The Feasibility, Effectiveness and Acceptance of Virtual Visits as Compared to In-Person Visits among Clinical Electrophysiology Patients during the COVID-19 Pandemic.

The feasibility and effectiveness of virtual visits (VVs) for cardiac electrophysiology patients are still unknown. We aimed to assess the feasibility and effectiveness of VVs as compared to in-person visits, and to describe patient experience with virtual care in clinical electrophysiology. We prospectively enrolled patients scheduled to receive a clinical electrophysiology evaluation, dividing them in two groups: a VV group and an in-person visit group. Outcomes of interest were: (1) improvement in symptoms after the index visit, (2) disappearance of remote monitoring (RM) alerts at follow-up, (3) necessity of urgent hospitalization and (4) patient satisfaction measured by the Patient Satisfaction Questionnaire-18 (PSQ-18). This study included 162 patients in the VV group and 185 in the in-office visit group. As compared to in-person visits, VVs resulted in a similar reduction in RM alerts (51.5% vs. 43.2%, p-value 0.527) and in symptomatic patient rates (73.6% vs. 56.9%, p-value 0.073) at follow-up, without differences in urgent hospitalization rates (p-value 0.849). Patient satisfaction with VVs was higher than with in-person evaluation (p-value < 0.012). VVs proved to be as feasible and as effective as in-person visits, with high patient satisfaction. A hybrid model of care including VVs and in-person visits may become the new standard of care after the COVID-19 pandemic is over.

Clinical Management of New-Onset Atrial Fibrillation in COVID-19 Patients Referred to a Tertiary Cardiac Arrhythmia Center after Hospital Discharge.

BACKGROUND: Available reports on the post-discharge management of atrial fibrillation (AF) in COVID-19 patients are scarce. The aim of this case series was to describe the clinical outcomes of new-onset AF in COVID-19 patients referred to a tertiary cardiac arrhythmia center after hospital discharge. METHODS: All consecutive patients referred to our center for an ambulatory evaluation from 18 May 2020 to 15 March 2022 were retrospectively screened. Patients were included in the current analysis if new-onset AF was diagnosed during hospitalization for COVID-19 and then referred to our clinic. RESULTS: Among 946 patients, 23 (2.4%) were evaluated for new-onset AF during COVID-19. The mean age of the study cohort was 71.5 ± 8.1 years; 87.0% were male. Median time from COVID-19 discharge and the first ambulatory evaluation was 53 (41.5-127) days; median follow-up time was 175 (83-336) days. At the in-office evaluation, 14 (60.9%) patients were in sinus rhythm, and nine patients were in AF. In 13.0% of cases, oral anticoagulation was stopped according to CHADS-VASc. Eight patients in AF were scheduled for electrical cardioversion; one patient was rate-controlled. Four patients were treated with catheter ablation (CA) during follow-up. Two post-cardioversion AF recurrences were detected during follow-up, while no recurrences were diagnosed among patients who underwent CA. CONCLUSION: Our data suggest that AF may not be considered as a simple bystander of the in-hospital COVID-19 course. Management of new-onset AF in post-COVID-19 patients referred to our clinic did not significantly differ from our usual practice, both in terms of long-term oral anticoagulation and in terms of rhythm control strategy.

Impact of prior statin use on clinical outcomes in COVID-19 patients: data from tertiary referral hospital during COVID-19 pandemic in Italy

Aims Epidemiological evidence suggests that anti-inflammatory and immuno-modulatory properties of statins may reduce the risk of infections and infection-related complications. In this observational multi-centre study, we aimed to assess the impact of prior statin use on coronavirus disease (COVID-19) severity and mortality. Methods and results Consecutive patients hospitalized for COVID-19 were considered and enrolled in four tertiary referral hospitals (Luigi Sacco Hospital, Milan;Policlinico Umberto I Hospital, Rome;Spedali Civili Hospital, Brescia;Humanitas Gavazzeni Hospital;Bergamo) From 23 February 2020 to 31 March 2020, in-hospital mortality and severity of COVID-19 assessed with National Early Warning Score (NEWS) were deemed primary and secondary outcomes, respectively. Among 842 patients enrolled, 179 (21%) were treated with statins before admission. Statin patients showed more comorbidities and more severe COVID-19 [NEWS 4 (IQR: 2–6) vs. 3 (IQR: 2–5), P < 0.001]. Despite having similar rates of intensive care unit admission, noninvasive ventilation, and mechanical ventilation, statin users appeared to show higher mortality rates. After balancing pre-existing relevant clinical conditions that could affect COVID-19 prognosis with propensity score matching, statin therapy confirmed its association with a more severe disease (NEWS ≥ 5;61% vs. 48%, P = 0.025) but not with in-hospital mortality (26% vs. 28%, P = 0.185). At univariate logistic regression analysis, statin use was confirmed not to be associated with mortality (OR: 0.901;95% CI: 0.537–1.51;P = 0.692) and to be associated with a more severe disease (NEWS ≥ 5 OR: 1.7;95% CI: 1.067–2.71;P = 0.026). Conclusions Our results did not confirm the supposed favourable effects of statin therapy on COVID-19 outcomes. Conversely, they suggest that statin use should be considered as a proxy of underlying comorbidities, which indeed expose to increased risks of more severe COVID-19.538 Figure 1

The role of virtual visits in cardiology: from the pandemic era to future perspectives

Aims During the Coronavirus Disease 2019 (COVID-19) pandemic in-person visits were reduced to prevent potential risk of exposure. Virtual visits (VVs) represent an innovative model to take care of patients with cardiac implantable electronic devices (CIEDs). The aim of this study is to evaluate the safety and feasibility of VV in the management of CIED patients. Methods and results We performed a prospective study including all CIED patients who received a VV from July 2020 to July 2021. Blood pressure, arterial oxygen saturation, heart rate, and body weight were registered by the patient. Moreover, we sent to the patient a questionnaire to evaluate the patients’ satisfaction about VV. We enrolled 182 patients in the study period. The mean age of patients was 70.2 ± 13.5 years-old and the majority (61.1%) was male. In two cases, VVs were not performed due to technical issues. Overall, 70.9% of patients utilized a smartphone, while 20.1% and 9% used, respectively, a tablet or a personal computer. The mean duration of VV was 27.8 ± 7.8 min. Patients helped by a caregiver were 64 (35.2%). One urgent/emergent in‐person visit was performed in a patient with acute heart failure. Overall, VV was preferred to in-person evaluation. Conclusion VV is a safe and feasible approach to follow-up CIED patients. A high degree of patient satisfaction was reached after VV. The use of VV has promising potential and should be implemented beyond COVID-19 period and integrated in the healthcare system as a new model of care.

Assessment of long-term arrhytmic sequelae in patients recovering from COVID-19 infection

Aims COVID-19 has been associated with acute cardiac complications including cardiac arrhythmias. We aimed to assess the prevalence of long-term cardiac arrhythmias in patients recovering from severe COVID-19 infection with proved or suspected of cardiac involvement. Methods and results All patients with COVID-19 infection discharged from the cardiology department of our institution from the 1 March to the 30 April 2020 were considered eligible for this study. Patients were fitted out with an adhesive patch and a wireless single-lead 24-h electrocardiogram (ECG) Holter monitor (Rooti Rx® System, Rooti Labs Ltd, Taipei, Taiwan). RootiRx® is a small device consisting of an integrated sensor system, a microelectronic board with memory storage, and an internal rechargeable battery. This system can provide continuous ECG and was set to monitor heart rhythm for 24 h. The Holter system provides also blood pressure measurements and sleep apnea data which are evaluated through chest wall motion/cyclic variation of heart rate and reported along with the sleep efficiency (percentage of time spent asleep while in bed). Arrhythmic findings, sleep apnea detections, and residual COVID-19 symptoms were reported. The study follow-up was performed 174 (range = 166–190) days after hospital discharge in a cohort of 63 (76% males, median age 66 years) patients. New diagnosis of atrial fibrillation (AF) was performed in three sinus rhythm patients (4.8%). Eleven (18%) patients had asymptomatic bradycardia (<45 b.p.m.) with no pauses lasting more than 3 s. Non-sustained ventricular tachycardia (<30 s) episodes were recorded in two (3.2%) patients, while no sustained ventricular arrhythmia was documented. The Holter system indicated the presence of moderate-to-severe obstructive sleep apnea episodes in 33 (53%) patients without known history of sleep disorders. Some previously unrecognized long-lasting COVID-19 symptoms were also described: fatigue (10, 16%), myalgia (3, 4.8%), and impaired attention (1, 1.6%). Conclusions Six months after the infection, we performed new diagnoses of AF in patients who recovered from severe COVID-19 infection with proved or suspected cardiac involvement using 24-h Holter monitoring. No other arrhythmias were observed, but the Holter system identified obstructive sleep apnea episodes in half of the patients. A relevant percentage of patients also described persisting symptoms of COVID-19 infection. These findings suggest further prospective studies to better describe long-term arrhythmic manifestations and residual symptoms in patients hospitalized with COVID-19 infection.

Arrhythmogenic Risk and Mechanisms of QT-Prolonging Drugs to Treat COVID-19.

While looking for a solution to treat COVID-19, the massive off-label use of several drugs in COVID-19 has generated concerns in the early phase of the pandemic because of possible arrhythmogenic effects in relation to QTc interval prolongation. Indeed, some of these drugs have been historically associated with QT prolongation and Torsade de Point, a potentially lethal ventricular arrhythmia, and their first-time use on a very large scale has raised several concerns in the scientific community. This work aims to summarize the underlying arrhythmogenic mechanisms related to the use of potentially QT-prolonging drugs used during the pandemic to treat COVID-19.

Prevalence and outcome of silent hypoxemia in COVID-19.

BACKGROUND: In the early stages of COVID-19 pneumonia, hypoxemia has been described in absence of dyspnea ("silent" or "happy" hypoxemia). Our aim was to report its prevalence and outcome in a series of hypoxemic patients upon Emergency Department admission. METHODS: In this retrospective observational cohort study we enrolled a study population consisting of 213 COVID-19 patients with PaO2/FiO2 ratio <300 mmHg at hospital admission. Two groups (silent and dyspneic hypoxemia) were defined. Symptoms, blood gas analysis, chest X-ray (CXR) severity, need for intensive care and outcome were recorded. RESULTS: Silent hypoxemic patients (68-31.9%) compared to the dyspneic hypoxemic patients (145-68.1%) showed greater frequency of extra respiratory symptoms (myalgia, diarrhea and nausea) and lower plasmatic LDH. PaO2/FiO2 ratio was 225±68 mmHg and 192±78 mmHg in silent and dyspneic hypoxemia respectively (P=0.002). Eighteen percent of the patients with PaO2/FiO2 from 50 to 150 mmHg presented silent hypoxemia. Silent and dyspneic hypoxemic patients had similar PaCO2 (34.2±6.8 mmHg vs. 33.5±5.7 mmHg, P=0.47) but different respiratory rates (24.6±5.9 bpm vs. 28.6±11.3 bpm respectively, P=0.002). Even when CXR was severely abnormal, 25% of the population was silent hypoxemic. Twenty-six point five percent and 38.6% of silent and dyspneic patients were admitted to the ICU respectively (P=0.082). Mortality rate was 17.6% and 29.7% (log-rank P=0.083) in silent and dyspneic patients. CONCLUSIONS: Silent hypoxemia is remarkably present in COVID-19. The presence of dyspnea is associated with a more severe clinical condition.

Arrhythmic safety of hydroxychloroquine in COVID-19 patients from different clinical settings.

AIMS: The aim of the study was to describe ECG modifications and arrhythmic events in COVID-19 patients undergoing hydroxychloroquine (HCQ) therapy in different clinical settings. METHODS AND RESULTS: COVID-19 patients at seven institutions receiving HCQ therapy from whom a baseline and at least one ECG at 48+ h were available were enrolled in the study. QT/QTc prolongation, QT-associated and QT-independent arrhythmic events, arrhythmic mortality, and overall mortality during HCQ therapy were assessed. A total of 649 COVID-19 patients (61.9 ± 18.7 years, 46.1% males) were enrolled. HCQ therapy was administrated as a home therapy regimen in 126 (19.4%) patients, and as an in-hospital-treatment to 495 (76.3%) hospitalized and 28 (4.3%) intensive care unit (ICU) patients. At 36-72 and at 96+ h after the first HCQ dose, 358 and 404 ECGs were obtained, respectively. A significant QT/QTc interval prolongation was observed (P < 0.001), but the magnitude of the increase was modest [+13 (9-16) ms]. Baseline QT/QTc length and presence of fever (P = 0.001) at admission represented the most important determinants of QT/QTc prolongation. No arrhythmic-related deaths were reported. The overall major ventricular arrhythmia rate was low (1.1%), with all events found not to be related to QT or HCQ therapy at a centralized event evaluation. No differences in QT/QTc prolongation and QT-related arrhythmias were observed across different clinical settings, with non-QT-related arrhythmias being more common in the intensive care setting. CONCLUSION: HCQ administration is safe for a short-term treatment for patients with COVID-19 infection regardless of the clinical setting of delivery, causing only modest QTc prolongation and no directly attributable arrhythmic deaths.

QT Interval Monitoring and Drugs Management During COVID-19 Pandemic.

While facing potentially high morbidity from COVID-19 without known effective therapies, the off-label use of several non-specific drugs has been advocated, including re-purposed anti- viral (e.g., remdesivir or the lopinavir/ritonavir combination), biologic agents (e.g., tocilizumab), and antimalarial drugs such as chloroquine and hydroxychloroquine, in association with or without azithromycin. Data regarding the effectiveness of these drugs in treating COVID-19 has been shown in some trials and clinical settings, but further randomised controlled trials are still being carried out. One of the main concerns regarding their widespread use, however, is their possible effects on the QT interval and arrhythmogenic potential. Some of these drugs have been associated with QT prolongation and Torsades de Point, a potentially lethal ventricular arrhythmia. The review aims to highlight the magnitude of this problem, to quickly refresh clinically impacting cornerstones of QT interval and TdP pathophysiology, to summarize the available evidence regarding the QT and arrhythmia impact of drugs used in different clinical settings in COVID-19 patients, and to help the physicians dealing with the knowledge needed in the everyday clinical duties in case of doubts regarding QT-induced arrhythmias in this time of emergency.

Redefining the Prognostic Value of High-Sensitivity Troponin in COVID-19 Patients: The Importance of Concomitant Coronary Artery Disease.

BACKGROUND: Although studies assessing cardiovascular comorbidities and myocardial injury in Coronavirus disease 2019 (COVID-19) patients have been published, no reports focused on clinical outcomes of myocardial injury in patients with and without chronic coronary syndromes (CCS) are currently available. METHODS: In this study, consecutive COVID-19 patients admitted to four different institutions were screened for enrolment. Patients were divided into two groups (CCS vs. no-CCS). Association with in-hospital mortality and related predictors represented the main study outcome; myocardial injury and its predictors were deemed secondary outcomes. RESULTS: A total of 674 COVID-19 patients were enrolled, 112 (16.6%) with an established history of CCS. Myocardial injury occurred in 43.8% patients with CCS vs. 14.4% patients without CCS, as confirmed by high-sensitivity cardiac troponin (hs-cTn) elevation on admission or during hospitalization. The mortality rate in the CCS cohort was nearly three-fold higher. After adjusting for disease severity, myocardial injury resulted significantly associated with in-hospital mortality in the no-CCS group but not in CCS patients. CONCLUSIONS: Patients with CCS and COVID-19 showed high mortality rate. Myocardial injury may be a bystander in CCS patients and COVID-19, while in patients without known history of CCS, myocardial injury has a significant role in predicting poor outcomes.

Acute Coronary Syndromes and Covid-19: Exploring the Uncertainties.

Since an association between myocardial infarction (MI) and respiratory infections has been described for influenza viruses and other respiratory viral agents, understanding possible physiopathological links between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and acute coronary syndromes (ACS) is of the greatest importance. The initial data suggest an underestimation of ACS cases all over the world, but acute MI still represents a major cause of morbidity and mortality worldwide and should not be overshadowed during the coronavirus disease (Covid-19) pandemic. No common consensus regarding the most adequate healthcare management policy for ACS is currently available. Indeed, important differences have been reported between the measures employed to treat ACS in China during the first disease outbreak and what currently represents clinical practice across Europe and the USA. This review aims to discuss the pathophysiological links between MI, respiratory infections, and Covid-19; epidemiological data related to ACS at the time of the Covid-19 pandemic; and learnings that have emerged so far from several catheterization labs and coronary care units all over the world, in order to shed some light on the current strategies for optimal management of ACS patients with confirmed or suspected SARS-CoV-2 infection.

Oral anticoagulation and clinical outcomes in COVID-19: An Italian multicenter experience.

BACKGROUND: Since the body of evidence addressing the coagulation derangements caused by Coronavirus disease (COVID-19) has been constantly growing, we investigated whether pre-hospitalization oral anticoagulation (OAC) or in-hospital heparin treatment could have a protective role among COVID-19 patients. METHOD: In this cohort study, consecutive COVID-19 patients admitted to four different Italian Institutions were enrolled. Baseline demographic, clinical, laboratory, and radiological characteristics, as well as in-hospital treatment and outcomes were evaluated. The primary outcome was mortality. RESULTS: A total of 844 COVID-19 patients were enrolled as study cohort, n = 65 (7.7%) taking OACs prior to hospitalization. Regarding clinical outcomes, OAC patients developed acute hypoxemic respiratory failure (AHRF) more frequently than non-OAC patients as well as presenting a higher mortality rate (44.6% vs 19.8%, p < 0.001). At overall multivariate logistical regression, use of heparin (n = 394, 46.6%) was associated with a better chance of survival to hospital discharge (OR 0.60 [0.38-0.94], p < 0.001), in particular in patients with AHRF, with no association found with the use of OACs. In a sub-analysis, the highest mortality rate was found for AHRF patients when heparin was not administered. CONCLUSION: In our cohort, OACs appeared to be ineffective in reducing mortality rate, while heparin resulted to be a useful treatment when lung disease was sufficiently severe, potentially suggesting a crucial role of microthrombosis in severe COVID-19. Due to the relatively small number of COVID-19 patients treated with OACs included in our analysis and their higher number of comorbidities, larger studies are needed in order to confirm our findings.

Ventricular tachycardia storm management in a COVID-19 patient: a case report.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has been associated with myocardial involvement. Among cardiovascular manifestations, cardiac arrhythmias seem to be fairly common, although no specifics are reported in the literature. An increased risk of malignant ventricular arrhythmias and electrical storm (ES) has to be considered. CASE SUMMARY: We describe a 68-year-old patient with a previous history of coronary artery disease and severe left ventricular systolic disfunction, who presented to our emergency department describing cough, dizziness, fever, and shortness of breath. She was diagnosed with COVID-19 pneumonia, confirmed after three nasopharyngeal swabs. Ventricular tachycardia (VT) storm with multiple implantable cardioverter defibrillator (ICD) shocks was the presenting manifestation of cardiac involvement during the COVID-19 clinical course. A substrate-based VT catheter ablation procedure was successfully accomplished using a remote navigation system. The patient recovered from COVID-19 and did not experience further ICD interventions. DISCUSSION: To date, COVID-19 pneumonia associated with a VT storm as the main manifestation of cardiac involvement has never been reported. This case highlights the role of COVID-19 in precipitating ventricular arrhythmias in patients with ischaemic cardiomyopathy who were previously stable.