Hypertension as an Independent Risk Factor for In-Patient Mortality in Hospitalized COVID-19 Patients: A Multicenter Study.

Despite the lack of direct evidence that hypertension increases the likelihood of new infections, hypertension is known to be the most common comorbid condition in COVID-19 patients and also a major risk factor for severe COVID-19 infection. The literature review suggests that data is heterogeneous in terms of the association of hypertension with mortality. Hence, it remains a topic of interest whether hypertension is associated with COVID-19 disease severity and mortality. Herein, we perform a multicenter retrospective analysis to study hypertension as an independent risk for in-hospital mortality in hospitalized COVID-19 patients. This multicenter retrospective analysis included 515 COVID-19 patients hospitalized from March 1, 2020 to May 31, 2020. Patients were divided into two groups: hypertensive and normotensive. Demographic characteristics and laboratory data were collected, and in-hospital mortality was calculated in both groups. The overall mortality of the study population was 25.3% (130 of 514 patients) with 96 (73.8%) being hypertensive and 34 (26.2%) being normotensive (p-value of 0.01, statistically non-significant association). The mortality rate among the hypertensive was higher as compared to non-hypertensive; however, hypertensive patients were more likely to be old and have underlying comorbidities including obesity, diabetes mellitus, coronary artery disease, congestive heart failure, stroke, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and cancer. Therefore, multivariable logistic regression failed to show any significant association between hypertension and COVID-19 mortality. To our knowledge, few studies have shown an association between hypertension and COVID-19 mortality after adjusting confounding variables. Our study provides further evidence that hypertension is not an independent risk factor for in-hospital mortality when adjusted for other comorbidities in hospitalized COVID-19 patients.

Comparison of Outcomes for Non-ST Elevation Acute Myocardial Infarction in Weekday vs Weekend Admissions: The Weekend Effect.

Background: Recent literature shows that reduced staffing over the weekends in hospitals may compromise patient care with acute conditions like acute coronary syndrome (ACS). Objective: Our study evaluated differences in the outcomes between patients presenting with non-ST segment elevation acute coronary syndrome (NSTE-ACS) on weekends versus those coming on weekdays. Methods: A single-center retrospective study was performed on NSTE-ACS patients. Data were analyzed using SPSS version 22 to calculate an independent sample t-test value for significance between the two groups. Results: The mean DTB time for patients admitted over the weekend was significantly higher than those admitted over weekdays (p = 0.000). The mean peak troponin level and length of stay (LOS) for patients admitted over the weekends vs. weekdays was significantly higher by 5 ng/dL (9.71 ± 5.23 vs. 4.194 ± 2.60, p = 0.0001) and 24 h (72 ± 10 vs. 48 ± 6 h, p = 0.003), respectively. While the mean left ventricular ejection fraction (EF) of patients on discharge was lower by 5% for patients admitted over the weekend compared to patients admitted on weekdays (p = 0.001). Conclusion: NSTE-ACS patients admitted over the weekends have a significantly higher myocardial injury evidenced by an increased LOS, higher peak troponin levels, and reduced EF due to delayed PCI compared to weekday admissions.

Contemporary trends in the incidence of spontaneous coronary artery dissection (SCAD) - ethnic and household income disparities.

OBJECTIVES: Spontaneous coronary artery dissection (SCAD) may contribute to 35% of acute coronary syndrome among women ≤50 years of age. We aimed to investigate the overall incidence, as well as the trends of SCAD incidence based on race, household income, and the U.S. census regions utilizing the National Inpatient Sample. METHODS: In this retrospective cohort study the discharge data were extracted from the NIS using 9th and 10th revisions of the International Classification Disease for SCAD. RESULTS: We found that the incidence of SCAD is rising in all U.S. census regions, and patients were predominantly females. Overall crude incidence of SCAD per 1,000,000 discharges per year was found to be 4.95 (2010), 5.73 (2011), 5.34 (2012), 6.18 (2013), 7.64 (2014), 8.11 (2015), 14.58 (2016), and 14.81 (2017). There was a higher incidence of SCAD in white population and higher-income groups. Among U.S. census regions, West has had the highest incidence followed by the Northeast, Midwest, and South. Statistically significant differences were observed in year-to-year SCAD incidence among racial groups, household income quintiles, and U.S. census regions (P < 0.0001). CONCLUSION: Recent trends indicate that the incidence is highest among White race, highest household income quintile, and in U.S. CENS-R4 (Census Region 4: West). These findings defy classic racial trends in cardiovascular disease burden which need further discovery.

A Review of Left Ventricular Non-compaction Cardiomyopathy (LVNC).

Left ventricular non-compaction (LVNC) is a rare congenital phenotype defined by the presence of prominent left ventricular trabeculae, deep intertrabecular recesses (continuous with the ventricular cavity), and a thin compacted layer. The most common presentation of LVNC is dyspnea (60%), followed by palpitations (18%), chest pain (15%), syncope (9%), and prior stroke (3%). LVNC presenting with acute myocardial infarction (MI) has rarely been reported in the literature. A forty-one-years old female presented with substernal chest pain and exertional dyspnea. On physical examination, she was alert without any distress, her lungs and heart examination were within normal limits. Peripheral pulses were palpable and regular, and +1 peripheral pitting edema was noted. EKG showed normal sinus rhythm with premature atrial contractions (PACs), left axis deviation, and ST-segment and T wave changes suggestive of inferior wall ischemia. Troponin I level was found to be elevated, which peaked within 24 hours, Troponinmax 110.08 ng/ml. Transthoracic echocardiography showed moderate LV dilatation with severely reduced EF (15-20%), and diffuse LV hypokinesis with a grade III restrictive pattern. There was heavy trabeculation of LV involving 2/3rd LV endocardium and wall thickness with sinusoidal tunnels perpendicular to LV wall. These morphological findings met the diagnostic criteria of LVNC/NCM. LVNC presenting with acute myocardial infarction (MI) can be related to poor outcomes, however, more data is needed to establish the clinical implication of this presentation. Asymptomatic LVNC can be observed while symptomatic LVNC should be treated with standard guidelines of HF.

Heart Failure Patients and Implications of Obesity: A Single-Center Retrospective Study.

Background and objective The prevalence of heart failure (HF) is on the rise; currently, it affects around five million people in the United States (US) and the prevalence is expected to rise from 2.42% in 2012 to 2.97% in 2030. HF is a leading cause of hospitalizations and readmissions, accounting for a major economic burden to the US healthcare system. Obesity is a widely accepted risk factor of HF; however, data regarding its independent association with HF mortality and morbidity is heterogeneous. Globally, more than two-thirds of deaths attributable to high body mass index (BMI) are due to cardiovascular diseases (CVD). This study aimed to investigate the potential role of obesity (BMI >30 Kg/m2) in HF patients in terms of 30-day readmissions, in-hospital mortality, and the use of noninvasive positive pressure ventilation (NIPPV). Methods In this single-center, retrospective study, all adult (age: >18 years) patients who were hospitalized with a primary diagnosis of HF at the Abington Jefferson Hospital from January 2015 to January 2018 were included. Demographic characteristics were collected manually from electronic medical records. Outcomes were 30-day readmission due to HF, all-cause in-hospital mortality, and requirement for NIPPV. Multivariable logistic regression analysis was conducted to investigate the association of obesity with HF outcomes. Results A total of 1,000 patients were initially studied, of these 800 patients were included in the final analysis based on the inclusion criteria. Obese patients showed higher odds for 30-day readmissions and the use of NIPPV compared to non-obese patients. There was no significant difference in in-hospital mortality in obese vs. non-obese patients. Conclusions Based on our findings, BMI >30 Kg/m2 is an independent risk factor for HF readmissions. Additionally, our results highlight the importance of guidelines-directed medical therapy (GDMT) for HF exacerbation, a low threshold for use of NIPPV in obese patients, promotion of lifestyle modifications including weight loss, and early follow-up after discharge to prevent HF readmissions in the obese population.

Hard Palate Perforation in an Elderly Man With Dementia.

A 74-year-old male with a history of mild cognitive impairment presented to the emergency department with failure to thrive and generalized weakness. He was having difficulty swallowing leading to 30 pounds of unintentional weight loss in the last three months. His social history was significant for 12.5 pack-year smoking and drinking (two to three glasses of wine/day). The oral cavity examination revealed a large (3 × 2 cm2) defect with the erythematous border that encompassed the mid-palatal structures and emanated from the hard palate into his nasal cavity. Auto-immune work-up was negative. Palatal biopsy showed squamous cell carcinoma (SCC; well-differentiated). A diagnosis of locally advanced (stage IVa) oral cavity squamous cell carcinoma (OSCC) was made based on PET scan findings. A palatal obturator (prosthesis) was placed to improve his eating, prevent regurgitation. The patient opted for palliative care and did not want to pursue further treatment. He was discharged home with a regular follow-up visit.

Wrapped Left Anterior Descending Artery Presenting As Inferior Myocardial Infarction: Case Report and Review of the Literature.

Acute occlusion of the left anterior descending (LAD) coronary artery generally results in ST-segment elevation in the anterior leads of the electrocardiogram and reciprocal ST-segment depression in the inferior leads. We present a case of LAD occlusion presenting as inferior wall ST-segment elevation myocardial infarction.

Is There any Additional Benefit of Multiple Doses of Tocilizumab in COVID-19 Patients?

Many patients with coronavirus disease 2019 (COVID-19) have a hyperactive immune response (cytokine storm) which has been incriminated in multiorgan dysfunction (MOD). Interleukin-6 (IL-6) and granulocyte-macrophage colony-stimulating factor (GM-CSF) are the key cytokines involved in mediating systemic inflammation and triggering endothelial dysfunction. To limit these effects, IL-6 receptor inhibitors (IL6ri) have been used in COVID-19 patients. The best approach regarding the total number of doses in COVID-19 patients is still unclear. In this single-center retrospective study, we investigated if multiple doses of tocilizumab (TCZ) prevented deterioration of COVID-19 patients. Patients were divided into two cohorts based on the number of TCZ doses; cohort 1 (received one dose) and cohort 2 (received ≥ two doses). In both cohorts, all-cause-mortality was the primary outcome. Of 270 hospitalized patients with COVID-19, 81 patients received TCZ. Fifty patients received one dose of TCZ and 31 received ≥ two doses. All-cause-mortality in cohort 2 remained higher (41.9%) suggesting that there was no additional benefit of multiple doses of TCZ to prevent the primary outcome. In addition, multiple doses of TCZ did not change any other secondary outcome [(ICU admission, acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), acute cardiac injury (ACI), thrombotic events, septic shock, and total hospital stay].