COVID-19 and Acute Coronary Syndrome: A Literature Review.

The coronavirus disease 2019, also known as the COVID-19 pandemic has had a deleterious impact on daily living, with health and socioeconomic effects of a global magnitude. Acute coronary syndrome (ACS), an important cardiovascular disease with significant morbidity and mortality rates, has been frequently reported in patients with this novel virus. This review aims to discuss the potential associations between COVID-19 and ACS with the use of multiple databases, including but not limited to; PubMed, ScienceDirect, World Health Organization, and American Heart Association. We have explored the pathophysiology of ACS, focusing on COVID-19 in particular with the use of various works of literature that highlights the pattern of viral entry and replication via the angiotensin-converting enzyme II. The review has also discussed the impact of the pandemic on hospital admissions, diagnosis, and management of ACS patients, as well as briefly highlighted a possible link between the widely available COVID-19 vaccines and possible cardiovascular complications. The association between COVID-19 and ACS needs more in-depth studies to help establish whether there exists a direct causal and or inciting correlation between them. Understanding this association might lead to new research and treatment options for ACS patients.

COVID-19 and Type II NSTEMI: A Comprehensive Overview

Introduction: Data on the incidence of type 2 NSTEMI (T2MI) in hospitalized patients with COVID-19 infection has been limited to single-center studies. We propose to define the incidence of T2MI in a national cohort and identify pre-hospital patient characteristics associated with a diagnosis of T2MI in hospitalized patients with COVID-19. We will also examine the impact of T2MI on morbidity and mortality. Method(s): We performed a retrospective analysis on data from the American Heart Association COVID-19 Cardiovascular Disease Quality Improvement Registry. This national registry contains data on tens of thousands of patients hospitalized with COVID-19 from at least 122 centers across the United States. From January 2020 through May 2021, there were 709 (2.2%) out of 32,015 patients with a coded diagnosis of T2MI. We performed Wilcoxon tests, chi-squared test, and multivariable logistic regression to (1) identify predictive pre-hospital patient characteristics (Table 1) of T2MI for patients hospitalized with COVID-19 and (2) investigate the impact of T2MI on mortality and morbidity. Result(s): Patients in the T2MI group were older (71 vs. 63 years, p<0.001), and in forward selection analyses, patients with a diagnosis of T2MI had higher odds of known HTN (OR 1.79 [1.01-3.1], p=0.026) and heart failure (OR 3.46 [2.24-5.34], p<0.001). Increased age, admission troponin, CRP, and d-dimer were also associated with higher odds of T2MI. Hispanic race (OR 0.517 [0.289-0.924], p=0.026) and use of antihyperglycemics (OR 0.562 [0.377-0.836], p=0.005) were both associated with lower odds of T2MI. T2MI led to increased mortality (HR 1.32, [1.17-1.5], P<0.001) and morbidity including cardiac arrest, major bleeding, and stroke. Conclusion(s): A history of heart failure was the strongest predictor of T2MI in hospitalized COVID19 patients. Patients with a T2MI compared to those without, had significantly higher mortality and morbidity. Limitations include the heterogenous ascertainment of the T2MI diagnosis across sites in this registry.

Abstracts From the American Heart Association's Epidemiology and Prevention/Lifestyle and Cardiometabolic Health 2022 Scientific Sessions

The proceedings contain 385 papers. The topics discussed include: racial and ethnic differences in the population burden of dementia attributable to modifiable risk factors in the United States;higher visit-to-visit variability in fasting glucose and HbA1c is associated with decline in global cognitive performance: the Multi-Ethnic Study of Atherosclerosis (MESA);prevalence of stroke symptoms among Hispanic/Latino adults in the Hispanic community health study/study of Latinos (HCHS/SOL);educational attainment and dementia risk: mediation by vascular risk factors at mid-life in the atherosclerosis risk in communities (ARIC) study;a healthy plant-based diet was associated with slower cognitive decline in African Americans: a biracial community-based cohort of older adults;outcome preferences related to cardiovascular preventive therapies in older adults: an online survey;subclinical myocardial injury, coagulopathy, and inflammation in Covid-19: a meta-analysis;COVID-19 and type II NSTEMI: a comprehensive overview;association of antecedent statin use with outcomes of people with Covid-19 admitted at northwestern medicine health system;and social determinants of health and ambulatory outcomes among Covid-19 positive patients: differences by race/ethnicity.

An Eventful Rotational Atherectomy Over the Left Main Stem and Left Anterior Descending Artery in an Elderly Male

Clinical Information Patient Initials or Identifier Number: SHS Relevant Clinical History and Physical Exam: Mr. SHS was admitted in August 2022 for acute decompensated heart failure secondary to NSTEMI, complicated with ventricular tachycardia (VT). CPR was performed for6 minutes on the day of admission and was subsequently transferred to the Cardiac Care Unit. His hospital stay was complicated with Covid-19 infection(category 2b) which he recovered well from. During admission, he developed recurrent episodes of angina. Physical examination was otherwise unremarkable. His ejection fraction was 45%. Relevant Catheterization Findings: Cardiac catheterization was performed, which revealed significant calcification of left and right coronary arteries. There was a left main stem bifurcation lesion (Medina 0,1,1) with subtotal occlusion over ostial the LAD, receiving collaterals from RCA and 90% stenosis over ostial LCx. RCA was dominant, heavily calcified with no significant stenosis. He was counselled for CABG (Syntex score26) but refused. As he was symptomatic, he was planned for PCI to the left coronary system. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: The left main was engaged with a 7F EBU 3.5guiding catheter via transradial approach. Sion Blue wired into LAD and LCx. IVUS catheter couldn't cross the LAD and LCx lesions, hence we decided for up front rotational atherectomy. Sion blue was exchanged to Rotawire with the assistance of Finecross microcatheter. A 1.5mm burr was used at 180000 rpm. After the first run of rotablation, patient developed chest pain and severe hypotension (BP ranging 50/30). 4 inotropes/vasopressors were commenced. The shock was refractory hence an intraarterial balloon pump was inserted. Symptoms and blood pressure improved. Another 2 runs of atherectomy done (patient developed hypotension after each run). IVUS examination then showed calcification of proximal to mid LAD with an IVUS Calcium score of 3. LAD was further predilated with Scoreflex balloon 3.0/20mm at 8-22ATM. LCx was predilated with Scoreflex balloon 2.0/15mm at 12-14ATM. DCB Sequent Please NEO2.0/30mm was deployed at 7ATM at ostial to proximal LCx. Proximal to mid LAD was stented with Promus ELITE 2.5/32mm at 11ATM, which was then post dilated with stent balloon at 11ATM. Ostial LM to proximal LAD (overlap) was stented with Promus ELITE 4.0/28mm at 11ATM. LMS POT was then done with NC Balloon 4.0/15mm at 24ATM. LCx was rewired and kissing balloon technique with NC balloon 4.0/15mm at 14ATM (LAD) and NC balloon 2.0/10mm at 12ATM (LCx) was done, followed by a final POT with NC balloon 4.0/15mm at 14ATM. Final IVUS showed good MSA. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): This patient developed hemodynamic instability with each rotational atherectomy run, hence we decided not to perform rotablation to the circumflex artery. His hemodynamic condition improved with the use of intra aortic balloon pump. IABP use can reduce procedural event rate and potentially reduce long term mortality in appropriately selected patients who are at high risk of adverse events. He was followed up a month following the procedure and remained asymptomatic. For complex, calcified coronary lesions involving the left main stem, coronary artery bypass graft surgery is an alternative option.Copyright © 2023

Symptomatic Myocarditis After Pfizer Covid-19 Vaccination

Widely considered safe, effective, and essential for pathogenic immunity, vaccines have proven to be one of the most important discoveries to date in medicine. Adverse reactions to vaccines are typically trivial but there have been extremely rare reports of vaccine induced myocarditis, particularly with the Tdap vaccine. This is thought to be due to a hypersensitivity reaction. In efforts to combat the SARS-CoV-2, prompt response from Pfizer-BioNTech and Moderna lead to vaccine development with a novel method, synthesized from modified messenger RNA. Despite minimal side effects on initial trials, reports of vaccine induced myocarditis have resulted. A majority of these cases occurred following subsequent doses for those previously inoculated. A descriptive study published in JAMA in January 2022 reviewed the Vaccine Adverse Event Reporting System (VAERS) in collaboration with the CDC described only 1626 cases of myocarditis, of which the majority occurred within days of the second dose. This review was limited by reviewing a passive reporting syndrome with variable quality data and without follow up data post diagnosis of myocarditis. Here we present a case of myocarditis occurring less than 24 hours after the second dose of Pfizer-BioNTech vaccine with 3 month follow up. A 23 year old man received his second dose of the COVID-19 vaccine in the morning. Within a few hours he experienced chest pain, chills, weakness, and fatigue. These dissipated by 7pm. He is a member of the National Guard and during drills the next day experienced stabbing substernal chest pain for which he sought evaluation. The pain radiated into his left jaw, worse with deep inspiration and worse in the left lateral decubitus position. He is a 1 PPD smoker with no personal or family history or cardiac disease. A friction rub was heard on physical exam. His troponin I peaked at 2.6ng/mL. His EKG showed normal sinus rhythm, a TTE showed a normal EF with no pericardial effusion. He was given aspirin 81 mg and started on a heparin drip for possible NSTEMI. The next day his pain decreased and a cardiac MRI demonstrated no inflammation. His serum coxsackie and parvovirus titers were negative. He was instructed to continue the aspirin, limit exercise for 8 weeks, and stop smoking. Upon follow up 3 months later the patient denied any recurrent chest pain and was advised to continue the aspirin. But the original bout of myocarditis limited his participation in the National Guard. Our case illustrates that exposure to an immunological trigger, the COVID-19 vaccine, leading to myocarditis was extremely short compared to typical cases of viral induced or vaccine hypersensitivity reaction. A proposed mechanism is molecular mimicry between the spike protein and myocardial contraction proteins. It also demonstrates that the vaccine can cause morbidity in patients, especially younger males. It also exemplifies that this may be a short lived phenomenon, long term follow up is still needed. With the rate of vaccination increasing, there needs to be a low threshold to consider myocarditis in young adults who have new chest pain after receiving an mRNA based vaccine.Copyright © 2022

Impact of COVID-19 pandemic on the occurrence and outcome of cardiogenic shock complicating acute myocardial infarction

Background: The COVID-19 pandemic had influenced the patient's behavior and impacted the homeostasis to a pro-thrombotic niveau. Aim(s): The study aimed to follow the impact of COVID-19 on the incidence and prognosis of cardiogenic shock complicated initially acute myocardial infarction (CS-AMI). Method(s): We used data entered into a large national all-comers registry of coronary intervention over five years. From 1/2016 to 12/2020, 50,745 AMI patients were included, and 2,822 (5.6%) initially had CS. Result(s): The incidence of CS-AMI was significantly higher in the COVID period (2020) than the mean incidence in 2016-2019 (5.5% vs 6%, p=0.032). The difference was caused by significant increase of CS in acute STEMI (7.6% vs. 8.7%, p=0.011);it was 7.1% in 2016, 7.8% (2017), 7.6% (2018), 7.8% (2019), and 8.7% (2020). The CS complicated 2.3% (2016), 2.7% (2017), 2.7% (2018), 2.8% (2019), and 2.8% (2020) of NSTEMI. The observed rise in CS-STEMI incidence each month during the pandemic compared to the average incidence in non-pandemic years correlated with the substantial increase in the number of COVID infected/ hospitalized (Table 1). In these months, no changes in time delay to reperfusion layout were observed in CS-STEMI patients (Table 2). Except of less frequent history of previous PCI (13.9% and 8.2%, p<0.001), we found no significant differences in the followed CS-STEMI patient characteristics in 2016-2019 and 2020;men 72.7% and 75.4% (p=0.1), mean age (SD) 66.3 (12.3)yrs and 66.3 (12.2) yrs, Diabetes 20.9% and 19.1% (p=0.2), CKD 5.4% and 5.7% (p=0.4), previous CABG 4.5 and 4.2% (p=0.5), left main disease (14.3% and 16%, p=0.5), one vessel disease 24.9% and 32.1% (p=0.9), pre-PCI TIMI flow 0 64.4% and 66.2% (p=0.6), post-PCI TIMI flow 3 76.7% and 76.9%. The COVID pandemic didn't influence the proportions of pre-hospital resuscitated CS-AMI patients (57.5% and 58.7%, p=0.6) and those on mechanical ventilation (67.8% and 68.3%, p=0.8). The 30-day mortality trend of CS-AMI was 53.7% in 2016, 51.6% (2017), 49.7% (2018), 49.3% (2019), and 47.9% (2020). And in CS-STEMI it was 50.8%, 47.1%, 46.4%, 44.1%, and 45.3% (P2019 vs. 2020 =0.8), respectively. Conclusion(s): Data from a large national all-comer registry showed an increase in the proportion of patients admitted to hospitals with STEMI complicated by CS in the year of the COVID pandemic. The CS rise correlated with the increase in the COVID infected population. Factors other than the patient's cardiovascular risk profile or prolongation of a time delay to reperfusion influenced this trend. We suggest that the availability of health care and patient adherence may have affected the risks control. We did not observe any effect of the pandemic on CS-AMI mortality. (Figure Presented).

Acute STEMI : Before and During the COVID-19 Pandemic Single Center Study

Background: During COVID-19 pandemic, the pattern of hospital admissions for acute ST-elevation myocardial infarction (STEMI) has been changing, and increased mortality and morbidity is being noted in these patients. Patient may present with acute myocardial infarction, myocarditis simulating a presentation like STEMI, coronary spasm, myocardial injury not fulfilling the criteria of type 1 & type 2 acute MI and cardiomyopathy. In this study we have tried to determine some important differences among the patients presented with STEMI during The COVID-19 pandemic versus non-COVID-19 era. Method(s): This prospective observational study was carried out in National Heart Foundation Hospital & Research Institute from 8thMarch,2019 to 7th March, 2021. Total 2531 patients were included. The study populations were divided into two groups. Group I: Acute STEMI patients presenting during pre COVID period (n=1385). Group II: Acute STEMI patients presenting during COVID period (n=1146). COVID period was calculated from 8th march, 2020 onward as first case of COVID -19 was detected on that day in Bangladesh. All patients presented with Acute STEMI was included in the study however NSTEMI-ACS, Unstable angina were excluded from the study. Result(s): Male was predominant in both groups. Regarding risk factors Hypertension, Obesity and family H/O of CAD was statistically significant (p<0.05). Acute STEMI patients presented lately during COVID-19 period probably due to lock down& lack of transport facility. Regarding coronary artery disease severity, vessel score was more during COVID period. SV-CAD were more during pre COVID period while DV-CAD & TV-CAD were more during COVID period. Gensini score was also calculated among the study populations, it was 57.21+/-28.42 and 63.16+/- 40.43respectively in group I and group I, which was statistically significant. Regarding treatment options of the patients, primary PCI was less during COVID period, however medical management, elective PCI and Thrombolysis were more during COVID era. Regarding in hospital outcome, acute LVF, cardiogenic shock were more during COVID period which were also statistically significant. [Formula presented] [Formula presented] Conclusion(s): During COVID -19, STEMI patients presented lately in comparison to pre COVID period. Coronary artery Disease were more severe during COVID period as evaluated by Vessel Score & Gensini Score. During COVID -19 period majority of patients got medical management& routine PCI were done more in comparison to primary PCI. In Hospital outcome of STEMI was worse during COVID-19 period in terms of acute LVF & cardiogenic shock. [Formula presented] [Formula presented] [Formula presented]Copyright © 2023

Does the quality index of adherence to the evidence-based guidelines predict mortality in patients with myocardial infarction

Background: The SWEDEHEART quality index of hospitals' adherence to the evidence-based (EB) guidelines for myocardial infarction (MI) patients has been continuously used for several decades in Sweden. The grading protocol is based on the consensus among hospitals. The hospitals are awarded points (0, 0.5, 1) for each of the 11 indicators depending on the proportion of patients who received EB treatment and achieved treatment goals. The 11 indicators at present are reperfusion treatment in STEMI (yes/no), time to-reperfusion treatment in STEMI, time to revascularisation in NSTEMI, P2Y12 antagonists at discharge, ACE-inhibitor/ARB at discharge, the proportion of patients at follow-up, smoking cessation at oneyear, participation in a physical exercise program, target LDL-cholesterol and target blood pressure at one year. Purpose(s): To evaluate whether the SWEDEHEART quality index predicts mortality in patients with MI. Method(s): We used data for all MI patients reported to the SWEDEHEART registry from 72 hospitals in Sweden between 2015-2021. We calculated the difference in quality index between 2021 and 2015. The hospitals were divided into quintiles based on the difference in the score. Logistic regression with log-time offset was used to adjust for confounders (age, gender, diabetes, hypertension, hyperlipidemia, STEMI/NSTEMI, cardiac arrest before admission, occupation status, history of heart failure, prior MI, prior PCI, prior CABG, cardiogenic shock). Result(s): We identified 98,635 patients with MI, 32,608 (33.1%) were women and 34,198 (34.7%) had STEMI. The average age was 70.8+/-12.2 years. The median follow-up time was 2.7 years (IQR 1.06-4.63). The crude all-cause mortality rate was 5.5% at 30-days and 22.3% after longterm follow-up. Most hospitals (72.1%) improved their quality index on average by 3.4% per year (P<0.001). The increase in the quality index continued during COVID-19 pandemic (2020-2021) with average increase of 8.6%, 95% CI, 0.97-1.02;P<0.001. The median change in SWEDEHEART quality index score among the quintiles were -1.5 (Q1), 0,5 (Q2), 2,5 (Q3), 3 (Q4), and 4 (Q5). We found no difference in mortality between the quintiles at 30-days (OR 0.99;95% CI 0.97-1.02;p=1.02) and longterm (OR 1.01;95% CI 0,99-1.02;p=0.850). Conclusion(s): The SWEDEHEART quality index provides valuable descriptive information about hospitals' adherence to the guidelines. However, the index, in its current form, does not predict mortality in patients with MI.

To Evaluate the Correlation between Dasi Mets and the Incremental Shuttle Walk Test (Iswt) in Patients with Cardiovascular Disease (Cvd)

Background The Duke Activity Status Index (DASI) questionnaire assesses functional capacity of patients with cardiovascular disease (CVD[1]figure 1.). DASI derives a total score and corresponding METs level. We utilised this questionnaire during COVID-19 when face to face (F2F) functional capacity testing was an unavailable outcome measure for cardiac rehabilitation (CR). Aim To evaluate the correlation between DASI METs and the incremental shuttle walk test (ISWT)and establish if it is a reliable tool to estimate functional capacity in patients with cardiovascular disease (CVD). Methods DASI questionnaire was completed over the phone as part of a subjective assessment. Two ISWTs were performed at a F2F appointment prior to starting class, best of two, taken. Measures were repeated post-CR completion. Results 93 patients, 64.5% male, mean age (SD) 65.3 (9.6) years, assessed at baseline. Patients' presentation: 27% NSTEMI, 24% STEMI, 16% Angina, 13% Heart failure and 20% other. Outcomes pre to post CR are shown in table 1. Correlation between DASI METs and the ISWT at baseline was r= 0.32 [weak positive (p<0.05)] and post-CR was r= 0.67[strong positive (p<0.01)]. The ISWT change was similar to the minimum important difference (MID) 70m in the CHD population. There is no MID for the DASI Conclusions Patients attending CR post-pandemic made significant improvements in both the DASI and ISWT. Correlations became stronger post programme, indicating patients may better self-evaluate physical performance after taking part in CR. DASI questionnaire may be a useful alternative outcome measure when F2F exercise testing is not an option. Future work could explore how to prescribe an exercise programme from this and what might represent a meaningful change in this outcome following CR (Table Presented).

Characteristics of patients with acute coronary syndrome in the COVID-19 pandemic: Acute coronary syndrome characteristics in patients with COVID-19

Aim: Coronavirus disease 2019 (COVID-19) has caused thrombotic disease. In this study, we aimed to determine the demographic and clinical characteristics of acute coronary syndrome (ACS) patients infected with COVID-19 and to investigate whether they differ from patients with ACS without COVID-19 in terms of these characteristics. Material(s) and Method(s): The study was designed as a single-center retrospective study. Thirty-three COVID-19 infected ACS patients (Group 1) and 100 ACS patients without COVID-19 infection (Group 2) were included in the study. Result(s): The groups were compared in terms of coronary angiographic data. Twenty-eight (84.8%) patients in Group 1 and 74 (74%) patients in Group 2 were presented as non-ST elevation myocardial infarctus. Patients were compared in terms of baseline Thrombolysis in Myocardial Infarctus (TIMI) flow, thrombus stage, myocardial blush (end), using of thrombus aspiration catheter, stent thrombosis, and TIMI flow after percutaneous coronary intervention, and it was observed that there was no statistical difference between the groups (p> 0.05). Discussion(s): COVID-19 infection can cause plaque rupture, myocardial damage, coronary spasm and cytokine storm by triggering the coagulation and inflammation process. The fact is that we did not encounter an increased thrombus load in this study.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Potential Cardiac Tamponade Development Secondary to SARS-CoV-2 Infection

Upon initial discovery in late 2019, severe acute respiratory syndrome coronavirus 2, SARS-CoV-2, has managed to spread across the planet. A plethora of symptoms affecting multiple organ systems have been described, with the most common being nonspecific upper respiratory symptoms: cough, dyspnea, and wheezing. However, the cardiovascular system is also at risk following COVID-19 infection. Numerous cardiovascular complications have been reported by physicians globally, in particular cardiac tamponade Physicians must hold a high index of suspicion in identifying and treating patients with cardiac tamponade who may have contracted the novel coronavirus. This review will describe the current epidemiology and pathophysiology of SARS-CoV-2 and cardiac tamponade, highlighting their clinical course progression and the implications it may have for the severity of both illnesses. The paper will also review published case reports of cardiac tamponade, clinical presentation, and treatment of this complication, as well as the disease as a whole. © 2022 Elsevier Inc.

Comparison of risk factors and outcome of patients with and without COVID-19-associated pulmonary aspergillosis from Pakistan: A case–control study

Background: Early identification of COVID-19-associated pulmonary aspergillosis (CAPA) is particularly challenging in low- middle-income countries where diagnostic capabilities are limited, and risk factors for CAPA have not been identified. It is also essential to recognise CAPA patients who are likely to have a poorer outcome to decide on aggressive management approaches. Therefore, this study aimed to identify risk factors and outcomes for CAPA among admitted moderate to critical COVID-19 patients at our centre in Pakistan. Methods: An unmatched case–control study with ratio of 1:2 was conducted on hospitalised adult patients with COVID-19 from March 2020–July 2021. Cases were defined according to European Confederation of Medical Mycology and the International Society for Human and Animal Mycology consensus criteria. Controls were defined as patients hospitalised with moderate, severe or critical COVID-19 without CAPA. Results: A total of 100 CAPA cases (27 probable CAPA;73 possible CAPA) were compared with 237 controls. Critical disease at presentation (aOR 5.04;95% CI 2.18–11.63), age ≥ 60 years (aOR 2.00;95% CI 1.20–3.35) and underlying co-morbid of chronic kidney disease (CKD) (aOR 3.78;95% CI 1.57–9.08) were identified as risk factors for CAPA. Patients with CAPA had a significantly greater proportion of complications and longer length of hospital stay (p-value <.001). Mortality was higher in patients with CAPA (48%) as compared to those without CAPA (13.5%) [OR = 6.36(95% CI 3.6–11)]. Conclusions: CAPA was significantly associated with advanced age, CKD and critical illness at presentation, along with a greater frequency of complications and higher mortality. © 2022 Wiley-VCH GmbH.

Effect of COVID-19 Pandemic on Acute Coronary Syndrome Clinical Practice Patterns: Findings from a Multicenter Clinician Survey in China

Background: The coronavirus disease 2019 (COVID-19) pandemic has severely affected healthcare systems around the world. This study aimed to investigate the perceptions of cardiologists regarding how the COVID-19 pandemic has affected the clinical practice patterns for acute coronary syndrome (ACS). Method(s): A multicenter clinician survey was sent to 300 cardiologists working in 22 provinces in China. The survey collected demographic information and inquired about their perceptions of how the COVID-19 pandemic has affected ACS clinical practice patterns. Result(s): The survey was completed by 211 (70.3%) cardiologists, 82.5% of whom were employed in tertiary hospitals, and 52.1% reported more than 10 years of clinical cardiology practice. Most respondents observed a reduction in ACS inpatients and outpatients in their hospitals during the pandemic. Only 29.9% of the respondents had access to a dedicated catheter room for the treatment of COVID-19-positive ACS patients. Most respondents stated that the COVID-19 pandemic had varying degrees of effect on the treatment of acute ST-segment elevation myocardial infarction (STEMI), acute non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina. Compared with the assumed non-pandemic period, in the designed clinical questions, the selection of coronary interventional therapy for STEMI, NSTEMI, and unstable angina during the COVID-19 pandemic was significantly decreased (all p < 0.05), and the selection of pharmacotherapy was increased (all p < 0.05). The selection of fibrinolytic therapy for STEMI during the pandemic was higher than in the assumed non-pandemic period (p < 0.05). Conclusion(s): The COVID-19 pandemic has profoundly affected ACS clinical practice patterns. The use of invasive therapies significantly decreased during the pandemic period, whereas pharmacotherapy was more often prescribed by the cardiologists. Copyright: © 2022 The Author(s).

Community-acquired Methicillin-resistant Staphylococcus aureus Pneumonia and Parapneumonic Effusion in a Male Patient with Diabetes: A Case Report

Methicillin-resistant Staphylococcus aureus (MRSA) infections are a primary health concern. They are commonly differentiated as hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA) and community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections, based on their epidemiology, susceptibility findings, and molecular typing patterns. Therefore, appropriate contact precautions and isolation measures should be implemented. CA-MRSA mostly causes skin and soft-tissue infections, but the probability and incidence of it causing sepsis and invasive infections have increased dramatically in recent years. In this study, we report a case of CA-MRSA pneumonia with pan-pneumonic effusion in a 59-year-old male diabetic patient with preexisting comorbidities such as diabetic ketoacidosis and non-ST elevated myocardial infarction. The early reporting of the organism's identity and its antimicrobial susceptibility, as well as timely initiation of antibiotic therapy, aided in the successful management and cure of the patient.

IMPACT OF SOCIAL DISTANCING DURING THE SARS-COV-2 PANDEMIC ON THE ASSOCIATION BETWEEN VIRAL RESPIRATORY ILLNESS AND CARDIOVASCULAR-RELATED EVENTS

SESSION TITLE: Studies on COVID-19 Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Beyond conventional risk factors, studies suggest acute viral infections, including influenza, are a potential risk factor for development of acute cardiovascular (CV) related events such as acute coronary syndrome (ACS) and stroke. On Mar 31st, 2020, the Texas state governor instated a shelter-in-place or quarantine order. With social distancing and masking the exposure respiratory viral illnesses dropped. This study seeks to evaluate the impact of reduced viral infections on CV related events. METHODS: A retrospective chart review of patients admitted to 18 affiliated Baylor Scott & White Texas hospitals in north and central Texas from January 20th, 2020 to Jun 1st, 2020 and between January 20th, 2019 to Jun 1st, 2019. We defined the pre-quarantine period as January 20, 2020 – March 31, 2020. The quarantine period was defined as April 1, 2020 – Jun 1st, 2020. We investigated ACS and stroke risk associated with lab-confirmed respiratory virus panel- PCR (RVP) positivity using a self-controlled case series. RVP positivity was reviewed to determine the presence or absence of increased risk interval. Risk intervals were identified as 7 days after respiratory specimen collection and associated control intervals were one year before and one year after the risk intervals. RESULTS: There were 3,782 patients who had ACS or stroke from January 20th, 2020 to June 1st, 2020. Average monthly rate of positive viral infection was significantly lower during the state mandate social distancing period than before social distancing mandate (5.5 ± 4.6 vs 19.7 ± 4.2, p<0.0001). During the prequarantine period, for stroke, there was a significant difference in positive RVP between the prequarantine and quarantine period (10.8% vs 0%, P=0.009). For ACS, there was a significant difference in positive RVP between the prequarantine and quarantine period (16.2% vs 1%, P<0.001). Rhinovirus infections accounted for 67% of patients of stroke prequarantine. Influenza accounted for 40% of infections in patients with ACS. Admissions for CV related events were higher in the pre-quarantine period compared to the quarantine period (893 vs 695 strokes;1,227 vs 967 ACS). Patients in the pre-quarantine and quarantine were similar in age and gender. For stroke, there was no significant difference in the type of stroke between the two time periods with ischemic stroke occurring in 67% of patients. For ACS, there was no significant difference in type with non ST-elevation MI occurring in 44% of patients. There was no statistical difference of survival to discharge or readmission at 30 days between the two periods. CONCLUSIONS: In our multicenter study, we note significant decline in cardiovascular events due to viral illness. This study strengthens the association between viral infections and cardiovascular events. CLINICAL IMPLICATIONS: This study reveals implications of cardiovascular events following viral illness. DISCLOSURES: No relevant relationships by Tayler Acton no disclosure on file for Alex Arroliga;No relevant relationships by Jason Ettlinger No relevant relationships by Shekhar Ghamande No relevant relationships by Mufaddal Mamawala No relevant relationships by Abirami Subramanian No relevant relationships by Heath White

Embedding clinical pharmacists in critical care rehab carousel clinics

Introduction: Clinical pharmacists specialising in critical care have become integrated into the critical care workforce providing valuable contributions to patient care.1 These findings are supported through the inclusion of clinical pharmacy services within national professional and commissioned standards for critical care.2,3 On admission to critical care, clinical focus changes from management of any chronic conditions to that of immediate preservation of life. This is inherently associated with acute changes in prescribed medicines.Medicines reconciliation on admission to and discharge from critical care is included specifically within the commissioning standards3 and aims to address any discrepancies generated by this change in focus. Unprecedented pressures experienced during the COVID-19 pandemic have resulted in stretched staff to patient ratios and mobilisation of less experienced staff. This has negatively impacted the end-to-end reconciliation process causing patients to be discharged home with unresolved medicines discrepancies. In line with recent NICE4 and Intensive Care Society guidance,5 rehabilitation of patients, post-critical care is important in completing unresolved actions and optimising care. Consequently, in September 2020 a carousel rehab clinic was introduced. All professional groups were invited to contribute. Objectives: To embed a pharmacist within the rehabilitation clinic to focus on any unresolved medicines reconciliation issues. Methods: Five senior critical care pharmacists (band 8a or above) participated in service provision to the clinic, which ran on two days a week. For consistency and structure, a local SOP and electronic note template was produced. All interventions recommended were discussed with the patient at the time and for GPs to review and action as appropriate in the context of their responsibility for ongoing care. Data collection for this service evaluation was retrospective and performed by one of the critical care pharmacists who had participated in the clinic. Historic clinic dates for September - November 2020 (inclusive) were reviewed on the electronic scheduling system to identify patients who attended clinic;these were then filtered for pharmacist entries to ascertain: • Number of patients reviewed • Number of medication-related interventions made • Intervention type and medication(s) involved Results: Over the 3-month period 51 patients were reviewed with a total of 59 medicine interventions made. The average number of interventions per patient was 1.2, with a range of 0 - 7. Eight intervention categories were identified (see Figure 1);the top three of which recommended stopping a medication (27%), reviewing a medication's need (19%) or restarting a medication (17%). The drugs most frequently intervened on were lansoprazole (12%) and bisoprolol (7%). Examples of significant clinical interventions made include: • Stopping acutely initiated bisoprolol (resolution of acute AF secondary to acute sepsis/dehydration on ICU) • Stopping of acutely started olanzapine for ICU-related agitation/delirium • Dose optimisation of bisporolol (post recent NSTEMI) • Re-initiation of atorvastatin (for secondary prevention of IHD) Conclusion: Medication interventions made by pharmacists in the post ICU rehabilitation clinic setting are clinically significant and add value to patient care both in terms of morbidity and mortality. Our results demonstrate a reduction in polypharmacy burden in line with wider healthcare initiatives.

DELAYED PRESENTATION OF MYOCARDIAL INFARCTION IN THE SETTING OF A GLOBAL PANDEMIC

CASE: A 52-yo male with hypertension and former smoker was transferred from outside hospital with dyspnea and hemoptysis. He had presented with chest pain and abnormal ECG to an urgent care 2 days earlier but declined to visit the emergency room in fear of the pandemic. This time, he had respiratory distress requiring intubation and transfer to a higher level of care. He developed cardiogenic shock and profound refractory hypoxia. ECG showed sinus tachycardia, Q waves V1-V3. Chest X-ray had right-side pulmonary edema. An urgent transthoracic echocardiogram (TTE) revealed evidence of papillary muscle rupture (PMR) and LVEF of 65%. An emergent coronary angiogram showed multivessel disease, and a simultaneous transesophageal echocardiogram confirmed torrential mitral regurgitation and PMR. An intra-aortic balloon pump was placed. Patient then underwent urgent CABG/valve replacement and was discharged 10 days later. At 4-month follow-up patient was asymptomatic in clinic. IMPACT/DISCUSSION: Here we present a case of Non-ST-segment elevation myocardial infarction (NSTEMI) whose presentation was delayed due to fear on contracting COVID-19, resulting in papillary muscle rupture (PMR). Acute mitral regurgitation (MR) due to PMR is a life-threatening mechanical complication occurring in 3/1000 patients with myocardial infarction (MI) per year. Prepandemic studies showed that mechanical complications had decreased their incidence over time given the numerous advances in reperfusion therapies. The mortality of such complications remained elevated in numerous studies (4-fold higher than patients without mechanical complications), especially for patients presenting with late-STEMI. Mechanical complications are significantly less common in patients with NSTEMI, such as our patient. The COVID-19 pandemic marked a surge in delayed presentations of MI, resulting in rising incidence of complications worldwide. Certain studies have demonstrated that the pandemic itself is an independent risk factor for delayed presentations of acute coronary syndrome. Echocardiogram remains the diagnostic modality of choice with sensitivity of 65-85% to detect complications from MI, however high clinical suspicion is key to prompt early use of this imaging modality. Our case illustrates that awareness of delayed presentations amongst clinicians may grant early diagnosis and good outcomes. CONCLUSION: Mechanical complications with catastrophic presentations had decreased after the reperfusion treatment era, however the advent of the COVID-19 pandemic has raised concerns for an increasing incidence of delayed presentations of acute coronary events resulting in lethal complications. High clinical suspicion is paramount in diagnosis and outcomes associated to patients suffering from papillary muscle rupture as well as other mechanical complications of MI.

OCULOMOTOR NERVE PALSY FOLLOWING COVID-19 INFECTION

CASE: Patient is a 60-year-old woman who works at a local hospital in billing department. She has a history of rheumatic fever, non ST elevation MI, osteoarthritis, Crohn's disease. Her husband was diagnosed with COVID-19 infection in November 2020. A Week later, patient developed myalgias, diarrhea and subsequent testing confirmed COVID-19 infection. Overall, her symptoms were mild and required no treatment or hospitalization. Six weeks following the infection she woke up one morning with diplopia and a large left pupil. She tried to manage this by covering one eye initially, but later visited with a neurologist, ophthalmologist, neuro-ophthalmologist. She was found to have fixed, dilated left pupil and horizontal diplopia with some diagonal component. There were no other neurological signs or meningismus. Laboratory tests showed hemoglobin of 12.5, White cell count 5.7, platelets 405. Electrolytes, kidney function, liver function tests were normal. ACH receptor antibodies were negative. Imaging studies included a negative CTA head, negative brain MRI, face, orbits and optic nerves. She was diagnosed with left third cranial nerve palsy possibly as a complication of COVID-19 infection. She was prescribed oral prednisone 60 mg with a slow taper. Her pupil size and vision gradually improved over the ensuing weeks and the recovery of the third cranial nerve was nearly complete. IMPACT/DISCUSSION: The third cranial nerve supplies the levator muscle of the eyelid, medial rectus, superior rectus, inferior rectus, and inferior oblique;constricts the pupil through its parasympathetic fibers. Patients with oculomotor cranial nerve palsy develop diplopia and droopy eyelid. Etiology for third cranial nerve palsy include many pathologies such as a structural lesion, infectious or inflammatory conditions, cerebrovascular disease and trauma. Our patient developed acute 3rd cranial nerve palsy 6 weeks following the COVID-19 infection. The workup was negative for any structural lesions, CVA or other known causes. This raised the possibility that her symptoms are possibly complications of COVID-19 infection. Neurological complications of COVID-19 infection have been well documented. These include encephalopathy, stroke, dysgeusia and anosmia. There were two case reports of oculomotor nerve palsy that occurred during the acute phase of COVID-19 infection. These were thought to be from direct invasion of the virus. Our patient however, had developed symptoms 6 weeks following the infection raising the possibility of immune mediated complication. She made near complete recovery with oral glucocorticoid treatment. However, it is not known whether the improvement is the result of the treatment. CONCLUSION: 1. Oculomotor cranial nerve palsy is potentially associated with COVID-19 infection. 2. Oculomotor cranial nerve palsy could present several weeks after the acute COVID-19 infection. 3. In patients presenting with 3rd cranial nerve palsy, it is important to obtain the history of past COVID-19 infection.

When Hearing Hoofbeats Is Actually Zebras: A Common Presentation of Uncommon Pathology

Since the beginning of the SARS CoV-2 pandemic two years ago respiratory complaints have been one of the most common presenting symptoms to the emergency departments across the United States. At this time, over 45 million Americans have tested positive for the SARS CoV-2 virus and the vast majority of the patients who present to the hospital with this infection are due to the consequences of systemic inflammation, most significantly in the lungs. We would like to share a case of a 79 year old female with known cystic lung disease (suspected Pulmonary Langerhans Cell Histiocytosis) on 4L oxygen via nasal cannula (NC) at baseline who presented to a community hospital from her nursing facility for hypoxia. Upon presentation to the hospital she was found to test positive for the SARS CoV-2 virus. In the course of her work up she received a CTA of the chest which did show mild ground glass changes consistent with a mild viral pneumonia, more significantly, the scan revealed numerous pulmonary arterio-venous malformations (AVMs) in bilateral lower lobes that were not present on previous imaging of the chest. A detailed work up of the patient was unable to be performed due to the patient declining invasive testing and wishing to pursue hospice. The patient was found to have an estimated shunt fraction >30% with a cardiac echo that confirmed an intrapulmonary shunt and an acute drop in the patient's left ventricular ejection fraction (LVEF) due to an NSTEMI 3 months prior to admission. We believe that this patient had underlying hereditary hemorrhagic telangiectasia resulting in pulmonary AVMs that were minimally symptomatic until the patient's acute drop in her LVEF which led to a drastic increase in her intrapulmonary shunt fraction.