ABSTRACT
Aim. To determine the prevalence and show the features of the development of newly diagnosed heart failure (HF) in patients with dyspnea after a coronavirus disease 2019 (COVID-19). Material and methods. This clinical prospective observational study was conducted during 2020-2022. The study consecutively included 368 outpatients with shortness of breath, who applied to the clinic. Depending on the presence of prior COVID-19, the patients were divided into 2 groups: the first group consisted of 205 patients with shortness of breath after COVID-19, the second group - 163 patients without prior COVID-19. All patients underwent a clinical examination within 3 days after presentation with an assessment of outpatient records and other medical documents for the differential diagnosis of dyspnea. The severity of dyspnea was determined using the Modified Medical Research Council Dyspnoea Scale (mMRC). The diagnosis of HF was verified in accordance with the 2020 Russian Society of Cardiology guidelines and in some cases reclassified in accordance with the 2021European Society of Cardiology guidelines. For further analysis, 2 subgroups of patients with HF were identified depending on the presence and absence of prior COVID-19. The subgroup analysis excluded patients with acute heart failure, acute illness, and conditions requiring hospitalization and/or intensive care. Results. Among 368 patients who presented to the clinic with dyspnea during 2020-2022, 205 patients (55,7%) had COVID-19. The average period of treatment after COVID-19 was 3,5 [1,5;22,4] months. Patients after COVID-19 applied earlier after the onset of dyspnea, which is associated with higher mMRC score. The prevalence of HF among patients with shortness of breath after COVID-19 was significantly higher than in patients without this pathology in history, and amounted to 19,0% vs 9,8% (p=0,021). Prior COVID-19 increased the relative risk (RR) of HF in patients with shortness of breath by 1,7 times. RR for HF in systolic blood pressure >140 mm Hg increased by 1,9 times, while in diastolic blood pressure >90 mm Hg - by 1,9 times, with the development of a hypertensive crisis - by 28%, with a heart rate >80 bpm at rest - by 1,4 times, with the development of type 2 diabetes - by 31%, in the presence of pulmonary fibrosis - by 2,3 times. Patients with shortness of breath after COVID-19 had more severe HF, both according to clinical tests and according to the blood concentration of N-terminal pro-brain natriuretic peptide (NT-proBNP), mainly with the preserved ejection fraction (EF) with a higher prevalence of left atrial (LA) enlargement in combination with a decrease in right ventricular (RV) systolic function and its dilatation. In patients after COVID-19 in the presence of chronic kidney disease, the RR for HF increased by 4,5 times;in the presence of C-reactive protein >4 mg/l - by 1,6 times. Conclusion. Every fifth patient with shortness of breath 3,5 months after COVID-19 had more severe HF, both according to clinical tests and according to blood NT-proBNP concentration, mainly with preserved EF with a higher prevalence of LA increase in combination with a decrease in RV systolic function and its dilatation. The risk of HF is interrelated with the female sex and multiple comorbidities.Copyright © 2023, Silicea-Poligraf. All rights reserved.
ABSTRACT
SESSION TITLE: Challenges in Lung Tumors SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Patients can have a variety of post Coronovirus induced disease (COVID) associated interstitial lung diseases (ILD) ranging from cystic lung disease to fibrinous organizing pneumonia. However, very little is known about malignancies that have been overshadowed by post COVID associated pulmonary changes. We present one such case of insidious invasive mucinous adenocarcinoma of the lung that was masked by post COVID related changes. CASE PRESENTATION: A 70 year old female with COPD, systolic heart failure and significant tobacco use disorder presented with progressively worsening hypoxemic respiratory failure. She has had 4 hospitalizations in past year all for acute on chronic hypoxemic respiratory failure following COVID. She has been on Supplemental Oxygen 3L/min since her infection with SARS-COV2. Patient was found to have worsening bibasilar ground glass opacities (GGO) on CT of chest over the past 1 year since having COVID. She was treated with several rounds of steroids without any relief. Patient had a PET scan that showed a very avid left upper lobe consolidation. Given these worsening abnormalities and symptoms, she underwent bronchoscopy with transbronchial biopsy guided by the positive PET scan and fluoroscopy. However, during bronchoscopy she had copious secretions which were therapeutically cleared helping relieve some of patient's hypoxemia. All her cultures and Fungitell assay on bronchoalveolar lavage were negative. However, post biopsy pathology came back positive for Invasive Mucinous Adenocarcinoma. Patient was treated with chemo and radiation therapy with good response against her malignancy and significant relief in her hypoxemia. DISCUSSION: COVID associated pneumonia is well known to cause chronic hypoxemic respiratory failure. Post COVID related pulmonary changes range from organizing pneumonia to fungal pneumonia. However, patients should start to recover with time as inflammatory changes resolve on CT scan with adequate steroids or anti-fungals. If patients continue to deteriorate then a prompt work-up that rules out other infections and even malignancies is warranted as seen in our patient. This case brings forth an important consideration for aggressively pursuing an adequate work-up in the face of worsening GGO on the CT and patient's continual deterioration due to her hypoxemic respiratory failure. Our patient was able to be adequately diagnosed with malignancy and was then started on chemotherapy that allowed for adequate control of her hypoxemic respiratory failure and helped improve her quality of life. CONCLUSIONS: Post COVID related pulmonary changes can be from a variety of ILD and infections. However, clinician should be vigilant in considering malignancy as a possible etiology of post COVID related changes and initiate an adequate work-up to help evaluate for cancer that can be masked amongst post COVID related ILD. Reference #1: Beck KS, Sung YE, Lee KY, Han DH. Invasive mucinous adenocarcinoma of the lung: Serial CT findings, clinical features, and treatment and survival outcomes. Thorac Cancer. 2020 Dec;11(12):3463-3472. doi: 10.1111/1759-7714.13674. Epub 2020 Oct 5. Reference #2: Matsui T, Sakakura N, Koyama S, Nakanishi K, Sasaki E, Kato S, Hosoda W, Murakami Y, Kuroda H, Yatabe Y. Comparison of Surgical Outcomes Between Invasive Mucinous and Non-Mucinous Lung Adenocarcinoma. Ann Thorac Surg. 2020 Nov 24:S0003-4975(20)32001-4. doi: 10.1016/j.athoracsur.2020.09.042. Epub ahead of print. Reference #3: Lee MA, Kang J, Lee HY, Kim W, Shon I, Hwang NY, Kim HK, Choi YS, Kim J, Zo JI, Shim YM. Spread through air spaces (STAS) in invasive mucinous adenocarcinoma of the lung: Incidence, prognostic impact, and prediction based on clinicoradiologic factors. Thorac Cancer. 2020 Nov;11(11):3145-3154. doi: 10.1111/1759-7714.13632. Epub 2020 Sep 25. DISCLOSURES: No relevant relationships by Danya Ahmed No relevant relationships by David Chambers No rele ant relationships by Jalal Damani No relevant relationships by Deon Ford No relevant relationships by Rachaita Lakra
ABSTRACT
SESSION TITLE: Critical Care Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: Extracorporeal membrane oxygenation (ECMO), typically veno-venous, is used to treat COVID19 patients with severe acute respiratory distress syndrome (ARDS) and is associated with decreased mortality in some reports. This study sought to determine the effect of ECMO versus conventional invasive mechanical ventilation (IMV) on hospital mortality for ARDS due to COVID19, and to compare functional status at discharge. METHODS: This was a retrospective, multicenter cohort study of adult patients admitted for COVID19 within a large US hospital network between March 1, 2020 and October 31, 2021. Patients were included if they required IMV with a fraction of inspired oxygen (FiO2) of at least 80% or VV ECMO. Patients were excluded if they were not independent, had a history of severe neurologic impairment, chronic obstructive pulmonary disease, chronic systolic heart failure, end stage renal disease, cirrhosis, metastatic malignancy, or a length of stay <24 hours. ECMO criteria and management were at the discretion of the treating center. Conventional IMV patients were assigned a randomized pseudo-baseline, and coarsened exact matching was used to match ECMO to conventional IMV patients based on age, sex, body mass index, pre-baseline severity of hypoxemia, prone positioning, receipt of corticosteroids, Tocilizumab, Baricitinib, acute renal replacement therapy, and vasopressors. Differences in hospital mortality and discharge destination were assessed through weighted logistic regression and weighted multinomial logit regression, respectively. RESULTS: We identified 207,965 patients across 168 hospitals for review, and 10,571 patients met study criteria. After matching, 275 ECMO patients and 5,808 conventional IMV patients were available for comparison. ECMO was associated with a significant mortality reduction, 36% versus 61% (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.34-0.57). Compared to conventional IMV survivors, ECMO survivors were significantly more likely to be discharged to acute rehabilitation than long term acute care (relative risk ratio (RRR) 2.23, 95% CI 1.16-4.32). ECMO survivors were also significantly more likely to be discharged to another acute care hospital for further management (RRR 3.21, 95% CI 1.75-5.92). CONCLUSIONS: This study demonstrates that ECMO support is significantly associated with reduced mortality in patients with severe ARDS due to COVID19 compared to conventional invasive mechanical ventilation. Further studies are needed to aid in prognostication, patient selection, and timing of intervention to maximize the benefit of this limited resource. CLINICAL IMPLICATIONS: These findings illustrate the importance of timely referral to an ECMO center for severely ill COVID19 patients, and may influence ECMO-capable centers to expand the use of ECMO in appropriate patients for this indication. DISCLOSURES: No relevant relationships by Elliott Cohen No relevant relationships by Katherine Cyr No relevant relationships by Jeffrey DellaVolpe No relevant relationships by Jamie Jarzembowski No relevant relationships by Chandra Kunavarapu no disclosure on file for Thomas Mcrae;Employee relationship with HCA Healthcare Please note: 6/1/2017 to current Added 04/04/2022 by Daniel Schlauch, value=Salary No relevant relationships by Owen Stell No relevant relationships by sage whitmore
ABSTRACT
Background: : To help reduce heart failure (HF) readmissions and improve patient outcomes, the Madison VA established a Nurse Practitioner (NP) led Heart Failure Access Clinic (HFAC) to provide patient follow-up within 4-7 days of discharge. Studies have demonstrated medication discrepancies and delayed implementation of guideline-directed medical therapy as potential contributors to 30-day hospital readmission. Thus, a clinical pharmacy specialist (CPS) was incorporated into the Madison VA HFAC model to focus on optimizing medication regimens. The purpose of this project is to evaluate the impact of an interdisciplinary NP-CPS HFAC versus a NP HFAC on 30-day patient outcomes. Methodology: A retrospective chart review was completed for all patients hospitalized with a primary discharge diagnosis of acute on chronic systolic heart failure (ADHF) at the Madison VA and seen in a HFAC after discharge between November 2019 and November 2020. Patients with LVEF greater than 50% and those discharged to hospice were excluded. During the early period of the COVID-19 pandemic (mid-March through July 2020), patients were seen by the NP only. Outcomes and interventions for patients who attended an interdisciplinary NP-CPS HFAC were compared to those who attended the NP HFAC. Primary outcomes included rehospitalization, emergency department (ED) visit, and all-cause mortality at 30 days. Secondary outcomes included HF medication adjustments, identification of inappropriate medications in patients with HF, medication discrepancies, alerts to another provider for follow up, referral to another service, or referral to HF CPS for continued optimization of GDMT. Results: A total of 90 veterans met the inclusion criteria;43 were seen in the NP HFAC and 47 were seen in the interdisciplinary NP-CPS HFAC. The incidence of adverse 30-day outcomes in this patient cohort was very low (readmission 5.6%, ED visit 1.1%, death 1.1%) and there were no significant between group differences. Statistically significant secondary outcomes favoring the interdisciplinary HF clinic included identification of medication discrepancies (P=<0.0001), alert to another providers for follow up (P=0.004), as well as referral to the HF CPS for continued medication titration (P=0.02). Conclusion: Patients seen in the interdisciplinary NP-CPS HFAC and HP HFAC had similarly low 30-day hospital readmission rates, ED visits and mortality. Involvement of a CPS in the HFAC led to more frequent identification of medication discrepancies, notification to providers regarding medication issues, and referral to a HF CPS for timely GDMT optimization. Further analysis is warranted to assess the impact of these early CPS interventions on long-term patient outcomes.
ABSTRACT
Case presentation A 36-year-old with recent vaginal delivery cocaine abuse, and COVID-19 infection was admitted for new acute systolic heart failure. Etiology of heart failure was suspected as peripartum cardiomyopathy, cocaine-induced, or COVID myocarditis. EKG had no ischemic changes and echocardiography revealed an ejection fraction (EF) of 10-15% with severe global hypokinesis. Additional diagnostics showed a BNP of 3600 and a stable high-sensitivity troponin with a negative delta of 60-65. No arrhythmia on telemetry noted as well. Cardiac MRI was suggestive of myocarditis and no evidence of ischemia on stress MRI (figure 1). The patient received diuresis until euvolemia and tolerated lisinopril and carvedilol. With a diagnosis of clinically suspected non-fulminant COVID myocarditis, she was discharged on a tapered oral dexamethasone for two weeks. On a follow-up telemedicine encounter, the patient denied any chest pain, shortness of breath, and was otherwise asymptomatic Discussion Currently, there remain no guidelines of treatment for COVID-19 myocarditis. Many published management strategies are focused on use of IV corticosteroids and other immunosuppression for cases of fulminant myocarditis. However there is limited data on outpatient management of nonfulminant myocarditis associated with COVID-19. In our case report, we demonstarte successfully managing a patient with non-fulimant myocarditis in the setting of severely reduced EF with an outpatient steroid regimen. Of note, her systolic dysfunction was not exclusively from myocarditis as the patient also had a history of cocaine abuse and possible peripartum cardiomyopathy. At the time of hospital discharge, she was clinically stable, euvolemic, tolerated guideline-directed medical therapy, and her troponins suggested no on-going myocardial injury.
ABSTRACT
Case Report Multisystem inflammatory syndrome (MIS-C) involves severe multi-organ inflammatory injury 2-6 weeks after COVID-19 infection. Seventy to 85% of patients have cardiovascular involvement, including diminished left ventricular ejection fraction (EF), coronary aneurysm, arrhythmias, valvular dysfunction, and pericardial effusion. Here we present a patient who arrived to the pediatric emergency department (ED) with MIS-C and suspected cardiogenic shock, though without the echocardiogram abnormalities commonly associated with MIS-C. A 7 year old African American male presented for a third time to our ED over the course of 4 days of febrile illness and was found to have MIS-C. During this time, he had no chest pain, palpitations, shortness of breath, or abnormal cardiopulmonary exam. At the first 2 ED visits, he was generally well appearing and after treating fever, had vital signs normal for his age. At his third visit, his vital signs were notable for borderline hypotension 86/48 (threshold 83/39 for his height of 1.25 meters). Troponins, chest X-ray, and EKG were normal. Bedside ultrasound was normal, with EF 55-60% so the hypotension was presumed to be secondary to hypovolemia and sepsis. However, despite 40 mL/kg of fluid boluses and maintenance fluid x1.5, his blood pressure continued to downtrend to a nadir of 79/39. He soon developed an S3 gallop and facial edema indicating fluid overload. His proBNP 4986 pg/mL also resulted at this time, suggesting cardiac injury was present. A formal cardiology echocardiogram confirmed the bedside ultrasound findings, noting normal ventricular size and motion, trivial pericardial effusion, and normal coronary artery size. However, it also detected diastolic dysfunction evident in mildly elevated E/e' of 10.86 of lateral mitral annulus, and 12.7 at medial mitral annulus. Three hours after starting solumedrol for treatment of MIS-C, his blood pressure improved to 110/52. The patient had no further episodes of hypotension, though it is unclear if steroids had resolved this by alleviating the underlying inflammation or as a secondary effect. We present a case of MIS-C that led to diastolic heart failure detected by mild hypotension, elevated proBNP, and subtle findings on formal echocardiogram. Although less common than systolic dysfunction in MIS-C, early recognition of diastolic heart failure is important for effective fluid management and initiation of vasoactive agents in criticallly 'ill patients. Diastolic heart failure with preserved systolic function has been seen on echo of MIS-C patients, and is hypothesized to be the subacute period after recovery of systolic function. However, we did not find clinical symptoms of systolic heart failure prior to the patient's development of diastolic heart failure. It is therefore essential to recognize that a patient with MIS-C may present with diastolic heart failure without preceding symptoms or echo findings of other cardiac anomalies.
ABSTRACT
Introduction: COVID 19 is a global pandemic that has stretched healthcare resources. We explored the shift in patient demographics and clinical management of systolic heart failure (HF) patients during the COVID 19 outbreak. Purpose: To examine the impact of COVID 19 on the hospitalization rates of decompensated systolic HF patients in a tertiary hospital in Asia and delineate differences in the clinical characteristics and management of these patients. Methods: Data was extracted from the admission registry for systolic HF patients admitted to the tertiary hospital from January to June 2019 (pre- COVID) and the corresponding time period in 2020 during the COVID outbreak. We compared the demographics, clinical management and outcomes of these patients. Results: There was a significant reduction in patients admitted for systolic HF during the COVID period, 174 (6.3%) compared to 240 (8.5%) pre- COVID (p=0.001). The baseline demographics were similar except for the age of patients admitted during the COVID 19 period, which were younger at 66.1±13.5 compared to 69.9±13.9 pre-COVID (p=0.007). The mean left ventricular ejection fraction (LVEF) was lower during the COVID period (22.9±10.1% vs 24.9±10.1%;p=0.032). More patients during the COVID period were placed on mineralocorticoid receptor antagonists (p=0.001) and SGLT2 inhibitors (p<0.001). For those with recurrent admission for systolic HF, the number for HF admissions in the preceding one year was lower during COVID period compared to pre-COVID (0.2±0.5 vs 0.5±1.0 readmissions, p<0.001). There was no COVID 19 infection among those admitted for systolic HF. The 30-day all-cause mortality and readmission rates were comparable between both groups. Cardiac related mortalities were higher during the COVID 19 period compared to the pre-COVID period (77.8% vs 100.0%, p=1.000). No difference was observed in the length of stay nor proportion of patients who required a higher level of care in high dependency or intensive care unit during the COVID outbreak. Those who were admitted during the COVID period were more likely first presentation of decompensated systolic HF, 119 (68.4%) compared to 135 (56.3%) pre-COVID (p=0.014). Conclusion: Similar to the existing publications, there was a reduction in patients admitted for HF during the COVID period. However, for those who were admitted, these patients were younger and had lower LVEF. Most of them were first diagnosed with systolic HF during the hospitalizations. For those who had previous history of systolic HF, they had a lower number of HF admissions in the preceding one year compared to those who were admitted during the pre-COVID period. There was no difference in the 30-day mortality and utilization of high dependency or intensive care unit during the COVID outbreak.