Elevated Brain Natriuretic Peptide Levels Research Articles

Atypical presentation of Andersen-Tawil syndrome: heart failure with reduced ejection without periodic paralysis or dysmorphic features

Background: Andersen-Tawil syndrome (ATS) is a rare autosomal dominant disorder caused by variants in the KCNJ2 gene. It is associated with periodic paralysis, dysmorphic features and cardiac arrhythmias. The syndrome exhibits incomplete penetrance, leading to a broad spectrum of clinical manifestations, making diagnosis challenging. Case description: A male in his mid-20s with class 3 obesity presented to the emergency department with a week-long history of worsening chest pain, orthopnoea and fatigue. His family history was significant for sudden cardiac death affecting both his mother and brother, with his father having died from complications of Wolff-Parkinson-White syndrome. Cardiovascular examination revealed an S3 heart sound and elevated brain natriuretic peptide levels at 875 pg/ml, with undetectable troponins; potassium level on admission was 3.6 mEq/l. An electrocardiogram showed normal sinus rhythm, first-degree heart block, left atrial enlargement, left bundle branch block and a prolonged QTc of 486 ms. A transthoracic echocardiogram demonstrated a 15-20% reduction in ejection fraction with global left ventricular hypokinesis and left atrial enlargement. Ultimately, he was diagnosed with non-ischaemic dilated cardiomyopathy and referred for genetic testing, which revealed a KCNJ2 variant. Shortly after discharge, he experienced a 55-second run of ventricular tachycardia, necessitating the placement of a single-chamber ICD. Currently, the patient remains on guideline-directed medical therapy and is listed for a heart transplant. Conclusions: Dilated cardiomyopathy, although a rare manifestation in ATS, can profoundly increase the risk of fatal arrythmias, necessitating the need for a low threshold of suspicion, to ensure timely diagnosis and management.

Abstract 4127345: National Cohort Study on Hypertensive Disorders of Pregnancy Among Women with Congenital Heart Disease: Insights from Multiple Centers

Background: Hypertensive disorders of pregnancy (HDP) are among the primary reasons for maternal and perinatal deaths globally. Encompassing chronic hypertension, pregnancy induced hypertension (PIH), and preeclampsia, HDP are among the most frequent complications encountered during pregnancy. Considering the emerging congenital heart disease (CHD) population globally, research on HDP in pregnancies with CHD is urgently needed. Methods: Outcomes for 2220 pregnant women with CHD were evaluated retrospectively from 1993 to 2016 and prospectively from 2017 to 2019 from 7 tertiary hospitals. Maternal death, cardiac complications, obstetric and offspring complications of completed pregnancies and their demographics, cardiac characteristics, and comorbidities were collected. To identify the risk factors for HDP, univariate and multivariate analysis were performed through logistic regression. Results: Of 2220 completed pregnancies with CHD from 7 tertiary institutions, 77 women had PIH, and 76 women had preeclampsia. The main CHD diagnosis of patients with PIH was shunt lesion (including ASD, VSD, and PDA), left heart abnormality (including AS/AI, BAV, and COA), and single ventricle (SV). The main CHD diagnosis of patients with preeclampsia was shunt lesion (including ASD, VSD, and PDA), left heart abnormality (including AS/AI and MS/MI), and right heart abnormality (including TOF, PS/PAS/PI, DORV and DCRV). In parturients with PIH, the mortality and incidence of heart failure were 2.60% and 15.58%, respectively. In parturients with preeclampsia, the mortality and incidence of heart failure were 6.58% and 23.68%, respectively. Pregnancies with HDP had a significantly higher incidence of adverse maternal and offspring events than pregnancies without HDP. Independent risk factors for HDP included multiple gestation, use of medically assisted reproduction, having elevated brain natriuretic peptide (BNP) level, delayed first ANC visit, and absence of strict antenatal supervision. Conclusion: In summary, the presence of HDP in women with CHD significantly increased the risk of mortality and morbidity for both the mother and the child, particularly in cases involving preeclampsia.

Prognostic role of right ventricular-pulmonary artery coupling assessed by TAPSE/PASP ratio in patients with heart failure and mildly reduced ejection fraction

Abstract Background The development of right ventricular (RV)-pulmonary arterial (PA) coupling has resulted in a novel and comprehensive index for evaluating RV function in relation to the underlying RV afterload. In patients with heart failure (HF), it is acknowledged that RV-PA uncoupling are features that are associated with poor outcome. The RV-PA coupling index can be readily assessed non-invasively using the ratio of two standard echocardiographic measurements: tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP). However, few studies have defined the prognostic impact of the TAPSE/PASP ratio in patients with HF and mildly reduced EF (HFmrEF). Methods From the prospective cohort study of 1,410 hospitalized HF patients (age 68+/-15, men 62%) between August 2015 and September 2019, this study enrolled 191 HFmrEF (i.e., left ventricular ejection fraction (LVEF) 41–49%) patients whose TAPSE and PASP were measured during hospitalization and discharged alive. We studied the prognostic impact of TAPSE/PASP ratio on HFmrEF patients using by cut-off value obtained from receiver operating characteristic (ROC) analysis. The primary and secondary endpoints was defined as the all-cause death and HF re-hospitalization after discharge, respectively. Results During median follow-up of 38 [23–52] months, 48 patients (25%) died. The deceased patients had a significantly older (median 75 vs. 71 years, p<0.05), higher rate of ischemic heart disease (50% vs. 23%, p<0.05), elevated brain natriuretic peptide levels (325 vs. 159 pg/ml, p<0.05) and lower rate of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (65% vs. 80%, p<0.05) at discharge. In the ROC analysis, the cut-off value of TAPSE/PASP ratio for mortality was 0.46. Patients with TAPSE/PASP ≤0.46 had a significantly higher all-cause mortality (log-rank p<0.05) and had a tendency of higher rate of HF re-hospitalization than patients with TAPSE/PASP >0.46 (log-rank p=0.06) (Figure). Using multivariate analysis, the lower TAPSE/PASP ratio had an independent predictive value of prognosis in patients with HFmrEF (hazard ratio 2.16, 95% confidence interval; 1.08–3.92, p<0.05) (Table). Conclusion The TAPSE/PASP ratio has a significant prognostic value in patients with HFmrEF. The RV-PA uncoupling assessed by TAPSE/PASP ratio might be useful for risk assessment in patients with HFmrEF.

Residual congestion in acute decompensated heart failure: A novel approach through microvascular imaging of renal circulation

Abstract Background In patients admitted for acute decompensated heart failure (ADHF), residual congestion at discharge is associated with adverse clinical outcomes. Traditionally, the extent of congestion has been inferred from central venous pressure, but it has also been highlighted that this is insufficient for a comprehensive evaluation of residual congestion. On the other hand, renal congestion is an important finding of organ congestion, and Superb Microvascular Imaging (SMI), a technique that reveals minute flow details, is promising for assessing renal circulation. We hypothesized that in patients with ADHF, assessment of renal circulation using SMI may be superior to conventional methods in assessing residual congestion. Methods In this prospective study, we enrolled 45 consecutive patients admitted with ADHF. We performed comprehensive evaluations including blood tests, echocardiography, and renal ultrasonography using SMI. The vascular index (VI), as measured by SMI, was calculated as the percentage of blood flow signal area in the region of interest. Subsequently, we calculated the intra-renal perfusion index (IRPI), representing cyclic variation in VI, as (maximum VI - minimum VI) within one cardiac cycle, divided by the maximum VI (Figure). Brain Natriuretic Peptide (BNP) levels were utilized to evaluate the state of decongestion. Results At discharge, the mean IRPI was 0.61±0.04, while the median BNP levels were 204.9 pg/ml (interquartile range: 102.7, 428.2). Patients exhibiting elevated log BNP levels at discharge (>2.31, based on median value) displayed significantly higher IRPI values [0.61(0.49, 0.86) vs 0.53(0.35, 0.59), p=0.02] and were older (80.8±8.5 vs 70.3±14.9 years, p=0.010). However, no significant differences were observed regarding laboratory parameters including hematocrit and creatinine levels, as well as echocardiographic parameters such as ejection fraction, E/e' ratio, and estimated right atrial pressure (RAP). Moreover, at discharge, creatinine levels (p=0.56) and estimated RAP (p=0.06) exhibited no significant correlation with IRPI. Conclusion Renal circulation evaluated by SMI may serve as a useful indicator of the extent of residual congestion at discharge compared to blood tests and echocardiographic estimates of right atrial pressure in patients admitted for ADHF.

Predictors of late recurrence after second catheter ablation for persistent atrial fibrillation

BackgroundLittle has been reported on the predictors of late recurrence (LR) after second radiofrequency catheter ablation (RFCA) for persistent atrial fibrillation (AF). ObjectiveThis study aimed to identify the predictors of LR after second RFCA in patients with persistent AF. MethodsWe retrospectively analyzed 123 patients who underwent a second RFCA because of LR after the initial RFCA for persistent AF. LR was defined as a recurrence of atrial tachyarrhythmia >3 months after the ablation procedure. The initial RFCA included pulmonary vein isolation alone or pulmonary vein isolation plus cavotricuspid isthmus block. The predictors of LR were evaluated by the Cox proportional hazards model. ResultsIn the univariate analysis, elevated brain natriuretic peptide levels, absence of pulmonary vein reconnections at the beginning of the second RFCA, and presence of early recurrence (ER, defined as a recurrence of atrial tachyarrhythmia within 3 months) after the second RFCA were associated with LR (P = .025, P = .018, and P < .001, respectively). The multivariate analysis revealed that absence of pulmonary vein reconnections and presence of ER were independent predictors of LR after the second RFCA (P = .004 and P < .001, respectively). ConclusionAbsence of pulmonary vein reconnections and presence of ER were strongly associated with LR after the second RFCA in patients with persistent AF.

Pediatric cirrhotic cardiomyopathy: literature review and effect size estimations of selected parameters

Liver cirrhosis is a significant global health concern, and cirrhotic cardiomyopathy (CCM) is a notable complication affecting both adults and children. While CCM is well-studied in adults, understanding its manifestation and diagnostic criteria in pediatric patients remains a challenge. This review explores the evidence for structural and functional cardiac alterations in children with liver cirrhosis. Structural abnormalities, including increased left ventricular mass index (LVMI) and altered left ventricular wall thickness ratios, are prevalent in pediatric CCM. These abnormalities persist even after liver transplantation, highlighting the systemic impact of liver disease. Evidence suggests that altered systolic and diastolic function, as well as electrocardiographic abnormalities such as prolonged QT intervals, are common in pediatric CCM. Blood biomarkers, including brain natriuretic peptide (BNP) and troponin levels, offer insights into cardiac function in pediatric cirrhotic patients. Elevated BNP levels correlate with adverse outcomes, indicating its potential as a prognostic marker. However, further research is needed to elucidate the diagnostic utility of these biomarkers in pediatric CCM. Conclusion: This review provides estimates of the standardized mean difference among selected cardiac parameters in children with and without cirrhosis. Tailored diagnostic criteria and comprehensive assessment methods will be essential for accurate diagnosis and effective management of pediatric CCM. What is Known:• CCM adds to the burden of care of patients with cirrhosis.• Diagnostic criteria for adults are evolving, but there are no specific criteria for pediatric CCM.What is New:• Cardiac function in children with cirrhosis indicates some parameters not considered in adults are altered.• Effect size estimations for certain parameters provide a guideline for future research into pediatric CCM.

Predicting elevated natriuretic peptide in chest radiography: emerging utilization gap for artificial intelligence.

This study assessed an artificial intelligence (AI) model's performance in predicting elevated brain natriuretic peptide (BNP) levels from chest radiograms and its effect on diagnostic performance among healthcare professionals. Patients who underwent chest radiography and BNP testing on the same day were included. Data were sourced from two hospitals: one for model development, and the other for external testing. Two final ensemble models were developed to predict elevated BNP levels of ≥ 200 pg/mL and ≥ 100 pg/mL, respectively. Humans were evaluated to predict elevated BNP levels, followed by the same test, referring to the AI model's predictions. A total of 8390 images were collected for model creation, and 1713 images, for tests. The AI model achieved an accuracy of 0.855, precision of 0.873, sensitivity of 0.827, specificity of 0.882, f1 score of 0.850, and receiver-operating-characteristics area-under-curve of 0.929. The accuracy of the testing by 35 participants significantly improved from 0.708 ± 0.049 to 0.829 ± 0.069 (P < 0.001) with the AI assistance (an accuracy of 0.920). Without the AI assistance, the accuracy of the veterans in the medical career was higher than that of early-career professionals (0.728 ± 0.051 vs. 0.692 ± 0.042, P = 0.030); however, with the AI assistance, the accuracy of the early-career professionals was rather higher than that of the veterans (0.851 ± 0.074 vs. 0.803 ± 0.054, P = 0.033). The AI model can predict elevated BNP levels from chest radiograms and has the potential to improve human performance. The gap in utilizing new tools represents one of the emerging issues.

Detection of microemboli in patients with acute ischaemic stroke and atrial fibrillation suggests poor functional outcome.

We investigated the burden of microembolic signals (MES) in patients with acute ischaemic stroke (AIS) and atrial fibrillation (AF), assessing their impact on functional outcomes. This multicentre international prospective cohort study involved patients with AIS and either a known or newly diagnosed anticoagulant-naïve AF. All centres utilised the same transcranial Doppler machine for 1-h monitoring with bilateral 2 MHz probes within 24 h of symptom onset. Recordings underwent MES analysis by a blinded central reader. The primary objectives were to ascertain the MES proportion and its association with functional outcomes assessed by the modified Rankin scale (mRS) score at 90 days. Between September 2019 and May 2021, we enrolled 61 patients, with a median age of 78 years (interquartile range 73-83) and a median stroke severity score of 11 (interquartile range 4-18). MES were observed in 14 patients (23%), predominantly unilateral (12/14, 86%), with a median rate of 6 counts/hour (interquartile range 4-18). MES occurrence was higher post-thrombectomy and among those with elevated brain natriuretic peptide levels (p < 0.05). A worse mRS score of 3-6 was more frequent in patients with MES, occurring in 11/14 (79%), compared to those without MES, 20/47 (43%), with an adjusted odds ratio of 5.04 (95% CI, 1.15-39.4), p = 0.04. Nearly a quarter of patients with AIS and AF exhibited silent microembolization after the index event. Detecting MES within 24 h post-stroke (using transcranial Doppler) could signify a marker of poor functional outcomes. Subsequent trials will assess if very early antithrombotic treatment might enhance outcomes in this highly selective group of cardioembolic stroke patients. (Clinicaltrials.gov ID: NCT06018090).

Assessment of biomarkers and clinical parameters as predictors of survival in patients with chagasic heart failure.

Chagas disease, endemic in Latin America and spreading globally due to emigration, has a significant health burden, particularly in relation to chagasic heart failure (HF). Chagasic cardiomyopathy (CCM) is characterized by chronic inflammatory myocardial disease. This study aimed to identify inflammatory parameters and biomarkers that could aid in the management of patients with chagasic HF. A cohort study was conducted at a tertiary cardiology single-center over a mean follow-up period of 2.4 years. The study included patients with HF secondary to CCM enrolled between October 2013 and July 2017. Various clinical parameters, echocardiography findings, parasitemia status, brain natriuretic peptide (BNP) and troponin T (TnT) levels, and inflammatory biomarkers (IL-6, IL-10, IL-12p70, IL-17A, adiponectin, and IFN-γ) were assessed. The study encompassed a cohort of 103 patients, with a median age of 53 years and 70% being male. The left ventricular ejection fraction (LVEF) was 28%, with 40% of patients classified as NYHA II functional class. The median BNP level was 291 pg/ml. The observed mortality rate during the study period was 38.8%. Predictors of lower survival were identified as elevated levels of BNP, TnT, reduced LVEF, and increased adiponectin (thresholds: BNP > 309 pg/ml, TnT > 27.5 ng/ml, LVEF < 25.5%, adiponectin > 38 μg/mL). Notably, there was no evidence indicating a relationship between parasitemia and the inflammatory parameters with lower survival in these patients, including INF-γ, IL-6, IL-10, IL12-(p70), and IL17a. Despite the presence of a chronic inflammatory process, the evaluated inflammatory biomarkers in this cohort were not predictive of survival in patients with chagasic HF with reduced ejection fraction (HFrEF). However, reduced LVEF, elevated BNP, adiponectin levels, and troponin T were identified as predictors of lower survival in these patients.

Biomarkers for Risk Stratification in Patients With Type A Acute Aortic Dissection

Type A acute aortic dissection (AAD) is a fatal disease and thus, accurate and objective risk stratification is essential. In the present study, we evaluated a prognostic value of readily available and assessable biomarkers in patients with type A AAD. This was a retrospective, multicenter, observational study. A total of 703 patients with type A AAD diagnosed by contrast-enhanced computed tomography were included. Therapeutic strategies were left to the physician's discretion in a real-world clinical setting. The prognostic value for in-hospital mortality was examined in 15 circulating biomarkers on admission which are routinely available in clinical practice. Of the 703 patients, 126 (17.9%) died during the hospitalization. Among the 15 biomarkers, the multivariable analysis identified positive cardiac troponin, a low total bilirubin (T-Bil) level, and elevated levels of brain natriuretic peptide (BNP) and lactate dehydrogenase (LDH) as significant predictors of in-hospital death. Receiver operating characteristics curve analysis showed that these 4 biomarkers had an independent additive prognostic value. With the cut-off values of T-Bil, BNP, and LDH in combination with positive troponin, the increase in the number of positive biomarkers was progressively associated with higher in-hospital mortality from 1.3% to 9.8%, 20.5%, 36.4%, and 75.0% (p<0.001). In conclusion, among patients with type A AAD, positive cardiac troponin, a low T-Bil level, and elevated levels of BNP and LDH on admission were related to higher in-hospital mortality with an incremental prognostic value, suggesting that the readily available and assessable biomarkers can aid in decision-making in therapeutic strategies.

Abstract 11601: Does Artificial Intelligence Dream of Elevated Natriuretic Peptide in Chest Radiography?

Introduction: Heart failure pandemic is a medical issue, and its diagnosis can be challenging. Hypothesis: To assess the hypothesis that the artificial intelligence (AI) model for predicting elevated brain natriuretic peptide (BNP) levels from chest X-ray images has sufficient performance and could improve the diagnostic performance of human. Methods: Patients who underwent chest radiography and BNP testing on the same day were enrolled in this study. The chest X-ray images were labeled based on plasma BNP levels &gt;= 200 pg/mL. We trained models that predicted the label, and the final ensemble model was constructed. Humans were trained and tested to predict labels, followed by the same test, referring to the prediction of the AI model. Diagnostic performance was assessed. Results: Among the 1607 patients, 10103 chest X-ray images and BNP values were collected. We assembled 31 models as the final model with an accuracy of 0.855, precision of 0.873, recall of 0.827, receiver-operating-characteristics area-under-curve (AUC) of 0.929, and precision-recall AUC of 0.934. The accuracy of the testing by 35 individuals significantly improved from 0.708±0.049 to 0.829±0.069 (P &amp;lt; 0.001) with AI assistance. The accuracy of the experts was higher than that of non-experts (0.692±0.042 vs. 0.728±0.051, P = 0.030); however, with the AI assistance, the accuracy of the non-experts was rather higher than that of the experts (0.851±0.074 vs. 0.803±0.054, P = 0.033). Conclusions: The AI model can predict elevated BNP levels from chest X-ray images and could improve the diagnostic performance of humans.

Differential diagnosis for multiple systemic inflammatory syndrome in children: clinical and laboratory clues

Objectives: We aimed to identify biochemical markers and clinical findings with high sensitivity and specificity that can be used in the differential diagnosis of patients suspected of having Multisystem Inflammatory Syndrome in Children (MISC) in the pediatric emergency department (PED). Moreover, we also examined early warning signs for predicting severe MIS-C patients requiring admission to intensive care unit (ICU). Methods: We conducted a retrospective analysis of patients presenting to the PED with suspected MIS-C. Patient records were assessed for initial complaints, physical examination findings, laboratory and ımaging test results, diagnoses, and follow-up plans. Patients diagnosed with MIS-C were categorized as the MIS-C group, while others were categorized as the non-MIS-C group. Comparisons were made between these two groups. Results: A total of 266 patients were included, with 68 diagnosed with COVID-19-associated MIS-C, including 20 monitored in the pediatric ICU. MIS-C patients had higher mean age, hospitalization, and ICU admission rates compared to non-MIS-C. MIS-C group showed higher prevalence of respiratory symptoms, hematological involvement, and shock. We observed lymphopenia, thrombocytopenia, hyponatremia, and elevated levels of blood C-reactive protein (CRP), procalcitonin, triglycerides, troponin, Brain Natriuretic Peptide (BNP), D-dimer, and fibrinogen in the MIS-C group. ICU patients had higher procalcitonin, aspartate aminotransferase, alanine aminotransferase, triglycerides, troponin, BNP, and ferritin levels, and lower sodium levels. Conclusions: COVID-19-associated MIS-C group had higher rates of respiratory symptoms, hematological involvement, and shock. Lymphopenia, thrombocytopenia, elevated CRP, and D-dimer can guide MIS-C differential diagnosis. Additional tests (procalcitonin, troponin, BNP, triglycerides, ferritin) are recommended for high-suspicion cases. Patients with elevated BNP levels may require ICU admission.

Biochemical, Serological and Immunological Tests for Diagnosis of Coronavirus Disease 2019 (COVID-19) Patients: A Comprehensive Systematic Review and Meta-analysis.

Recent studies have suggested the role of primary laboratory tests in addition to clinical symptoms for patients suspected to have coronavirus disease 2019 (COVID-19), which play a significant role in the diagnosis of COVID-19. However, the results of these studies are contradictory. The present study was conducted to evaluate biochemical, serological, and immunological tests for the diagnosis of COVID-19 patients. This study was presented in accordance with the PRISMA protocol. This protocol is registered with the code CRD42019145410 in PROSPERO. We conducted a comprehensive literature search in databases, including Web of Science, PubMed/Medline, CINAHL Scopus, Cochrane Library, EMBASE, Science Direct, and EBSCO to find citations from the beginning of January 2019 until the beginning of April 2020 without any restrictions. Finally, 51 studies, including 5,490 COVID-19 patients, were included in the present metaanalysis. The prevalence of different factors observed in laboratory findings was as follows: the prevalence of lymphopenia in patients with COVID-19 accounted for 51.6% (95% CI: 44.0-59.1), elevated C-reactive protein (CRP) was 63.6% (95% CI: 57.0-69.8), elevated erythrocyte sedimentation rate (ESR) was 62.5% (95% CI: 50.1-73.5), elevated tumor necrosis factor alpha (TNFα) was 28.7% (95% CI: 9.0-62.1), elevated serum amyloid-A level was 74.7% (95% CI: 50.0-89.7), elevated procalcitonin level was 72.6% (95% CI: 58.1-83.5), elevated interleukin-6 level was 59.9% (95% CI: 48.2-70.5), reduced CD3 level was 68.3% (95% CI: 50.1-82.2), reduced CD4 level was 62.0% (95% CI: 51.1- 71.6), elevated lactate dehydrogenase (LDH) level accounted for 53.1% (95% CI: 43.6-62.4), elevated brain natriuretic peptide (BNP) accounted for 48.9% (95% CI: 30.4-67.7), reduced albumin and reduced pre-albumin levels in patients with COVID-19 were estimated to be 54.7% (95% CI: 38.1-70.2) and 49.0% (95% CI: 26.6-71.8), and D-dimer level was 44.9% (95% CI: 31.0-59.6). The results show lymphopenia, elevated ESR level, elevated CRP level, elevated serum amyloid-A, elevated TNFα, elevated procalcitonin level, elevated interleukin-6 level, reduced CD3, reduced CD4, elevated BNP, elevated LDH, reduced albumin, reduced pre-albumin, and elevated Ddimer levels as the most common findings at the time of admission.

COVID-19-Associated Acute Myocarditis: Risk Factors, Clinical Outcomes, and Implications for Early Detection and Management.

Background The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel coronavirus causing acute respiratory distress with multisystem complications, including cardiac complications. Acute myocarditis is onepossible complicationof coronavirus disease 2019 (COVID-19). Previous studies revealed that mortality from COVID-19 was higher in patients with cardiac complications. Objectives We aim to identify if patients with COVID-19 developmyocarditisand if this condition is associated with an increased incidence of ventilatory support and mortality. We also aim to identify if preexisting cardiac conditions are associated with an increased incidence of ventilatory support and mortality in those who developed COVID-19. Methods This is a multicenter, retrospective study including patients aged 18 years and older. Statistical analysis was performed to compare the incidence of in-hospital mortality and ventilatory support in COVID-19-positive patients with and without myocarditis. In this study, we defined myocarditis using elevated troponin-T (TnT) and brain natriuretic peptide (BNP) levels as proxy. Results A total of 8,162 patients with a positive COVID-19 polymerase chain reaction (PCR) testwere identified. Of those, 1,643 (20.1%) were found to have new-onset acute myocarditis. The risk of ventilation and mortality in these patients was significantly elevated (p<0.001) compared to patients without acute myocarditis. Underlying heart failure was associated with increased odds of in-hospital mortality, which was 1.6 times greater when compared to patients without heart failure. The odds of in-hospital mortality were 2.33 times as likely for those who had non-ischemic cardiomyopathy as opposed to those who did not. Conclusion Myocarditis is a serious and potentially fatal complication of COVID-19. The results of this study highlightthe importance of routine testing of troponin-T and BNP levels to identify those at risk. Furthermore, underlying heart conditions are associated with a worse outcome, and those patients should be watched closely.

Systematic review and meta-analysis on the serological, immunological, and cardiac parameters of the multisystem inflammatory syndrome (MIS-C) associated with SARS-CoV-2 infection.

Diverse clinical and laboratory features of multisystem inflammatory syndrome (MIS-C) have been reported in the literature. Despite the worldwide distribution, systemic studies regarding the laboratory results do not exist. Therefore, we aimed to perform this systematic review and meta-analysis to evaluate the serological, immunological, and cardiac parameters of the MIS-C associated with SARS-CoV-2 infection. We searched the PubMed, Scopus, and Web of Science databases using specific keywords for any papers published in English since the disease onset and the first report until July 19, 2020. The inclusion criteria were children <21 years diagnosed with MIS-C without any limitation on defining criteria.Forty-eight studies were included in the final analysis, with a total population size of 3543 children with MIS-C. The median age of the included patients was 8.3 (6.7-9) years. The pooled prevalence of male patients was 59% (95% CI: 56%-61%) and 62% (95% CI: 55%-69%) were admitted in ICU. The pooled prevalence of positive SARS-CoV-2 RT-PCR, SARS-CoV-2 IgM, and SARS-CoV-2 IgG antibody tests was 33% (95% CI: 27%-40%), 39% (95% CI: 22%-58%) and 81% (95% CI: 76%-86%), respectively. The positivity rate of the inflammatory markers was as follows: CRP (96%, 95% CI: 90%-100%), d-dimer (87%, 95% CI: 81%-93%), ESR (81%, 95% CI: 74%-87%), procalcitonin (88%, 95% CI: 76%-97%), ferritin (79%, 95% CI: 69%-87%), and fibrinogen (77%, 95% CI: 70%-84%). The pooled prevalence of elevated brain natriuretic peptide (BNP) level, pro-BNP, and troponin were found in 60% (95% CI: 44%-75%), 87% (95% CI: 75%-96%), and 55% (95% CI: 45%-64%), respectively. The majority of patients had positive SARS-CoV-2 IgG test. Nearly one-third of the cases showed negative RT-PCR results. Cardiac and inflammatory markers were elevated in the majority of cases. These findings suggest that hyperinflammation and cardiac dysfunction are common complications of MIS-C.

Predictors and impact of postoperative atrial fibrillation following thoracic surgery: a state-of-the-art review.

This review of 19 studies (39,783 patients) of atrial fibrillation after thoracic surgery addresses the pathophysiology, incidence, and consequences of atrial fibrillation in this population, as well as its prevention and management. Interestingly, atrial fibrillation was most often identified in patients not previously known to have the disease. Rhythm control with amiodarone was the most commonly used treatment and nearly all patients were discharged in sinus rhythm. Major predictors were age; male sex; history of atrial fibrillation; congestive heart failure; left atrial enlargement; elevated brain natriuretic peptide level; and the invasiveness of procedures. Overall, patients with atrial fibrillation stayed 3 days longer in hospital. We also discuss the importance of standardising research on this subject and provide recommendations that might mitigate the impact postoperative atrial fibrillation on hospital resources.

Tight vs liberal control of mild postpartum hypertension: a randomized controlled trial

High-quality evidence to inform the management of postpartum hypertension, including the optimal blood pressure threshold to initiate therapy, is lacking. Randomized trials have been conducted in pregnancy, but there are no published trials to guide management in the postpartum period. This study aimed to test the hypothesis that initiating antihypertensive therapy in the postpartum period at a threshold of 140/90 mm Hg would result in less maternal morbidity than initiating therapy at a threshold of 150/95 mm Hg. We performed a pragmatic multicenter randomized controlled trial of patients aged 18 to 55 years with postpartum hypertension. Patients with chronic hypertension, gestational hypertension, and preeclampsia without severe features were randomized to 1 of 2 blood pressure thresholds to initiate treatment: persistent blood pressure of ≥150/95 mm Hg (institutional standard or "liberal control" group) or ≥140/90 mm Hg (intervention or "tight control" group). Our primary outcome was composite maternal morbidity defined as: severe hypertension (blood pressure ≥160/110 mm Hg) or preeclampsia with severe features, the need for a second antihypertensive agent, postpartum hospitalization >4 days, and maternal adverse outcome secondary to hypertension as evidenced by pulmonary edema, acute kidney injury (creatinine level ≥1.1 mg/dL), cardiac dysfunction (eg, elevated brain natriuretic peptide level) or cardiomyopathy, posterior reversible encephalopathy syndrome, cerebrovascular accident, or admission to an intensive care unit. Secondary outcomes included hospital readmission for hypertension, persistence of hypertension beyond 14 days, medication side effects, and time to blood pressure control. We calculated that 256 women would provide 90% power to detect a relative 50% reduction in the primary outcome from 36% in the standard blood pressure threshold group to 18%, with a 2-sided alpha set at 0.05 for significance. Data were analyzed using R statistical software. A total of 256 patients were randomized, including 128 to the "tight control" group (140/90 mm Hg) and 128 to the "liberal control" group (150/95 mm Hg). Patients in the "tight control" group had a higher body mass index at delivery (37.1±9.4 vs 34.9±8.1; P=.04); other demographic and obstetrical characteristics were similar between groups. The rate of the primary outcome was similar between groups (8.6% vs 11.7%; P=.41; relative risk, 0.73; 95% confidence interval, 0.35-1.53). The rates of all secondary outcomes and the individual components of the primary and secondary outcome measures were also similar between groups. In the postpartum period, initiation of antihypertensive therapy at a lower blood pressure threshold of 140/90 mm Hg did not decrease maternal morbidity or improve outcomes compared with a threshold of 150/95 mm Hg.

Abstract 11217: Pregnancy Outcomes in Unrepaired Congenital Heart Disease a Multicenter Experience From 1272 Patients

Introduction: The prevalence of unrepaired congenital heart disease (CHD) before pregnancy is tremendously high, especially in developing countries. And their maternal outcomes haven’t been investigated at scale in a contemporaneous population. This study describes the maternal outcomes among pregnancies with unrepaired CHD. Methods: From 1993 to 2019, we nationally enrolled 2,220 CHD pregnancies from 7 tertiary centers. Patients were subdivided into two groups: pregnancies with unrepaired CHD and with repaired CHD. Maternal and offspring outcomes of completed pregnancies and their demographics, antenatal cardiac situation, and comorbidities were collected. To identify the risk factors for cardiac outcomes, univariate and multivariate analyses were performed through logistic regression. Results: Of 2,220 completed pregnancies with CHD, 1,272 women had unrepaired CHD. The main CHD diagnosis of unrepaired CHD patients was shunt lesion (64.54%). In parturients with unrepaired CHD, the incidence of mortality and heart failure were 1.73% and 14.94%, respectively. Pregnancies with unrepaired CHD had a significantly higher incidence of adverse maternal and offspring events than pregnancies with repaired CHD. Preterm delivery (22.56%) and low birth weight (21.15%) were the most common obstetric and offspring complications. Independent risk factors for maternal cardiac events included having a New York Heart Association functional class III-IV, elevated brain natriuretic peptide level, pulmonary hypertension, delayed first antenatal care visit, absence of strict antenatal supervision, and lack of multidisciplinary team management. Conclusions: In conclusion, pregnant women with unrepaired CHD were associated with significant morbidity and mortality. And they had significantly worse maternal and offspring outcomes than pregnant women with repaired CHD.

The influence of atrial fibrillation on the prognostic value of brain natriuretic peptide (BNP) in risk assesment of paroxysmal ventricular tachycardia

Introduction. Brain natriuretic peptide (BNP) as marker of higher left ventricular myocardial mechanical stress has a strong prognostic value in patients with heart failure (HF). Elevated BNP levels are associated with the of malignant ventricular arrhythmias. Atrial fibrillation (AF) is known to futher elevate BNP levels and this can influence on BNP prognostic value. The aim of the study was to assess the predictive value of BNP in risk assessment of paroxysmal ventricular tachycardia (PVT) in patients with HF and AF. Materials and methods. Totally, 92 patients with sustained or persistent AF, HF with left ventricular ejection fraction &lt; 50 %. All patients underwent transthoratic echocardiography; 24-hour ECG monitoring to assess the ventricular arrhythmia burden. BNP determination by enzyme immunoassay in venous blood serum. Results. Patients with HF, AF and PVTcompared with patients with HF and AF without PVT have higher levels of BNP (298,8 [149; 500,6] pg/ml versus 152 [145,7; 335,4] pg/ml, р = 0,02). There is a significant positive correlation between the level of BNP and the amount of PVT per 24 hours (r = 0,26; р &lt; 0,05). Increased BNP levels are associated with an increased risk of VPT, OR = 3,71 [95 % CI 1,2 to 13,1]. Discussion. BNP is a novel biomarker to improve risk stratification of sudden cardiac death not only for patients in sinus rhythm but for patients with AF. Conclusions. BNP has a predictive value in risk assessment of PVT in patients with HF and AF.

Prognostic value of brain natriuretic peptide in COVID-19 with or without acute heart failure

Abstract Background Although Brain Natriuretic Peptide (BNP) provides strong prognostic information of an unfavorable outcome in patients with acute heart failure (AHF), there is little information of its relevance as a biomarker for outcomes in COVID-19 and its complications Purpose To evaluate the association of increased BNP levels with complications and in-hospital mortality in a cohort of hospitalized COVID-19 patients. Methods The study included COVID-19 patients with data on BNP levels included in the ISACS COVID-19 registry. The population was categorized according to the presence of peak BNP levels ≥100 pg/mL during hospitalization. Primary outcomes included in-hospital mortality, AHF or acute respiratory failure (ARF, defined as PiO2/FiO2&amp;lt;300 mmHg or need for mechanical ventilation). Calculations were conducted using age and sex-adjusted multivariable logistic regression analyses. Results were also stratified according to presence or absence of cardiovascular disease (CVD) history. Differences between subgroups were verified for statistical significance using test for interaction. Results Of the 1152 patients included in the study, 615 (53.4%) had elevated BNP levels. These subjects were older (69.9±13.8 vs 59.1±16.8, p-value&amp;lt;0.001), had higher rates of cardiovascular risk factors (82.9% vs 57.7%, p-value&amp;lt;0.001) and presented more frequently with a prior history of CVD (either ischemic heart disease, cerebrovascular disease, venous thromboembolism, atrial fibrillation or a history of revascularization) (50.1% vs 27.5%, p-value&amp;lt;0.001). No sex differences were observed. When considering outcomes, BNP levels ≥100 pg/mL were associated with increased rates of in-hospital mortality (32.9% vs 4.9%, p-value&amp;lt;0.001), even after adjustment for demographic characteristics (OR: 7.35; 95% CI: 4.75–11.40; p-value&amp;lt;0.001). High BNP levels were also strongly associated with an increased risk of AHF (OR 19.9; 95% CI 8.6–45.9; p-value&amp;lt;0.001), a correlation that persisted both in patients with and without a prior CVD history (p for interaction=0.29). Of note, patients with elevated BNP also had a higher likelihood of developing ARF (OR 2.7; 95% CI 2.1–3.6; p-value&amp;lt;0.001), even in absence of AHF (OR 3.00; 95% CI 2.20–4.1; p-value&amp;lt;0.001). Conclusions In COVID-19, blood BNP level not only appears to be predictor of in-hospital mortality and AHF but was also independently associated with an increased risk of ARF. This finding supports the routine use of BNP in all patients admitted to hospital for COVID-19, regardless of a prior history of CVD. Funding Acknowledgement Type of funding sources: None.