The long-term effects of the Covid-19 infection on cardiac symptoms.

BACKGROUND: Besides the lungs, coronavirus disease 2019 (COVID-19) can affect the cardiovascular, digestive, urinary, hepatic, and central nervous systems. Other than its short-term effects, COVID-19 may also cause long-term complications. In this study, we assessed long-term COVID-19 cardiovascular symptoms among patients in a cardiovascular clinic. METHOD: A retrospective cohort was conducted between October 2020 to May 2021 on patients at an outpatient cardiovascular clinic in Shiraz, Iran. Patients with a history of COVID-19 at least one year before their referral were included. Baseline information was extracted from the clinic's database. Data were collected regarding symptoms like dyspnea, chest pain, fatigue, and palpitations after a year of COVID-19. We also noted any major adverse cardiac events (MACE). RESULTS: Most common symptoms after a year of COVID-19 were exertional dyspnea (51.2%), dyspnea at rest (41.6%), fatigue (39%), and chest pain (27.1%). The symptoms were more prevalent in hospitalized patients than in non-hospitalized patients. The prevalence of MACE was about 6.1% during the 12-month follow-up, with this rate being higher in those with a history of hospitalization or comorbid diseases. CONCLUSION: The prevalence of cardiovascular symptoms was fairly high in patients at our clinic a year after COVID-19, and the most common symptom was dyspnea. Hospitalized patients had more MACE. (Clinicaltrial.gov number: NCT05715879)(04/02/2023).

Chest Tightness with Cycling Turned Out To Be Pneumomediastinum.

BACKGROUND Pneumomediastinum, or mediastinal emphysema, means air present inside the mediastinum. It usually presents with symptoms of chest pain and shortness of breath. Examination can be significant for crepitus along the neck area. There are many risk factors associated with pneumomediastinum, including asthma and COVID-19. Most cases of pneumomediastinum improve with conservative management, and surgery (mediastinotomy) is reserved for complicated cases with tension pneumomediastinum. CASE REPORT This is the case of a 23-year-old man who presented with chest tightness after 3.5 h of cycling. The patient did have a prior history of clinically stable asthma, with no recent exacerbation, and denied any other associative factors. Imaging was significant for pneumomediastinum. The patient was admitted for observation in the hospital and treated with supportive care, without any surgical intervention. The patient had appropriate improvement in his symptoms in 24 h. Repeat imaging showed improvement in the pneumomediastinum, and the patient was discharged to outpatient follow-up. CONCLUSIONS Our case presents a unique link between cycling and pneumomediastinum. Prolonged cycling may emerge as a risk factor for this complication. People with a previous history of pneumomediastinum should be careful to review other risk factors prior to planning long-distance bicycling. Physicians need to keep this differential diagnosis in mind when encountering a patient with similar symptoms so that a timely diagnosis is made.

Evaluating chest pain in patients with post COVID conditions permission to think outside of the box.

Chest pain is among the most common symptoms of post-COVID-19 Conditions (PCC) that prompts medical attention. Because the SARS-CoV-2 virus has proclivity for many organs and organ systems in the chest, ranging from the heart, lungs, great vessels, lymphatics, and peripheral nerves, clinicians evaluating patients with chest pain must consider a broad differential diagnosis and take a comprehensive approach to management.

Effect of a Senior Cardiology Nursing Role on Streamlining Assessment of Emergency Cardiology Presentations During COVID-19: An Observational Study.

INTRODUCTION: The Emergency Cardiology Coordinator (ECC) was a senior nursing role implemented from 14 April 2020 to 15 September 2020 at the Gold Coast Hospital and Health Service in South-East Queensland, Australia to streamline and expedite assessment of patients presenting to the Emergency Department (ED) with suspected cardiac problems. ECC implementation occurred in the context of the emergence of COVID-19. Evaluation of the impact of the ECC role focussed primarily on the time interval from triage to cardiology consult (TTCC). METHODS: ED and Cardiology Department data were extracted from electronic medical records for the period 2 September 2019 to 1 March 2021. The TTCC for each presenting problem (chest pain, palpitations, shortness of breath, altered level of consciousness) was compared between patients seen by the ECC and those not seen on the days the ECC worked. The effect of COVID-19 on TTCC was assessed by an interrupted time series analysis. Data recorded by the ECC included patients seen and interventions provided. RESULTS: The ECC saw 378 patients. Most presented with chest pain (269/378, 71.2%). The ECC determined that 68.8% (260/378) required a cardiac assessment. Following COVID-19 the median weekly TTCC increased by 0.029 hours (1.74 min) each week on average relative to that beforehand (p=0.008). For patients seen by the ECC the median TTCC was 2.07 hours (interquartile range [IQR]: 1.44, 3.16) compared to 2.58 hours (IQR: 1.73, 3.80; p=0.007) for patients not seen by the ECC. Chest pain (ECC: 1.94 hours; no ECC: 2.41 hours; p=0.06) and non-obvious cardiac presenting problems (ECC: 1.77 hours; no ECC 3.05 hours; p=0.004) displayed the largest reductions in TTCC when the ECC was involved. Presentations with palpitations, respiratory distress and altered level of consciousness had similar TTCCs. CONCLUSION: The ECC role resulted in an overall decrease in TTCC despite the role coinciding with the emergence of COVID-19. In order to clarify the optimal strategy for the ECC role, further analyses involving patient risk factors and presenting problems along with a health economic evaluation of this model of care and the effect on patient outcomes will be required.

Persistent Elevation of Troponin I in a Pediatric Patient Resulting From Macrotroponin Complex.

ABSTRACT: Although chest pain is a common chief complaint among pediatric patients, cardiac pathology historically has accounted for a small percentage of cases. However, the emergence of COVID-19 and particularly its potential for leading to multisystem inflammatory syndrome has changed the threshold for the evaluation of cardiac etiologies of chest pain. This evaluation often includes measurement of the serum cardiac troponin I level. We present a case of a 16-year-old male athlete who presented to an outside emergency department with chest pain and was found to have elevated serum troponin I levels. Despite sports restriction, his troponin level remained elevated for months in the absence of other clinical findings and he was subsequently referred to our outpatient pediatric cardiology clinic. Further laboratory evaluation revealed that, in addition to troponin I, the assay measured an immune complex of uncertain significance formed by anti-troponin I antibodies bound to troponin I, known as macrotroponin. Delayed clearance of this complex from the bloodstream can result in overestimation of troponin I levels that can affect clinical management and create anxiety for our patients and their families. Macrotroponin complex deserves increased recognition among the research and clinical communities, especially in the pediatric realm.

Myocarditis and coronavirus disease 2019 vaccination: A systematic review and meta-summary of cases.

Vaccination is significant to control, mitigate, and recover from the destructive effects of coronavirus disease 2019 (COVID-19). The incidence of myocarditis following COVID-19 vaccination has been increasing and growing public concern; however, little is known about it. This study aimed to systematically review myocarditis following COVID-19 vaccination. We included studies containing individual patient data of myocarditis following COVID-19 vaccination published between January 1, 2020 and September 7, 2022 and excluded review articles. Joanna Briggs Institute critical appraisals were used for risk of bias assessment. Descriptive and analytic statistics were performed. A total of 121 reports and 43 case series from five databases were included. We identified 396 published cases of myocarditis and observed that the majority of cases was male patients, happened following the second dose of mRNA vaccine administration, and experienced chest pain as a symptom. Previous COVID-19 infection was significantly associated (p < 0.01; OR, 5.74; 95% CI, 2.42-13.64) with the risk of myocarditis following the administration of the first dose, indicating that its primary mechanism is immune-mediated. Moreover, 63 histopathology examinations were dominated by non-infective subtypes. Electrocardiography and cardiac marker combination is a sensitive screening modality. However, cardiac magnetic resonance is a significant noninvasive examination to confirm myocarditis. Endomyocardial biopsy may be considered in confusing and severe cases. Myocarditis following COVID-19 vaccination is relatively benign, with a median length of hospitalization of 5 days, intensive care unit admission of <12%, and mortality of <2%. The majority was treated with nonsteroidal anti-inflammatory drugs, colchicine, and steroids. Surprisingly, deceased cases had characteristics of being female, older age, non-chest pain symptoms, first-dose vaccination, left ventricular ejection fraction of <30%, fulminant myocarditis, and eosinophil infiltrate histopathology.

The change in pediatric subject symptoms during the COVID-19 pandemic in China: an increase in cardiac consultation.

BACKGROUND: It is reported that the adverse impact of nonpharmaceutical interventions (NPIs) on the mental health of children and adolescents may lead to psychologically related disorders during the coronavirus disease 2019 (COVID-19) period. Subject symptoms such as chest pain, chest tightness, and palpitation may be related to increased stress and anxiety in children and adolescents. The present research aimed to determine the number of pediatric consults and etiology of subject symptoms during the COVID-19 pandemic period and compared it with the same timelines in 2019 and 2021 to discuss the impact of different periods on the organic disease onset of children with subject symptoms, especially in cardiac involvement. METHODS: Children who visited Qingdao Women and Children's Hospital, Qingdao University between January 23 to April 30, 2019 (pre-COVID-19 period), January 23 to April 30, 2020 (COVID-19 period), and January 23 to April 30, 2021 (post-COVID-19 period) presenting chest pain, chest tightness, and palpitation were recruited. Information to determine gender, age, medical history, department for the initial visit, clinical manifestations, time from the latest onset to the visit, and diagnosis were recorded. RESULT: A total of 891 patients were enrolled in the present study (514 males; median age: 7.72). One hundred twenty-three patients presented during the pre-COVID-19 period while 130 during the COVID-19 period, nevertheless, the number substantially increased during the post-COVID-19 period (n = 638). Cardiac etiology accounted for 1.68% (n = 15) of the patient population, including arrhythmias (n = 10, 1.12%), myocarditis (n = 4, 0.44%), and atrial septal defect (n = 1, 0.11%). There was no significant difference among groups in the distribution of organic etiology. The median time from the latest onset to the visit during the pre-COVID-19 period was 7 days compared to 10 days during the COVID-19 period and 3 days during the post-COVID period. CONCLUSION: During the post-COVID-19 period, the median time from the latest onset to the visit was significantly shorter than that in the pre-COVID-19 period or COVID-19 period. The pediatric consult of children with subject symptoms presented increased substantially during the post-COVID-19 period, while there was no significant difference in the number of patients involving the cardiac disease. Clinicians ought to be more careful to screen heart diseases to prevent missed diagnosis and misdiagnosis during special periods.

Acute Perimyocarditis - an ST-Elevation Myocardial Infarction Mimicker: A Case Report.

BACKGROUND A normal coronary angiogram in ST-elevation myocardial infarction (STEMI) can be considered a myocardial infarction with non-obstructive coronary arteries (MINOCA) until an alternative diagnosis is obtained. However, the COVID-19 pandemic might delay urgent coronary angiography in a resource-limited setting. Perimyocarditis often causes symptoms, such as chest pain, as well as ST-elevation and high cardiac troponin levels. This STEMI mimicker can also cause cardiogenic shock and death when not treated properly. CASE REPORT A 40-year-old man reported having acute onset of substernal chest pain, which was suspected to be STEMI. The patient was an active smoker without any risk factors or a history of cardiovascular disease. The examination showed elevated cardiac troponin I, ST-elevation in high lateral leads, and regional wall motion abnormality (RWMA) by echocardiogram. Furthermore, thrombolytic therapy had failed, and rescue percutaneous coronary intervention was not performed due to the catheterization laboratory limitation during the COVID-19 pandemic. Before coronary angiography, the patient was scheduled for 2 consecutive days of COVID-19 polymerase chain reaction (PCR) swabs. On the second day of hospitalization, the patient experienced a cardiogenic shock. The COVID-19 PCR results were negative, while coronary angiography revealed normal coronary arteries. The patient was eventually diagnosed with probable acute perimyocarditis. CONCLUSIONS Myocarditis is implicated in young patients without typical cardiovascular risk factors or in those with recent infection and cardiovascular symptoms mimicking acute coronary syndrome. It might also be present in situations where ST-elevation distribution on the electrocardiogram is discordant with the RWMA observed on the echocardiogram.

Myocarditis and related complications of SARS-CoV-2 infection.

BACKGROUND: Myocarditis and pericarditis are associated with a wide range of presentations and have received renewed interest because of the association with SARS-CoV-2 infection. Some of these complications have also been reported with the mRNA vaccines used for preventing the infection, which has caused widespread anxiety and uncertainty in the community. OBJECTIVE: The aim of this article is to summarise an approach to the clinical problem of myocarditis and treatment/management of patients with myocarditis in the community. This article also discusses SARS-CoV-2 infection and vaccines. DISCUSSION: Myocarditis and pericarditis need to be considered as a differential, especially in all adolescents or young adults presenting with acute chest pain, shortness of breath or palpitations. Other serious causes of chest pain - such as acute myocardial infarction, pulmonary embolism, aortic dissection and pneumothorax - also need to be excluded. Initial electrocardiography, troponin and C-reactive protein tests are recommended, and cardiology advice should be sought for all suspected cases.

Long-term Cardiovascular Manifestations and Complications of COVID-19: Spectrum and Approach to Diagnosis and Management.

Survivors of coronavirus disease 2019 (COVID-19) may experience persistent symptoms, abnormal diagnostic test findings, incident disease in specific organ systems, or progression of existing disease. Post-acute COVID-19 syndrome (PACS) is defined by persistent, recurrent, or new symptoms, findings, or diagnoses beyond four weeks after the initial infection. PACS has been characterized as a multi-organ syndrome, often with cardiopulmonary symptoms that include fatigue, dyspnea, chest pain, and palpitations. Cardiovascular pathologies in PACS include new-onset arrhythmia, myocarditis, unmasked coronary artery disease, and diastolic dysfunction as well as abnormal findings on electrocardiogram, troponin testing, and cardiac magnetic resonance imaging. In this review, we discuss the cardiovascular symptoms, pathophysiology, clinical investigation, and management strategies for cardiopulmonary symptoms of PACS. We offer a treatment algorithm for primary care clinicians encountering patients with cardiopulmonary PACS and discuss ongoing research on this topic.

High risk and low prevalence diseases: Acute chest syndrome in sickle cell disease.

INTRODUCTION: Acute chest syndrome (ACS) in sickle cell disease (SCD) is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of ACS in SCD, including diagnosis and management in the emergency department (ED) based on current evidence. DISCUSSION: ACS is defined by respiratory symptoms and/or fever and a new radiodensity on chest imaging in a patient with SCD. There are a variety of inciting causes, including infectious and non-infectious etiologies. Although ACS is more common in those with homozygous SCD, clinicians should consider ACS in all SCD patients, as ACS is a leading cause of death in SCD. Patients typically present with or develop respiratory symptoms including fever, cough, chest pain, and shortness of breath, which can progress to respiratory failure requiring mechanical ventilation in 20% of adult patients. However, the initial presentation can vary. While the first line imaging modality is classically chest radiograph, lung ultrasound has demonstrated promise. Further imaging to include computed tomography may be necessary. Management focuses on analgesia, oxygen supplementation, incentive spirometry, bronchodilators, rehydration, antibiotics, consideration for transfusion, and specialist consultation. Empiric antibiotics that cover atypical pathogens are necessary along with measures to increase oxygen-carrying capacity in those with hypoxemia such as simple transfusion or exchange transfusion. CONCLUSIONS: An understanding of ACS can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Myocarditis after COVID-19 mRNA vaccination: A systematic review of case reports and case series.

BACKGROUND: The coronavirus disease of 2019 (COVID-19) is a global pandemic with over 266 million cases and 5 million deaths worldwide. Anti-COVID-19 vaccinations have had exceptional success in subduing the incidence, prevalence, and disease severity of COVID-19, but rare cases of myocarditis have been reported after COVID-19 vaccinations. HYPOTHESIS: Myocarditis occurring after COVID-19 mRNA vaccinations have distinguishable clinical characteristics. They usually have a favorable prognosis. METHODS: We performed a systematic literature search on PUBMED and MEDLINE database from inception to December 5, 2021. Studies were analyzed based on predetermined eligibility criteria. RESULTS: A total of 57 studies containing 275 cases of COVID-19 vaccine-associated myocarditis were catalogued. Mean age was 26.7 years and male to female ratio was 14:1. For 86.9% of patients, myocarditis occurred after the second dose. Average time to onset and length of hospitalization were 3.7 and 3.9 days, respectively. Prognosis was largely benign, but there was a 1.1% reported mortality. Chest pain (95.2%), elevation of troponin (100%), and ST elevation on electrocardiography (68.5%) were common. Nonsteroidal anti-inflammatory drugs (81.4%) were the most used medication, followed by colchicine (33.1%). CONCLUSIONS: Patients with COVID-19 vaccine-associated myocarditis are usually younger males presenting with chest pain 3-4 days after receiving their second dose of COVID vaccine. Diagnosis is made by exclusion of all other etiologies. Given significant population benefit from COVID-19 vaccination, physicians should continue to encourage vaccination while remaining vigilant of the very rare occurrence of myocarditis following COVID-19 vaccination.

Coronary calcium scoring as first-line test to detect and exclude coronary artery disease in patients presenting to the general practitioner with stable chest pain: protocol of the cluster-randomised CONCRETE trial.

INTRODUCTION: Identifying and excluding coronary artery disease (CAD) in patients with atypical angina pectoris (AP) and non-specific thoracic complaints is a challenge for general practitioners (GPs). A diagnostic and prognostic tool could help GPs in determining the likelihood of CAD and guide patient management. Studies in outpatient settings have shown that the CT-based coronary calcium score (CCS) has high accuracy for diagnosis and exclusion of CAD. However, the CT CCS test has not been tested in a primary care setting. In the COroNary Calcium scoring as fiRst-linE Test to dEtect and exclude coronary artery disease in GPs patients with stable chest pain (CONCRETE) study, the impact of direct access of GPs to CT CCS will be investigated. We hypothesise that this will allow for early diagnosis of CAD and treatment, more efficient referral to the cardiologist and a reduction of healthcare-related costs. METHODS AND ANALYSIS: CONCRETE is a pragmatic multicentre trial with a cluster randomised design, in which direct GP access to the CT CCS test is compared with standard of care. In both arms, at least 40 GP offices, and circa 800 patients with atypical AP and non-specific thoracic complaints will be included. To determine the increase in detection and treatment rate of CAD in GP offices, the CVRM registration rate is derived from the GPs electronic registration system. Individual patients' data regarding cardiovascular risk factors, expressed chest pain complaints, quality of life, downstream testing and CAD diagnosis will be collected through questionnaires and the electronic GP dossier. ETHICS AND DISSEMINATION: CONCRETE has been approved by the Medical Ethical Committee of the University Medical Center of Groningen. TRIAL REGISTRATION NUMBER: NTR 7475; Pre-results.

A 31-Year-Old Man With Fever, Atypical Chest Pain, and Mediastinal Mass.

CASE PRESENTATION: A 31-year-old Asian male never-smoker living in the upper Midwest with a past medical history of congenital bilateral hearing loss sought treatment with a 1-week history of fever, fatigue, right-sided pleuritic chest pain, shortness of breath, productive cough with mild intermittent hemoptysis, night sweats, and unintentional 10-lb weight loss over 4 weeks. He was adopted from South Korea as an infant, and thus the family history was unknown. He worked in the heating, ventilation, and air conditioning business, performing installations and repairs. There was no known exposure to animals, caves, rivers, lakes, or wooded areas. He travelled to South Korea and New Hampshire approximately 9 months previously. He did not take any medication.

Role of antibodies, inflammatory markers, and echocardiographic findings in postacute cardiopulmonary symptoms after SARS-CoV-2 infection.

Shortness of breath, chest pain, and palpitations occur as postacute sequelae of COVID-19, but whether symptoms are associated with echocardiographic abnormalities, cardiac biomarkers, or markers of systemic inflammation remains unknown. In a cross-sectional analysis, we assessed symptoms, performed echocardiograms, and measured biomarkers among adults more than 8 weeks after confirmed SARS-CoV-2 infection. We modeled associations between symptoms and baseline characteristics, echocardiographic findings, and biomarkers using logistic regression. We enrolled 102 participants at a median of 7.2 months following COVID-19 onset; 47 individuals reported dyspnea, chest pain, or palpitations. Median age was 52 years, and 41% of participants were women. Female sex, hospitalization, IgG antibody against SARS-CoV-2 receptor binding domain, and C-reactive protein were associated with symptoms. Regarding echocardiographic findings, 4 of 47 participants (9%) with symptoms had pericardial effusions compared with 0 of 55 participants without symptoms; those with effusions had a median of 4 symptoms compared with a median of 1 symptom in those without effusions. There was no strong evidence for a relationship between symptoms and echocardiographic functional parameters or other biomarkers. Among adults more than 8 weeks after SARS-CoV-2 infection, SARS-CoV-2 RBD antibodies, markers of inflammation, and, possibly, pericardial effusions are associated with cardiopulmonary symptoms. Investigation into inflammation as a mechanism underlying postacute sequelae of COVID-19 is warranted.