ESC Congress 2022 Imaging Highlights.

Cardiac imaging is an ever-evolving area, with imaging parameters and application in constant re-evaluation. This was reflected in many imaging debates and by the increased number of scientific contributions at the European Society of Cardiology Congress in 2022. While clinical trials tried to answer clinical questions related to the performance of different imaging modalities, many high-quality presentations focused on new imaging biomarkers in different scenarios, such as heart failure with preserved ejection fraction, valvular heart disease or long COVID. This highlights the need for the translation of cardiac imaging technology from research interests towards established measures of clinical practice.

Outcomes of Heart Failure Related Hospitalizations During the COVID-19 Pandemic.

BACKGROUND:  The incidence and prevalence of heart failure (HF) in the United States has steadily increased in the past few decades. Similarly, the United States has experienced an increase in HF-related hospitalizations which has added to the burden of a resource-stretched healthcare system. With the emergence of the coronavirus disease 2019 (COVID-19) pandemic in 2020, hospitalizations due to the COVID-19 infection sky-rocketed further exacerbating the burden on both patient health and the healthcare system. The focus of this study is to examine how a secondary COVID-19 diagnosis affects the outcome of HF patients, and how a pre-existing diagnosis of heart failure impacts the outcomes of patients hospitalized with COVID-19 infection. METHODS: This was a retrospective observational study of adult patients hospitalized with heart failure and COVID-19 infection in the United States in the years 2019 and 2020. Analysis was conducted using the National Inpatient Sample (NIS) database of the Healthcare Utilization Project (HCUP). The total number of patients included in this study from the NIS database 2020 was 94,745. Of those, 93,798 had heart failure without a secondary diagnosis of COVID-19; 947 had heart failure along with a secondary diagnosis of COVID-19. The primary outcome of our study was in-hospital mortality, length of stay, total hospital charges and time from admission to right heart catheterization, which were compared between the two cohorts.  Results: Our main study findings are that mortality in HF patients with secondary diagnosis of COVID-19 infection was not statistically different compared to those who were without a secondary diagnosis of COVID-19. Our study findings also showed that length of stay (LOS) and hospital costs in HF patients who had a secondary diagnosis of COVID-19 were not statistically different compared to those who did not have the secondary diagnosis. Time from admission to right heart catheterization (RHC) in HF patients who had a secondary diagnosis of COVID-19 was shorter in heart failure with reduced ejection fraction (HFrEF) but not in heart failure preserved ejection fraction (HFpEF) compared to those without secondary diagnoses of COVID-19. Finally, when evaluating hospital outcomes for patients admitted with COVID-19 infection, we found that inpatient mortality increased significantly when they had a pre-existing diagnosis of heart failure. CONCLUSION: The COVID-19 pandemic significantly impacted hospitalization outcomes for patients admitted with heart failure. The time from admission to right heart catheterization was significantly shorter in patients admitted with heart failure reduced ejection fraction who also had a secondary diagnosis of COVID-19 infection. When evaluating hospital outcomes for patients admitted with COVID-19 infection, we found that inpatient mortality increased significantly when they had a pre-existing diagnosis of heart failure. Length of hospital stay and hospital charges also were higher for patients with COVID-19 infection who had pre-existing heart failure. Further studies should focus not just on how medical comorbidities like COVID-19 infection, affect outcomes of heart failure but also on how overall strains on the healthcare system, such as pandemics, may affect the management of conditions such as heart failure.

Myeloperoxidase Inhibition in Heart Failure With Preserved or Mildly Reduced Ejection Fraction: SATELLITE Trial Results.

BACKGROUND: Inflammation is a key driver of heart failure with preserved left ventricular ejection fraction. AZD4831 inhibits extracellular myeloperoxidase, decreases inflammation, and improves microvascular function in preclinical disease models. METHODS AND RESULTS: In this double-blind phase 2a study (Safety and Tolerability Study of AZD4831 in Patients With Heart Failure [SATELLITE]; NCT03756285), patients with symptomatic heart failure, left ventricular ejection fraction of ≥40%, and elevated B-type natriuretic peptides were randomized 2:1 to once-daily oral AZD4831 5 mg or placebo for 90 days. We aimed to assess target engagement (primary end point: myeloperoxidase specific activity) and safety of AZD4831. Owing to coronavirus disease 2019, the study was terminated early after randomizing 41 patients (median age 74.0 years, 53.7% male). Myeloperoxidase activity was decreased by more than 50% from baseline to day 30 and day 90 in the AZD4831 group, with a placebo-adjusted decreased of 75% (95% confidence interval, 48, 88, nominal P < .001). No improvements were noted in secondary or exploratory end points, apart from a trend in Kansas City Cardiomyopathy Questionnaire overall summary score. No deaths or treatment-related serious adverse events occurred. AZD4831 treatment-related adverse events were generalized maculopapular rash, pruritus, and diarrhea (all n = 1). CONCLUSIONS: AZD4831 inhibited myeloperoxidase and was well tolerated in patients with heart failure and left ventricular ejection fraction of 40% or greater. Efficacy findings were exploratory owing to early termination, but warrant further clinical investigation of AZD4831. LAY SUMMARY: Few treatments are available for patients with the forms of heart failure known as heart failure with preserved or mildly reduced ejection fraction. Current treatments do not target inflammation, which may play an important role in this condition. We tested a new drug called AZD4831 (mitiperstat), which decreases inflammation by inhibiting the enzyme myeloperoxidase. Among the 41 patients in our clinical trial, AZD4831 had a good safety profile and inhibited myeloperoxidase by the expected amount. Results mean we can conduct further trials to see whether AZD4831 decreases the symptoms of heart failure and improves patients' ability to participate in physical exercise.

Proteomic profiling of epicardial fat in heart failure with preserved versus reduced and mildly reduced ejection fraction.

In order to explore the proteomic signatures of epicardial adipose tissue (EAT) related to the mechanism of heart failure with reduced and mildly reduced ejection fraction (HFrEF/HFmrEF) and heart failure (HF) with preserved ejection fraction (HFpEF), a comprehensive proteomic analysis of EAT was made in HFrEF/HFmrEF (n = 5) and HFpEF (n = 5) patients with liquid chromatography-tandem mass spectrometry experiments. The selected differential proteins were verified between HFrEF/HFmrEF (n = 20) and HFpEF (n = 40) by ELISA (enzyme-linked immunosorbent assay). A total of 599 EAT proteins were significantly different in expression between HFrEF/HFmrEF and HFpEF. Among the 599 proteins, 58 proteins increased in HFrEF/HFmrEF compared to HFpEF, whereas 541 proteins decreased in HFrEF/HFmrEF. Of these proteins, TGM2 in EAT was down-regulated in HFrEF/HFmrEF patients and was confirmed to decrease in circulating plasma of the HFrEF/HFmrEF group (p = 0.019). Multivariate logistic regression analysis confirmed plasma TGM2 could be an independent predictor of HFrEF/HFmrEF (p = 0.033). Receiver operating curve analysis indicated that the combination of TGM2 and Gensini score improved the diagnostic value of HFrEF/HFmrEF (p = 0.002). In summary, for the first time, we described the proteome in EAT in both HFpEF and HFrEF/HFmrEF and identified a comprehensive dimension of potential targets for the mechanism behind the EF spectrum. Exploring the role of EAT may offer potential targets for preventive intervention of HF.

Prognostic value of H2FPEF score in COVID-19.

STUDY OBJECTIVE: This study sought to assess the predictive value of H2FPEF score in patients with COVID-19. DESIGN: Retrospective study. SETTING: Rush University Medical Center. PARTICIPANTS: A total of 1682 patients had an echocardiogram in the year preceding their COVID-19 admission with a preserved ejection fraction (≥50%). A total of 156 patients met inclusion criteria. INTERVENTIONS: Patients were divided into H2FPEF into low (0-2), intermediate (3-5), and high (6-9) score H2FPEF groups and outcomes were compared. MAIN OUTCOME MEASURES: Adjusted multivariable logistic regression models evaluated the association between H2FPEF score group and a composite outcome for severe COVID-19 infection consisting of (1) 60-day mortality or illness requiring (2) intensive care unit, (3) intubation, or (4) non-invasive positive pressure ventilation. RESULTS: High H2FPEF scores were at increased risk for severe COVID-19 infection when compared intermediate to H2FPEF score groups (OR 2.18 [CI: 1.01-4.80]; p = 0.049) and low H2FPEF score groups (OR 2.99 [CI: 1.22-7.61]; p < 0.05). There was no difference in outcome between intermediate H2FPEF scores (OR 1.34 [CI: 0.59-3.16]; p = 0.489) and low H2FPEF score. CONCLUSIONS: Patients with a high H2FPEF score were at increased risk for severe COVID-19 infection when compared to patients with an intermediate or low H2FPEF score regardless of regardless of coronary artery disease and chronic kidney disease.

Characterization of Heart Failure Patients in an Academic Home Hospital Program and Identification of Patient Factors Requiring Escalation of Care

Background: Hospital capacity concerns exacerbated by the COVID-19 pandemic have accelerated growth of hospital at home (HaH) programs. However, for HaH admissions related to heart failure, information on patient characteristics and clinical outcomes remain sparse. We aimed to better characterize heart failure admissions in a HaH model and assess characteristics of patients who later needed escalation of care to a traditional hospitalization. Method(s): This retrospective, descriptive study examined HaH admissions for heart failure at an academic medical center between 2017 and 2022. We compared baseline characteristics and outcomes using the Chi-squared test for categorical variables and t-test for continuous variables for patients who required escalation of care to those who did not. Using the same methods, we also compared patients based on their location prior to admission (e.g. emergency department (ED), home). Result(s): Heart failure was the primary diagnosis for 32% of HaH admissions. The majority of the heart failure cohort (N=199, average age 80.6 years), 73.9%, had heart failure with preserved ejection fraction (HFpEF). Escalation of care to traditional hospitalization was required for 22.6% of patients. 9.0% of patients died within 90 days, and 20.1% and 36.2% of patients were readmitted for any reason within 30 and 90 days respectively. Patients whose care was escalated were more likely to have a history of chronic kidney disease (84.1% vs 66.9%, p=0.043), higher admission BUN (41.5 vs 31.1, p=0.004) and creatinine (1.74 vs 1.41, p=0.011), and a history of PCI (20.5% vs 5.3%, p=0.005). Patients referred directly from home compared to the ED had similar baseline characteristics and rates of 90 day inpatient readmission and mortality. Conclusion(s): Patients admitted to HaH for heart failure represent a high risk cohort who are commonly older with multiple comorbidities and more likely to have HFpEF. Among this cohort, patients with kidney dysfunction and/or history of percutaneous coronary intervention are more likely to require escalation of care. These results suggest that heart failure patients admitted to HaH who will later need traditional hospitalization could be identified prospectively using these characteristics.

A MULTIMODALITY IMAGING DIAGNOSIS OF A CHALLENGING CASE OF CONCOMITANT GROUP 1 PULMONARY HYPERTENSION AND PARADOXICALLY LOW- FLOW, LOW-GRADIENTAORTIC STENOSIS

A 76 year old woman was admitted to our hospital for self-limiting dyspnoea (NYHA class III) in oxygen dependence and frequent lipothymia following Valsalva manoeuvres. She was previously admitted to a Spoke Centre for heart failure (HF) with preserved ejection fraction (EF) and a new diagnosis of “pre-capillary pulmonary hypertension (PH)”. Despite a diagnosis of PH of unclear aetiology, she was started on macitentan without being reassessed for functional capacity due to Covid emergency;because of worsening symptoms, she was admitted to our Hub Centre. Resting ECG showed right axis deviation, right ventricle (RV) hypertrophy, first-degree atrioventricular block and right bundle branch block. Transthoracic echocardiography (TTE) showed reduced left ventricular (LV) volume with preserved EF (diastolic volume= 37 ml, EF=88%), severe right atrial and RV dilation with flattening of the interventricular septum, estimated pulmonary artery systolic pressure (PASP) of 124 mmHg, and moderate calcific aortic stenosis (peak aortic velocity 3.3 m/s, mean gradient 25 mmHg, valve area 1.1 cm2). Right and left heart catheterization showed severe pre-capillary PH (mean pulmonary pressure 60 mmHg, mean wedge 11 mmHg, pulmonary vascular resistance 14.41 WU), a severe aortic valve stenosis (aortic valve area 0.68 cmq and peak-to-peak gradient 25 mmHg, slight reduction of cardiac index 2.04 l/min/mq) and no significant coronary artery disease. The degree of aortic stenosis was considered as moderate-severe by integrating data of transesophageal echocardiography (planimetric area 1cm2) and assessment of calcium score (1615 Agatson units). Pneumological causes, chronic thromboembolic PH, rheumatologic diseases, HIV infection, paraneoplastic origin and veno-occlusive disease were all ruled out as potential PH causes and a diagnosis of Idiopathic pulmonary arterial hypertension (IPAH) was finally made. The Heart Team established the best therapeutic option was a transcatheter aortic valve replacement (TAVI) allowing better haemodynamic tolerability of PH therapy. The patient underwent TAVI and was started on PH therapy;a complete atrio-ventricular block developed after the procedure, requiring permanent pacemaker (PM) implantation. Unfortunately, few days later, the patient died following pacemaker's lead dislocation. Conclusion: PH has a diverse aetiology, and prognosis is generally poor, especially in patients with severe comorbidities. (Figure Presented).

Microvascular dysfunction and magnesium - impact in COVID times and further on

For decades, the macrovascular system was in the focus of diagnostic and therapeutic medicine. The relevance of microvascular pathology was widely underestimated but is revealed in a new break-through cardiological study. Increasing knowledge reveals the microvascular system as the essential target structure of chronic magnesium-depletion, mediating smoldering chronic disease processes. Microvascular dysfunction could be the common basis for the association of chronic magnesium deficiency and polytopic diseases of high-energy dependent organs: diabetic retinopathy, renal failure - diabetic and other -, microvascular = non-Alzheimer dementia, diastolic cardiac dysfunction (HFpEF - heart failure with preserved ejection fraction) - analog arterial hypertension - microvascular angina, atrial fibrillation but also diabetic foot and diabetic neuropathy. In early studies the actual COVID-19 pandemic is related to microvascular pathomechanisms. Following earlier results reporting better survival of intensive care patients with highly normal magnesium as well as epidemiological associations we recommended for all patients from the beginning of the COVID 19 epidemic high-dose magnesium supplementation 15 - 25 mmol (and zinc 20 mg, vitamin D 2,000 IE each/day). In the context of COVID-19, we can assume four constellations of possibly positive effects of this magnesium strategy: 1. Due to our own limited cohorts the most evident: Tolerance of immunization with Biontech/Pfizer COVID-19 vaccine was distinctly better in our cohort of over 412 vaccinations compared with published data. 2. Rare, but a few patients with more intense adverse reactions had low magnesium and/or abnormal microvascular results in pulse wave analysis. 3. COVID patients (also elderly) with documented high serum magnesium - and pre-supplemented - recovered well from the disease. 4. Two post-Corona, long-COVID patients with symptoms of fatigue, reduced mental concentration, and dizziness reacted well after repeated parenteral magnesium infusion. Whether SARS-Cov-2-antibody formation correlates with magnesium or zinc values is topic of running investigations. Systematic prospective investigations are warranted. But due to the circumstances - considering that there are no evidence-based alternatives - for healthy individuals, for persons at risk, for patients at risk of magnesium depletion as well as for COVID-19 vaccination candidates, optimizing of magnesium is justified (Global Mg COVID-19 project) - and in terms of other health concerns, the prevention of chronic microvascular disease entities also justifies supplementation. Personalized magnesium dosage in medical office should be oriented by practical serum Mg/Ca (mmol/mmol) target 0.4 - including calcium. This approach seems to us to be expedient and more successful didactically. (outpatient medicine: Mg/Ca in serum;intensive care: ionized magnesium).

Hyperdynamic left ventricular ejection fraction is associated with higher mortality in COVID-19 patients.

Study objective: To compare the characteristics and outcomes of COVID-19 patients with a hyperdynamic LVEF (HDLVEF) to those with a normal or reduced LVEF. Design: Retrospective study. Setting: Rush University Medical Center. Participants: Of the 1682 adult patients hospitalized with COVID-19, 419 had a transthoracic echocardiogram (TTE) during admission and met study inclusion criteria. Interventions: Participants were divided into reduced (LVEF < 50%), normal (≥50% and <70%), and hyperdynamic (≥70%) LVEF groups. Main outcome measures: LVEF was assessed as a predictor of 60-day mortality. Logistic regression was used to adjust for age and BMI. Results: There was no difference in 60-day mortality between patients in the reduced LVEF and normal LVEF groups (adjusted odds ratio [aOR] 0.87, p = 0.68). However, patients with an HDLVEF were more likely to die by 60 days compared to patients in the normal LVEF group (aOR 2.63 [CI: 1.36-5.05]; p < 0.01). The HDLVEF group was also at higher risk for 60-day mortality than the reduced LVEF group (aOR 3.34 [CI: 1.39-8.42]; p < 0.01). Conclusion: The presence of hyperdynamic LVEF during a COVID-19 hospitalization was associated with an increased risk of 60-day mortality, the requirement for mechanical ventilation, vasopressors, and intensive care unit.

New therapies for the treatment of heart failure with preserved ejection fraction.

PURPOSE: This review of chronic heart failure with preserved ejection fraction (HFpEF), including new and emerging evidence for treatment of patients with this condition, is intended to offer data supporting the use of specific agents for this patient population. SUMMARY: Chronic heart failure is a major health concern affecting millions of Americans annually and remains a significant burden on the healthcare system. Heart failure is divided into categories based on left ventricular ejection fraction (LVEF). Current treatments for heart failure with reduced ejection fraction, defined by an LVEF of less than 40%, involve a variety of agents with established morbidity and mortality benefits. This is in stark contrast to directed treatments for patients with HFpEF, defined by an LVEF of greater than 50%. Treatments for this form of heart failure have been elusive until recently, when studies were published with sacubitril/valsartan and empagliflozin. Results of the PARAGON-HF trial suggested benefit from sacubitril/valsartan in patients with an ejection fraction between 45% and 57%, leading to its approval in 2021 as the first medication indicated for treatment of patients with a preserved ejection fraction. Months later, the results of the EMPEROR-Preserved trial demonstrated a statistically significant benefit in the composite outcome of heart failure hospitalizations and cardiovascular death in patients with HFpEF taking empagliflozin. This medication has yet to gain approval for HFpEF; however, these data along with ongoing and future trials will likely impact standard treatment for these patients. CONCLUSION: The PARAGON-HF and EMPEROR-Preserved trials will serve as the foundation for a new era in the treatment of HFpEF.

Characteristics and outcomes of hospitalized patients with cardiovascular complications of covid-19

Introduction: Recent reports have indicated that a considerable portion of patients experiences a cardiac injury, ranging from 7.2% to 22.2%, which is linked to higher mortality. Nevertheless, previous studies have exclusively focused on the cardiac injury defined as a raised cardiac marker without a definitive diagnosis. To our knowledge, the present retrospective cohort study is the first study to comprehensively address cardiovascular (CV) complications and related outcomes in COVID-19 patients. Purpose: To address CV complications and their relationship to clinical outcomes in hospitalized patients with COVID-19. Methods: A total of 196 adult hospitalized patients admitted to our hospital with a confirmed diagnosis of COVID-19 and a consultation requested from the cardiology department were enrolled in this retrospective single-center cohort study from September 10, 2020, to December 10, 2020, with a median age of 65 years (IQR, 52-77). Cardiac examinations included cardiac biomarkers, electrocardiography, and echocardiography. Data regarding complications during hospitalization were extracted, and patients were categorized into two groups concerning the presence or absence of CV complications. All transthoracic echocardiographic (TTE) assessments were performed by a single cardiologist, who was provided with personal protective gear according to national guidelines. Follow-up continued for 3 months after hospital discharge. Results: CV complication was observed in 54 (27.6%) patients, with arrhythmia being the most prevalent (14.8%) followed by myocarditis, acute coronary syndromes, ST-elevation myocardial infarction, cerebrovascular accident, and deep vein thrombosis in 15 (7.7%), 12 (6.1%), 10 (5.1%), 8 (4.1%), and 4 (2%) patients, respectively. The proportion of patients with elevated hs-TpI, NT-proBPN, left ventricular diastolic dysfunction, and heart failure with preserved ejection fraction was greater in the CV complication group. Severe forms of COVID-19 comprised nearly two-thirds (64.3%) of our study population and constituted a significantly higher share of the CV complication group members (75.9% vs 59.9%;P = 0.036). Intensive care unit admission (64.8% vs 44.4%;P = 0.011) and stay (5.5 days vs 0 day;P = 0.032) were notably higher in patients with CV complications. Among 196 patients, 50 died during hospitalization and 10 died after discharge, yielding allcause mortality of 30.8%. However, there were no between-group differences concerning mortality. Heart failure, cancer/autoimmune disease, severity, interferon beta-1a, and arrhythmia were the independent predictors of all-cause mortality during and after hospitalization. Conclusion: CV complications occurred widely among COVID-19 patients. Moreover, arrhythmia, as the most common complication, was associated with increased mortality.

Dexamethasone in acute cardiopulmonary syndrome with hyperinflammatory state

Introduction: Elderly patient hospitalized due to acute heart failure often have a concomitant acute lung disease (acute bronchitis, pneumonia, chronic obstructive pulmonary disease-COPD- exacerbation). Establishing the role of each disease in a clinical picture of acute cardiopulmonary syndrome can be challenging. Procalcitonin has been used as a guide to antibiotic therapy with contrasting results. A common thread of these diseases is inflammation;a hyperinflammatory response determines more serious symptoms and a worse prognosis. Purpose: We evaluated the effectiveness of a treatment with dexamethasone in patients with acute cardiopulmonary syndrome and a strong inflammatory response. Materials and methods:We evaluated 157 consecutive HFPEF (heart failure with preserved ejection fraction) patients ≥80 years of age, with concomitant symptoms attributable to acute bronchitis, pneumonia, or COPD exacerbation, hospitalized due to worsening dyspnoea, with an NT-proBNP ≥3,000 pg/ml, and a finding X-ray of lung congestion with or without a consolidation. Reactive C Protein was measured. Patients with SARS-CoV-2, indication to corticosteroids use for other clinical conditions or need for mechanical ventilation were excluded. The 96 patients with values>20 mg/dl were randomized into 2 groups: 48 patients were treated open-label with dexamethasone at a dose of 8 mg iv/day for a maximun of ten days, in addition to the usual therapies for acute heart failure and lung disease, while the same number of patients were treated with the usual therapy. In both groups the antibiotic was administered only if the procalcitonin was≥0.25 μg/L. Clinical recovery time, length of hospitalization, in-hospital mortality, the need for a new hospitalization and mortality at one month were evaluated. Results: The mean age of the patients was 88±4 years in the dexamethasone group and 87±5 in the usual therapy group. The results are shown in Table 1. Patients treated with dexamethasone experienced a faster clinical recovery and a shorter length of hospitalization. No significant differences were found regarding either in-hospital mortality or need for rehospitalization and mortality at 30 days. Conclusions: Very elderly patients with acute cardiopulmonary syndrome and hyperinflammatory state associated with an excessive increase in Reactive Protein C have a favorable response to dexamethasone therapy in addition to the usual therapy in terms of clinical improvement and length of hospitalization. Our case history is small to evaluate a possible improvement in mortality. These findings need to be consolidated from double-blind randomized controlled trials.

Myocardial Involvement in COVID-19: an Interaction Between Comorbidities and Heart Failure with Preserved Ejection Fraction. A Further Indication of the Role of Inflammation.

PURPOSE OF THE REVIEW: Coronavirus Disease 2019 (COVID-19) and cardiovascular (CV) disease have a close relationship that emerged from the earliest reports. The aim of this review is to show the possible associations between COVID-19 and heart failure (HF) with preserved ejection fraction (HFpEF). RECENT FINDINGS: In hospitalized patients with COVID-19, the prevalence of HFpEF is high, ranging from 4 to 16%, probably due to the shared cardio-metabolic risk profile. Indeed, comorbidities including hypertension, diabetes, obesity and chronic kidney disease - known predictors of a severe course of COVID-19 - are major causes of HFpEF, too. COVID-19 may represent a precipitating factor leading to acute decompensation of HF in patients with known HFpEF and in those with subclinical diastolic dysfunction, which becomes overt. COVID-19 may also directly or indirectly affect the heart. In otherwise healthy patients, echocardiographic studies showed that the majority of COVID-19 patients present diastolic (rather than systolic) impairment, pulmonary hypertension and right ventricular dysfunction. Such abnormalities are observed both in the acute or subacute phase of COVID-19. Cardiac magnetic resonance reveals myocardial inflammation and fibrosis in up to the 78% of patients in the chronic phase of the disease. These findings suggest that COVID-19 might be a novel independent risk factor for the development of HFpEF, through the activation of a systemic pro-inflammatory state. Follow-up studies are urgently needed to better understand long-term sequelae of COVID-19 inflammatory cardiomyopathy.

Heart failure with preserved ejection fraction in coronavirus disease 2019 patients: the promising role of diuretic therapy in critically ill patients.

The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on diastolic function is less known. We describe a 46-year-old man with a history of mild hypertension who presented to the emergency department with fever, cough, and myalgia for 2 days. The patient was tested positive for SARS-CoV-2. He was admitted and started on a combination of antiviral and antimicrobial therapy. He developed respiratory distress 2 days later, and O2 saturation declined. Blood tests showed an increased N-terminal pro-B type natriuretic peptide (NT-proBNP) level, and echocardiography showed normal left ventricular ejection fraction and E/e' ratio of 16. Computed tomography scan showed interstitial pulmonary oedema and prominent peripheral pulmonary vascular markings. Given these findings, heart failure with preserved ejection fraction (HFpEF) was considered. Low-dose diuretic was started, and fluid administration was restricted, resulting in a decrease in NT-proBNP level, clinical and haemodynamic stabilization, and improved oxygenation. This case highlights the occurrence of HFpEF in coronavirus disease 2019.

Heart Failure with Preserved Ejection Fraction in a Postpartum Patient with Superimposed Preeclampsia and COVID-19.

Our understanding of COVID-19 in pregnant and postpartum women is rapidly evolving. We present a case from March 2020 of a 25-year-old G2P2002 whose delivery was complicated by preeclampsia with severe features who presented to the emergency department 9 days after cesarean delivery with chest tightness and dyspnea on exertion. On presentation she had severe hypertension, pulmonary edema, elevated brain natriuretic peptide, and high-sensitivity troponin-I, suggesting a diagnosis of hypertensive emergency leading to heart failure with a preserved ejection fraction resulting in pulmonary edema and abnormal cardiac screening tests. However, bilateral opacities were seen on a computed tomography of the chest, and COVID-19 testing was positive. A high index of suspicion for both COVID-19 and cardiovascular complications are critical for optimal patient outcomes and protection of health care workers.

Electrical Storm in COVID-19.

COVID-19 is a global pandemic caused by SARS-CoV-2. Infection is associated with significant morbidity and mortality. Individuals with pre-existing cardiovascular disease or evidence of myocardial injury are at risk for severe disease and death. Little is understood about the mechanisms of myocardial injury or life-threatening cardiovascular sequelae. (Level of Difficulty: Intermediate.).