical variables are shown in percentages;continuous variables are shown in mean (SD). Data were extracted manually using the hospital's electronic medical record. Categorical variables were compared using the chi-square test;continuous variables were compared using the t-test (with equal variance assumption). P-value <0.05 was considered significant. Results: A total of 720 patients were admitted to the hospital. Of these, 11% had new-onset tachyarrhythmias. The onset of new tachyarrhythmias was significantly high in patients who were admitted to ICU/CCU vs non-ICU setting (p-value, <0.001). 13% of patients admitted to ICU/CCU developed new-onset atrial fibrillation vs 7% in the non-ICU setting. 1.5% developed new-onset atrial flutter in ICU/CCU setting vs 1% in the non-ICU setting. Incidence of VT and VF were also higher in ICU/CCU settings. Table1 Conclusions: Patients who were hospitalized with COVID-19 and received ICU/CCU level care were more likely to develop new-onset tachyarrhythmias.

Incidence and Prognostic Impact of New-Onset Atrial Fibrillation in Patients with Severe Covid-19: A Retrospective Cohort Study.

BACKGROUND: Corona virus disease 2019 (COVID-19) contributes to cardiovascular complications including arrhythmias due to high inflammatory surge. Nevertheless, the common types of arrhythmia amongst severe COVID-19 is not well described. New onset atrial fibrillation(NOAF) is frequentlyseen in critically ill patients and therefore we aim to assess the incidence of NOAF in severe COVID -19and its association with prognosis. METHODS: This is a retrospective multicentre study including 109 consecutive patients admitted to intensive care units (ICU) with confirmed COVID-19 pneumonia and definitive outcome (death or discharge). The study period was between 11th March and 5th May 2020. RESULTS: Median age of our population was 59 years (IQR 53-65) and 83% were men. Nearly three-fourth of the population had two or more comorbidities. 14.6% developed NOAF during ICU stay with increased risk amongst older age and with underlying chronic heart failure and chronic kidney disease. NOAF developed earlier during the course of severe COVID-19 infection amongst non-survivors than those survived the illness andstrongly associated with increased in-hospital death (OR 5.4; 95% CI 1.7-17; p=0.004). CONCLUSIONS: In our cohort with severe COVID-19, the incidence of new onset atrial fibrillation is comparatively lower than patients treated in ICU with severe sepsis in general. Presence of NOAF has shown to be a poor prognostic marker in this disease entity.

Outcomes and mortality associated with atrial arrhythmias among patients hospitalized with COVID-19: A systematic review and meta-analysis.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia in the adult population. Herein, is a systematic review with meta-analysis to determine the impact of AF/atrial flutter (AFL) on mortality, as well as individual complications in patients hospitalized with the coronavirus disease 2019 (COVID-19). METHODS: A systematic search of the SCOPUS, Medline, Web of Science, CINAHL and Cochrane databases was performed. The a priori primary outcome of interest was in-hospital mortality. A random-effects model was used to pool study results. RESULTS: Nineteen studies which included 33,296 patients were involved in this meta-analysis. Inhospital mortality for AF/AFL vs. no-AF/AFL groups varied and amounted to 32.8% vs. 14.2%, respectively (risk ratio [RR]: 2.18; 95% confidence interval [CI]: 1.79-2.65; p < 0.001). In-hospital mortality in new onset AF/AFL compared to no-AFAFL was 22.0% vs. 18.8% (RR: 1.86; 95% CI: 1.54-2.24; p < 0.001). Intensive care unit (ICU) admission was required for 17.7% of patients with AF/AFL compared to 10.8% for patients without AF/AFL (RR: 1.94; 95% CI: 1.04-3.62; p = 0.04). CONCLUSIONS: The present study reveals that AF/AFL is associated with increased in-hospital mortality and worse outcomes in patients with COVID-19 and may be used as a negative prognostic factor in these patients. Patients with AF/AFL are at higher risk of hospitalization in ICU. The presence of AF/AFL in individuals with COVID-19 is associated with higher risk of complications, such as bleeding, acute kidney injury and heart failure. AF/AFL may be associated with unfavorable outcomes due to the hemodynamic compromise of cardiac function itself or hyperinflammatory state typical of these conditions.

Atrial fibrillation is associated with poor clinical trajectory of COVID-19

Background: Atrial fibrillation (AF) has been described as a common cardiovascular manifestation in patients suffering from coronavirus disease 2019 (COVID-19) and is discussed to be a potential risk factor for a poor clinical course. AF is also already known to be associated with increased risk for all cause death. Purpose: In the present study we sought to investigate the impact of AF on the clinical trajectory of patients suffering from COVID-19. Methods:We included all patients hospitalized due to COVID-19 in 2020 in our Hospital. A poor clinical trajectory was defined as transfer to intensive care unit (ICU), intermediate care unit (IMC) or death from any cause. Initial ECGs were analyzed in consensus by two experienced readers. First, we compared patients with poor clinical trajectory vs. good clinical course. Secondly, the study population was categorized into two groups with or without AF on admission. A subgroup analysis was performed to differentiate between new onset AF and patients with known history of AF. To compensate for confounders (age, BMI, known cardiomyopathy (CMP), known coronary artery disease (CAD), chronic airway disease, renal insufficiency, diabetes, arterial hypertension and sex), a full clinically validated multiple logistic regression model with poor clinical trajectory as dependent target variable was performed. Results: From our enrolled 666 patients in 2020 (58% male, average age: 66 (IQR:58-80)) 223 patients (33.5%) experienced a poor clinical course. 179 (27%) patients were transferred to IMC/ICU and 86 (13%) patients died. All in all, patients with poor clinical trajectory were more frequently male (70% vs. 52%;P<0.001), older (71±14 vs. 64±20;P<0.001) and had significantly more co-morbidities such as CAD, CMP, hypertension and diabetes in comparison to patients with a good clinical course. 96 (14.4%) had AF on admission. Among these 37.5% had new-onset AF, which showed similar baseline characteristics as patients without AF. Indeed, patients with COVID-19 and new onset AF were more likely to die (25% vs 12%;P=0.038), or be in need for ICU/IMC (25% vs. 62%;P<0.001) and therefore experienced a poor clinical trajectory more frequently (75% vs. 31%;P<0.001) with a confounder adjusted OR of 5.89. In the subgroup analysis of all patients with AF on admission. Patients with new onset of AF had significantly more underlying CMP, Diabetes and chronic airways disease. While mortality was not higher in patients with new onset of AF, IMC/ICU transfers (62% vs 24%;P<0.001) and as a result poor clinical trajectory (75% vs 40%;P=0.001) was significantly increased in comparison to patients with known AF. Conclusion: In patients suffering from COVID-19, new onset of AF on admission was associated with a poor clinical course and higher in-hospital mortality.

Prognostic value of atrial fibrillation in COVID-19 admitted patients

Introduction/Background: COVID-19 is the disease caused by SARSCov2. Various prognostic factors have been studied and described. Atrial fibrillation (AF) is an arrhythmia associated with increased complications and mortality in acute situations. The onset of AF in patients hospitalized for COVID-19 could associate a worse prognosis during admission and in the short term. Purpose: The objective of this study is to evaluate the adverse events in the population admitted for COVID-19 that develops AF as well as its possible prognostic value. Methods: Retrospective, cohort study on 391 patients admitted for COVID- 19 in a tertiary hospital. Descriptive and comparative analysis between those with new onset AF versus those who had AF previously in terms of: baseline characteristics, In hospital mortality, bleeding and thrombotic phenomena. Follow-up during three months after discharge. Univariate and multivariate analysis of in-hospital and three-months mortality is also performed. Results: 391 patients were included. 21 of them developed AF. These patients are older, more hypertensive and with more history of cardiopathy. At admission, they presented higher mortality (52.4% vs 19.7%;p<0.001) and bleeding (19% vs 8.4%;p<0.001), also compared to those with previous AF (not significant). New onset AF is not an independent predictor of in-hospital mortality, but rather an independent predictor of three-month mortality. In-hospital mortality predictors are: age >70 years, BCRSS scale >2 points, and severe hypotension. Three-month mortality predictors are: high-sensitive T-troponin <50ng/dl, age >70 years, BCRSS scale >2, creatinine >1.5 mg/dl and new-onset AF. Conclusions: New onset AF appears in 5,3% of these hospitalized patients, who have greater comorbidity, bleeding and in-hospital mortality as well as three-months mortality. New onset AF is not an independent predictor of in-hospital mortality but rather an independent predictor of mortality during the first three months after discharge (Figure Presented).

Impact of telemedicine network provided by local pharmacies in the management of symptomatic tachyarrhytmias during COVID-19 outbreak

Background: During the lockdown in Italy, from March 11th to May 4th 2020, a progressive increase in COVID-19 cases occurred in all Italian regions, in particular in Lombardy. The current rise in COVID-19 cases has led to an increasing involvement of hospitals, in order to face the Coronavirus outbreak, shifting healthcare resources towards the management of COVID+ patients. This has led, on the other hand, to a progressive decrease in hospital admissions due to conditions not associated with SARSCoV2 infection. In other European countries interested by a national lockdown, a decrease in registered new-onset atrial fibrillation (AF) cases was observed. Undiagnosed AF patients can develop complications that could potentially translate into poorer long-term outcomes. Purpose: In this scenario, we aimed to verify the impact of telemedicine (TLM) during lockdown, in comparison with the same period in 2019. Materials and method: We analyzed 12-lead ECGs recorded by 5000 country pharmacies, evaluated and stored in one TLM platform provided by Health Telematic Network (HTN), in cooperation with our Cardiology Department, Federfarma, and Italian National Health Institute. Results: During the lockdown period in 2020, 6,104 ECGs were performed in territorial pharmacies, compared to 17,280 ECGs recorded in the same period in 2019. Among ECGs performed, we detected AF in 344 patients (5.64%) in lockdown period, compared to 393 cases (2.27%) detected in the same period in 2019, with an increase of 40.25%. We detected also Atrial Flutter in 32 patients (0.52%) in lockdown period, compared to 25 cases (0.14%) detected in the same period in 2019. The difference was +26.92%. Moreover, we found Paroxysmal Supraventricular Tachycardia in 8 patients (0.13%) during lockdown, compared to 6 cases (0.03%) detected in the same period in 2019, with an increase of 23.07%. In lockdown period, a total of 384 patients (6.29%) were referred to ED because of symptomatic tachyarrhythmia, compared to 424 patients (3.47%) referred to ED in the same period in 2019, with an increase of 55.16%. In the Lombardy Region, during lockdown, were reported 194 cases of tachyarrhythmia in territorial pharmacies (about 50.52% of all cases in Italy). Among these, 93 cases of tachyarrhythmia were in the Brescia area (about 47.94%), whereas 50 cases were in the Bergamo one (about 25.77%). Conclusion: These data shown that, during the COVID outbreak, a large number of patients with CV symptoms preferred to go to territorial pharmacies rather than the closer hospital. TLM played a prominent role in managing patients with CV symptoms at home. Moreover, this service allowed to refer to the hospital only patients with clinically relevant tachyarrhythmia, avoiding the risks of treatment delay. This once again underlines how TLM network provided by pharmacies may become an important tool offered to citizens, especially during coronavirus pandemic emergency, within the Italian National Health System.

HeartLogic algorithm for heart failure monitoring in the era of CoViD-19 pandemic and remote monitoring/telemedicine

Background: Due to the current CoViD-19 pandemic, the number of outpatient hospital visits has significantly decreased, creating a fundamental need for telemedicine. Remote monitoring of implantable cardiac devices has emerged as a powerful and well-validated tool to follow patients with heart failure (HF) and cardiac resynchronization therapy (CRTs) devices. Purpose: The aim of our study was to evaluate the CRT HeartLogic algorithm performance in the detection of HF episodes in a real-life population followed with remote monitoring. Methods: Fifty-four patient (mean age 73±7 years, 72% males) with HF and reduced left ventricular ejection fraction were implanted with a Heart- Logic-enabled CRT device and were enrolled in the Boston Scientific Latitude remote monitoring platform. Remote data were reviewed every month and at the time of an alert. The HeartLogic nominal value of 16 was used to trigger an alert episode. Patients were then contacted by phone and actions were taken to manage the potential HF condition detected by the alert. Results: During a median follow-up of 12 (6-18) months, the HeartLogic alert was triggered in 9 patients (9/54, 17%). The median time between threshold crossing and a HF clinical event was 11 (2-19) days. The maximum HeartLogic index value was 43 (mean 29±8). Three events occurred after inappropriate discontinuation of HF therapy. All the events required clinical action. Four out of 9 patients required diuretic dosage increase, 1/9 electrical cardioversion for new onset atrial fibrillation, 3/9 hospitalization for i.v. therapy. One patient showed only mild HF symptoms but was found to have concomitant CoViD-19 infection. Conclusion: The HeartLogic algorithm is useful to detect HF worsening and undertake appropriate clinical actions. Telemedicine and device remote monitoring are very helpful tools allowing early detection of HFrelated clinical conditions. This is of utmost importance in the era of CoViD- 19 pandemic, when scheduled access to the hospital for routine follow-up appointments might be limited.