Elevated Cardiac Biomarkers Research Articles

Cardiac Manifestations of Acute Febrile Illness Amongst Intensive Care Unit Patients

Background: There are various incidences of cardiac involvement in acute febrile illness (AFI). As the acute febrile illnesses are spreading, there is an increase in atypical cardiac manifestations ranging from asymptomatic bradycardia to life threatening manifestations like myocarditis and pericardial effusion. Objective: To determine cardiac manifestations of AFI amongst intensive care unit patients in rural populations. Methods: Twenty patients of AFI were studied between January 2021 to June 2021. Echocardiography (ECG), and cardiac enzymes were evaluated. Patients were from either gender from 15 to 60 years and were willing to sign consent. patients admitted with fever and on examination were found abnormal cardiac functions like hypotension, arrhythmia, hypertension, cardiac enzyme changes and reduced ejection fraction on 2D Echo. Patients with preexisting heart disease, cardioactive drugs affecting the heart rate were not involved in this study. Results: In total, 20 patients having cardiac manifestations with AFI were studied, out of which 9 cases presented with bradycardia, 3 cases presented with asymptomatic pericardial effusion, and 8 cases presented with ECG abnormalities such as narrow QRS complex, ST, and T changes. Conclusion: Cardiac Manifestations in adults with AFI were common, ranging from elevated cardiac biomarkers to myocarditis. Persistent shock despite adequate fluid resuscitation can be a crucial cardiac manifestation and should guide the treating physician towards underlying cardiac involvement such as systolic or diastolic dysfunction.

COVID-19 Pneumonia with Ischemic Heart Event After Neglect Yasser's COVID-19 Discrepancy Phenomenon and Its Regimen; The Seriousness Impact and Deterioration Outcome

Rationale: A novel COVID-19 is a multi-systemic serious worldwide pandemic. Undoubtedly, strict management with protocols and guidelines in the COVID-19 pneumonia is remarkable advice but its neglect may be leading to a critical event. Yasser’s COVID-19 Discrepancy phenomenon is a novel descriptive phenomenon that is always seen in all COVID-19 pneumonia. Initial dramatic improvement of the clinical status of COVID-19 pneumonic patient, not a simultaneously after the management, not a coincide with laboratory, radiological, and electrocardiographic workup. Patient Concerns: A 65-year-old married housewife Egyptian female patient was presented to the physician outpatient clinic with COVID-19 pneumonia that deteriorates after early spontaneous stoppage of all COVID-19 medications after the sense of generalized temporary improvement. Diagnosis: COVID-19 pneumonia with angina after neglect Yasser's COVID-19 discrepancy phenomenon and its regimen. Interventions: Electrocardiography, oxygenation, chest CT, and echocardiography. Outcomes: Initial good and dramatic outcome but, the worst outcome with deterioration had happened after early spontaneously stopped all COVID-19 medications. Lessons: The missed time, long-stay hospitalization, patient and governmental economic costs, and psychological stress on both patient and family are hazardous sequels due to neglect to follow Yasser’s COVID-19 Discrepancy phenomenon and its regimen. This is a typical applied example of this phenomenon. Female sex, unstable angina with coronary artery spasm, elevated cardiac biomarkers, a Wavy triple sign (Yasser’s sign) of hypocalcemia and COVID-19 pneumonia represent bad prognostic points and is indicating a high-risk condition.

Atypical Takotsubo Cardiomyopathy Secondary to COVID-19 Presenting Late as Chest Pain with Subsequent Late Sudden Death

Background: Cardiac involvement at time of COVID-19, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is associated with poor prognosis. However, post-COVID-19, the recovery period might also be associated with lingering effects or predisposition to some cardiac manifestations including sudden death, which can not only be missed but which might also remain undefined. This is a report of 56-year man who developed chest pain diagnosed as atypical Takotsubo type cardiomyopathy presenting after recovery from COVID-19 pneumonia 12 days following confirmation of SARS-CoV-2 infection by real-time quantitative polymerase chain reaction (RT-qPCR) testing. Case Report: 56 years old male who re-presented after clinical recovery from COVID-19 pneumonia (diagnosed on 1st admission from a nasopharyngeal swab using RT-qPCR assay/test; Xpertâ Xpress SARS-CoV-2 in vitro diagnostic device), with new cardiac symptoms (3rd admission), which after appropriate investigations was diagnosed as non-coronary cardiac injury/atypical Takotsubo type cardiomyopathy leading to sudden fatal outcome. Plausible mechanisms include direct cardiac toxicity (myocarditis) and/or microthrombi/hypoxia. The precise timing of the cardiac injury was difficult to elucidate but the potential for lingering cardiac consequences was realistic with eventual negative prognostic outcome. Conclusions: This case presentation after full clinical recovery from COVID-19 pneumonia highlights the new challenges for such cases, including potential longer-term enduring impact on cardiovascular morbidity and late mortality. The implications on use/benefits from conventional cardio-protective therapies including duration remains unclear. Further studies to screen high-risk patients with elevated cardiac biomarkers or cardiac risk factors post COVID-19 recovery (if not all patients) might be helpful but at the expense of significant consequences on existing cardiac services and cardiologists.

Cardiovascular manifestations and echocardiographic findings in pediatric multisystem inflammatory syndrome associated with COVID-19 (MIS-C): A retrospective study

Background: The multisystem inflammatory syndrome in children (MIS-C) has been described recently during COVID-19 pandemic. It is a delayed post-infectious response with a lag time of 4–6 weeks following the exposure to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), involving multiple systems which is being increasingly reported worldwide. Aim: The study aims to investigate and report the cardiovascular manifestation and echocardiographic findings in pediatric patients diagnosed with MIS-C. Materials and Methods: The present study is a retrospective analysis of clinical data gathered from 40 admitted children diagnosed with MIS-C. The study was conducted for 1 year (from 1st June 2020 to 30th May 2021) at Cheluvamba Hospital, a tertiary care center attached to Mysore Medical College And Research Institute, Mysore, Karnataka. Results: Out of 40 children, 21 (52.5%) had manifestation of cardiovascular system in the form of shock, requiring ionotropic support and care at the Intensive Care Unit. Among them, 90% patients show elevated cardiac biomarker (Troponin T), 33.3% had two-dimensional echocardiographic (2D echo) findings in which 9.5% show coronary artery dilatation and 23.8% show left ventricular hypertrophy. Conclusion: MIS-C is a hyperinflammatory syndrome related to SARS-CoV-2 infection. Cardiac involvement is evidenced by perturbation of cardiac chamber size, function, coronary artery abnormalities, and elevated cardiac biomarker. Though, most of the patients responded to the initial treatment and recovered, there is scarcity of data regarding long-term cardiovascular complication.

285 A rare case of atypical, non-triggered takotsubo recurrence

Abstract Aims Takotsubo syndrome (TTS) is an acute and reversible heart failure syndrome that, at presentation, mimics acute myocardial infarction. The most common echocardiographic manifestation is the so-called ‘apical ballooning’, but other much less common wall motion patterns have been described. The pathophysiology of the syndrome is not fully understood, but there is considerable evidence that sympathetic stimulation plays a central role. The prevalence of this syndrome is higher in post-menopausal women and in most cases, but not invariably, precipitated by an emotional or physical triggering event. A close relation between brain and circulatory system has been observed and for this reason psychiatric and neurologic disorders are often recognized as precipitating conditions. Although many risk factor persist after the acute manifestation, Takotsubo recurrences do represent an exception, especially in the absence of a clear precipitating event. Methods and results A 70-year-old woman was admitted for anginal pain associated with ischaemic electrocardiographic alterations and elevation of cardiac biomarkers. The coronary angiography with left ventriculogram and the echocardiographic findings were consistent with a diagnosis of mid-ventricular Takotsubo. Cardiac magnetic resonance confirmed the absence of an ischaemic pattern or evidence of infectious myocarditis. This case represents a recurrence of TTS, in fact two years earlier the patient was hospitalized to our division for stress cardiomyopathy with typical apical ballooning. Also in the present occasion, she had a favorable clinical course, with a complete recovery of the cardiac function at subsequent evaluations. The unicity of this case lies above all in the absence of a clear trigger event. Although, an altered mental status was present because the patient suffered from anxiety and depression on pharmacological treatment, with periods of exacerbation but not in occasion of the recurrence. Conclusions TTS is not a benign condition, with recurrence being possible even in the absence of precipitating events. Based on registry data, annual rate of Takotsubo recurrence is 1.5–1.8% and is estimated to reach 4% in life. A variable TTS pattern at recurrence is common in up to 20% of cases. Our paper reports a unique case of recurrent Takotsubo syndrome with variable patterns of ventricular involvement, with neither physical nor psychological trigger. Nevertheless, for what concerns our case, the psychiatric condition the patient suffered from, could have played a role of permanent status of sympathetic activation, that in the end elicitates the occurrence of the syndrome. A better understanding of the pathophysiology of the syndrome is needed to find evidence-based therapeutic strategies that could prevent recurrence.

Case Series of Steroid-Resistant Immune Checkpoint Inhibitor Associated Myocarditis: A Comparative Analysis of Corticosteroid and Tofacitinib Treatment.

Background: Immune checkpoint inhibitor (ICI)–associated myocarditis is an uncommon and potentially fatal immune-related adverse event (irAE). Although corticosteroids are recommended as the first-line treatment by current guidelines, patients still have variable responses to it, and the guidelines vary significantly in terms of treatment strategies. Objectives: In this study, we performed a retrospective analysis of ICI-associated myocarditis in our hospital to propose a new comparative analysis to aid individualized treatment. Methods: We reviewed detailed records of 24 patients with confirmed ICI-associated myocarditis in our hospital from July 1, 2019, to April 1, 2021. Although all the cases in our study received recommended initial corticosteroid treatment according to the guidelines, different responses to corticosteroid were observed during the process of subsequent corticosteroid tapering. Basing on troponin cardiac troponin T rebound during corticosteroid tapering, we propose a new classification analysis of ICI-associated myocarditis that included two subgroups: corticosteroid-sensitive (n = 8) and corticosteroid-resistant group (n = 16). Results: Compared with corticosteroid-sensitive patients, larger doses of corticosteroid, longer period of treatment, and higher mortality rate were found in corticosteroid-resistant patients. Corticosteroid-resistant patients were characterized by more prominent ptosis, muscle weakness, elevated cardiac biomarkers, creatine kinase, and hepatic enzymes levels than that in the corticosteroid-sensitive patients. Tofacitinib (5 mg twice a day) was used in 11 corticosteroid-resistant patients, with seven patients recovered from ICI-associated myocarditis, showing a promising therapeutic effect. Conclusion: Our group analysis of corticosteroid responsiveness in patients with ICI-associated myocarditis may help clinicians to apply individualized treatment in this high-risk cohort. In addition, tofacitinib could provide clinical benefits when used early in the corticosteroid-resistant patients and may provide a new option for the treatment of ICI-associated myocarditis.

Cardiovascular Spectrum and Cardiac Biomarkers in Pediatric Inflammatory Multisystem Syndrome with Kawasaki-Like Disease - Our Experience During the COVID-19 Pandemic in the West Part of Romania

Abstract Aim In COVID-19 Pandemic, a new hyperinflammatory syndrome was reported with clinical features of Kawasaki disease, named PIMS-TS. We want to present a single center experience where the patients were diagnosed with Kawasaki-like in PIMS-TS with cardiac affliction. Material and method The study was observational and retrospective, enrolled 14 patients fulfilling the criteria of PIMS-TS with the median age of 9 (IQR, 1.6–11), 9 male (64.2 %) and 5 female (35.8 %). Results ECG revealed tachycardia and ST-T changes in 60% of patients. In evolution, ECG modified in 20% and consisted of long QT in 7% of cases, bradycardia in 7%, 3% transitory sick sinus syndrome and 3% grade I/II degree atrio-ventricular block. Cardiac disfunction was evidenced in 4 patients (28%), with reduced ejection fraction under 50%, mitral insufficiency in 6 (42.8%), pericardial fluid in 8 (57.1%) and perivascular brightness in 8 (57.1%). The cardiac biomarkers: NT-proBNP (increased in 9), cTroponin T (increased in 7) and cTroponin I (increased in 5) confirmed heart dysfunction. During the hospitalization and under medical treatment, all the modifications recover. Evolution was good for 12 children. Conclusions Cardiac dysfunction and myocardial injury were confirmed by elevated cardiac biomarkers. Rapid recognition allows prompt treatment for a good outcome. NT-proBNP, cTroponin T and I are of capital significance in monitoring the myocardial injury, the treatment and evolution of these patients.

Differentiation syndrome-induced Myopericarditis in the induction therapy of acute Promyelocytic leukemia: a case report

BackgroundAll trans retinoic acid (ATRA) has revolutionized the treatment and outcomes of patients with Acute Promyelocytic Leukemia (APL). Induction therapy with ATRA is associated with the rare but potentially fatal complication of differentiation syndrome. While the presentation of this syndrome is varied, myopericarditis as a manifestation of differentiation syndrome is often fatal and rarely reported in literature. We present a case of myopericarditis as the sole manifestation of differentiation syndrome in a patient on induction therapy with ATRA and arsenic trioxide for APL.Clinical presentationA 62 year old woman with remote history of breast and uterine cancer presented to the hospital for expedited work up of easy bruising and expanding hematomas. She was diagnosed with APL with peripheral blood and bone marrow cytogenetics revealing t (15;17) translocation and initiated on induction therapy with ATRA and ATO as well as steroids for differentiation syndrome prophylaxis. Eighteen days into induction therapy, patient developed pleuritic chest pain, elevated cardiac biomarkers, ECG changes suggestive of pericarditis. Cardiac magnetic resonance imaging showed patchy multifocal sub-epicardial late gadolinium enhancement and elevated T2 signal consistent with acute myopericarditis. Given the timing of symptom onset and lack of other identifiable cause, patient was diagnosed with differentiation syndrome- induced myopericarditis and promptly initiated on high dose steroids with rapid improvement in symptoms, ECG, and cardiac biomarkers. Patient successfully resumed dose-reduced ATRA and arsenic trioxide without complication.ConclusionMyopericarditis can be the sole manifestation of differentiation syndrome and the presentation may be atypical owing to the use of prophylactic steroids as illustrated in our patient’s case. A high index of suspicion for differentiation syndrome, multimodality imaging, and prompt input from multidisciplinary providers is crucial for making the timely diagnosis and initiating life-saving treatment.

Abstract 9489: Echocardiographic Characteristics, Cardiovascular Factors, and Disease-Directed Therapy Do Not Explain Differences in Covid-19 Related Hispanic Outcomes

Introduction: Severe coronavirus disease 2019 (COVID-19) is associated with cardiovascular injury and disparate outcomes in different ethnic groups. However, the reason for this difference has not been elucidated. Methods: A retrospective cross-sectional study was done on adult COVID-19 patients at a single center from April 2020 to January 2021. Mortality, length of stay, mechanical ventilation use, and intensive care unit (ICU) status were compared across demographic groups, echocardiographic indices, and COVID-19-specific treatments. Results: One hundred fifty patients were included. In univariate analysis, elevated cardiac biomarkers, COVID-19 directed therapies, and elevated right-sided pressures were associated with higher mortality, mechanical ventilation use, length of stay, and ICU admission. Multivariable logistic regression predicted higher mortality for Hispanic ethnicity (odds ratio, OR, 6.7) even when adjusting for advanced age (OR 5.3), mechanical ventilation use (OR 18), and right ventricular systolic pressure (OR 1.1 per 1mmHg). There were no differences in underlying comorbidities, echocardiographic indices, cardiac biomarkers, or treatments between Hispanic and non-Hispanic patients. Conclusions: Despite being a younger cohort, Hispanic patients had a higher rate of mortality even when controlling for age, biomarkers, and echocardiographic indices. This suggests Hispanic ethnicity is an independent risk factor for mortality in COVID-19 infection, highlighting an important health inequity that warrants further investigation.

Cardiovascular and Neurological Complications in a Patient with Diphtheria: About a Case

Diphtheria is an infectious disease, caused by Corynebacterium diphtheriae, which produces an exotoxin, which is responsible for the local clinical manifestations and can lead to complications such as renal tabular necrosis, thrombocytopenia, cardiomyopathy and/or neuropathy. We present the case of a 36-year-old male patient, with no known pathological history, admitted with a diagnosis of Suspicious Case of Diphtheria, received Diphtheria Antitoxin, Tetanus Toxoid, Sodium Penicillin for 3 days and then continued with Azithromycin for 11 days. During his in-hospital evolution, the patient presented chest pain in the precordial region, electrocardiographic changes and elevated cardiac biomarkers were evidenced. Later, he was discharged from the institution due to an improvement in the clinical picture, however, 3 weeks later, he presented dysphagia to solids and decreased muscular strength in the lower extremities, bilateral, symmetrical, limiting ambulation, ascending, with subsequent involvement of the upper extremities; The physical examination revealed paralysis of the IX right cranial nerve, global IV/V muscle strength, global hyporeflexia, for which he was admitted with the diagnosis of acute post-infectious diphtheria inflammatory demyelinating polyradiculoneuropathy, later the patient presented torpid and unfavorable evolution that arrived upon death. Despite early diagnosis and timely treatment, diphtheria has a high mortality rate, which warrants efficient epidemiological surveillance and a multidisciplinary team for the management and control of cases.

The Prognostic Value of Cardiac Biomarkers and Echocardiography in Critical COVID-19.

Background: Early risk stratification is crucial in critically ill COVID-19 patients. Myocardial injury is associated with worse outcome. This study aimed to evaluate cardiac biomarkers and echocardiographic findings in critically ill COVID-19 patients and to assess their association with 30-day mortality in comparison to other biomarkers, risk factors and clinical severity scores.Methods: Prospective, single-center, cohort study in patients with PCR-confirmed, critical COVID-19. Laboratory assessment included high sensitive troponin T (hs-cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) on admission to ICU: a hs-cTnT ≥ 14 pg/mL and a NT-proBNP ≥ 450 pg/mL were considered as elevated. Transthoracic echocardiographic evaluation was performed within the first 48 h of ICU admission. The primary outcome was 30-day all-cause mortality. Predictive markers for mortality were assessed by ROC analysis and cut-off values by the Youden Index.Results: A total of 100 patients were included. The median age was 63.5 years, the population was predominantly male (66%). At the time of ICU admission, 47% of patients had elevated hs-cTnT and 39% had elevated NT-proBNP. Left ventricular ejection fraction was below 50% in 19.1%. Elevated cardiac biomarkers (hs-cTnT P-value < 0.001, NT-proBNP P-value = 0.001) and impaired left ventricular function (P-value = 0.011) were significantly associated with mortality, while other biomarkers (D-dimer, ferritin, C-reactive protein) and clinical scores (SOFA) did not differ significantly between survivors and non-survivors. An optimal cut-off value to predict increased risk for 30-day all-cause mortality was 16.5 pg/mL for hs-cTnT (OR 8.5, 95% CI: 2.9, 25.0) and 415.5 pg/ml for NT-proBNP (OR 5.1, 95% CI: 1.8, 14.7).Conclusion: Myocardial injury in COVID-19 is common. Early detection of elevated hs-cTnT and NT-proBNP are predictive for 30-day mortality in patients with critical COVID-19. These markers outperform other routinely used biomarkers, as well as clinical indices of disease severity in ICU. The additive value of routine transthoracic echocardiography is disputable and should only be considered if it is likely to impact therapeutic management.

Covid-19 Combined with Stress Cardiomyopathy: Case Report and Review of the Literature

Introduction: Severe COVID-19 can cause multiple organ dysfunction or failure, often associated with cardiac dysfunction, known as stress cardiomyopathy or apical spherical syndrome. Patient Concerns: Severe COVID-19 patients in Hebei province have 5 cases of stress cardiomyopathy. Two cases in Cangzhou are summarized from Feb 2020 to May 2020. Diagnosis: Based on the precipitating factor, pathophysiology, Mayo diagnostic criteria and differential diagnosis of stress cardiomyopathy, the patients were diagnosed with stress cardiomyopathy, which is characterized by elevated biomarkers, hemodynamic instability, and cardiomyopathy. Interventions: Early and dynamic monitoring of ECG, myocardial enzymes, cardiac troponin and echocardiography are needed to predict and assess the risk of stress-induced cardiomyopathy. Noradrenaline and dobutamine were continued to be given, and neokine, levosimendan, Cediland and other drugs were given successively to strengthen the heart. Outcomes: After several days of supportive care, the patients’s cardiac output and the apical movement were gradually improved. Conclusion: Reversible stress cardiomyopathy may occur in the setting of COVID-19 infection with elevated cardiac biomarkers and an abnormal ECG and echocardiographic. We should pay more attention to the treatment of stress cardiomyopathy.

Covid-19 Combined with Stress Cardiomyopathy: Case Report and Review of the Literature

Introduction: Severe COVID-19 can cause multiple organ dysfunction or failure, often associated with cardiac dysfunction, known as stress cardiomyopathy or apical spherical syndrome. Patient Concerns: Severe COVID-19 patients in Hebei province have 5 cases of stress cardiomyopathy. Two cases in Cangzhou are summarized from Feb 2020 to May 2020. Diagnosis: Based on the precipitating factor, pathophysiology, Mayo diagnostic criteria and differential diagnosis of stress cardiomyopathy, the patients were diagnosed with stress cardiomyopathy, which is characterized by elevated biomarkers, hemodynamic instability, and cardiomyopathy. Interventions: Early and dynamic monitoring of ECG, myocardial enzymes, cardiac troponin and echocardiography are needed to predict and assess the risk of stress-induced cardiomyopathy. Noradrenaline and dobutamine were continued to be given, and neokine, levosimendan, Cediland and other drugs were given successively to strengthen the heart. Outcomes: After several days of supportive care, the patients’s cardiac output and the apical movement were gradually improved. Conclusion: Reversible stress cardiomyopathy may occur in the setting of COVID-19 infection with elevated cardiac biomarkers and an abnormal ECG and echocardiographic. We should pay more attention to the treatment of stress cardiomyopathy.

Symptomatology, prognosis, and clinical findings of COVID 19 induced myocarditis: a systematic review

Abstract Background With the advent of the novel coronavirus (COVID-19) in December 2019, numerous case studies have been reported on its impact on cardiac cells, and we purpose to perform a systematic review that explains the symptomatology, prognosis, and clinical findings of COVID-19-related myocarditis patients. Methods PRISMA guidelines were employed and peer–reviewed journals in English related to COVID – 19 were included. Exclusion criteria included &amp;lt;50 y, known heart problems. Age criteria was guided by prior systematic report by Kariyanna et al (2020). Search engines included Pubmed, Google scholar, Cochrane Central and Web of Science database using “SARS-CoV-2” or “COVID 19” and “myocarditis”. The data were analyzed and synthesized qualitatively using MS Excel PIVOT and quality was rated using the “Research and Quality Scoring Method” by Sackett and Haynes, the Jadad scale, and the items published by Cho and Bero (Han et al., 2011). Results A total of 22 studies on 37 patients were included; 6 were confirmed myocarditis while the rest have possible myocarditis. Among all these 62% were male and showing dominance. The most common presenting symptoms appear to be fever, chest pain, shortness of breath, and cough. Most of the patients have shown elevation in cardiac biomarkers (troponin levels, CRP, CK level, CK-MB, NT-pro BNP). Electrocardiogram changes include sinus rhythm, tachycardia, and non specific ST - segment elevation and T wave changes. Echocardiography results commonly found were left ventricular dysfunction and increased wall thickness. CMR was performed in 8 patients, with features of reduced ejection fraction, myocardial edema, and hypokinesia, whereas biopsy has been performed among 3 patients due to the invasive nature of the procedure and common findings include inflammatory biomarkers were raised. Overall Prognosis appears to be bad in which 25% of patients were not able to survive and 75% of them were recovered. Conclusions Myocarditis-related COVID-19 mortality continues to be high and under-estimated. The patient manifestations are identical and difficult to distinguish from COVID-19-related symptoms. Just a limited number of patients undergo confirmatory tests, such as an MRI or an endomyocardial biopsy, which may not be available. Further studies are needed to confirm and quantify the actual prognosis and outcomes of patients with COVID-19 myocarditis. Moreover, available data on the usage of glucocorticoids in the coronavirus infection is controversial to our knowledge. Corticosteroid therapy is unsuccessful in the treatment of viral myocarditis, according to a Cochrane systematic review conducted in 2013. It also allows viral clearance to be overdue. Corticosteroids, on the other hand, reduce the chance of mortality for ICU patients in Wuhan. To concede, more studies, clinical trials, and duration is needed for a thorough understanding of COVID – 19, and its impact on cardiac health Funding Acknowledgement Type of funding sources: Other.

Predictors of mortality in patients with intermediate risk pulmonary embolism

Abstract Introduction Information about treatment and outcome of patients with pulmonary embolism (PE) intermediate risk remains limited. Little is known about the benefits of reperfusion therapy in patients with intermediate risk PE and evidence of right ventricular dysfunction. Objective To evaluate clinical outcomes and predictors of mortality in patients admitted to ICU with pulmonary embolism and intermediate risk. Methods In a prospective single-center study 103 normotensive patients with an established diagnosis of pulmonary embolism confirmed by pulmonary CT were included. All patients met intermediate risk criteria according to the European Society of Cardiology guidelines (ESC 2019) for pulmonary embolism using severity index [PESI] with signs of right ventricular dysfunction and elevated cardiac biomarkers. The average age of patients was 67.6 years (95% CI, 65.1–70.5), 42 (41%) of them were men. Thrombolysis with standard dose of alteplase was performed in 54 (52%) patients. CT scan and echocardiography were done for all patients. Results Outcome data were collected for all patients through the 30-day and 180-day follow-up. During 30 days follow up 14 patients died (13,6%, 95% CI, 6,9–20%). The all-cause mortality rate after 180 days was 22,2% (95% CI, 13,5–31%) - 22 patient. In the thrombolysis group only 2 patients died after 180-day follow-up, mortality rate was 4,4% (95% CI, 1,7–10,6%), the mortality rate in patients not treated by thrombolysis was 40% (95% CI, 25,3–54,7%). Thrombolysis was associated with a significant decrease in mortality [OR 0.07 (95% CI, 0.01–0.31)]. In the thrombolysis group 2 patients (4.1%; 95% CI, 1.1–10%) had a non-fatal major bleeding event. The presence of chronic heart failure [OR 6 (95% CI, 1.8–20.2)] and previous stroke [OR 4.3 (95% CI, 0.9–21.1)] were higher among non-survivors when compared to survivors (p≤0.05). TAPSE less than 16 mm was found to be negatively associated with survival [OR 5.5 (95% CI, 0.9–40.3)], p=0.02. Conclusion In our study thrombolysis in patients with pulmonary embolism and intermediate-risk was associated with improved prognosis. Predictors of mortality were the presence of CHF, previous stroke and TAPSE of less than 16 mm. Funding Acknowledgement Type of funding sources: None. Kaplan-Meier mortality curves. p&amp;lt;0.05

Smoky heart: cardiovascular manifestations of carbon monoxide poisoning

Abstract Background Carbon monoxide (CO) poisoning is one of the most critical health concerns worldwide due to severe clinical effects with high morbidity and mortality. Tissue hypoxia and cellular damage from CO poisoning results in oxidative stress. Organs and tissues with high O2 demand including central nervous system (CNS) and cardiovascular (CV) system are the most susceptible to this oxidative stress. We investigate and describe the cardiovascular manifestations in 350 patients who were admitted for moderate to severe CO poisoning and treated with hyperbaric oxygen (HBO2) therapy. Purpose This study was conducted to identify the common cardiovascular manifestations of carbon monoxide poisoning. Methods We retrospectively collected data on 350 consecutive adult patients treated for CO poisoning between January 2011 to April 2018. Cardiac biomarkers, EKG and carboxyhemoglobin (COHb) levels were obtained from pre-hospital sources including EMS (emergency medical services) and from outside hospital records at the time of transfer. Glasgow Coma Scale (GCS) measurements were obtained at initial pre-hospital evaluation and upon arrival to the emergency room. Patient demographics, CV, CNS history and cardiac risk factors including hypertension, hyperlipidemia, diabetes, smoking history were obtained from electronic medical record. Myocardial injury was defined by cardiac troponin I level of ≥0.05 ng/mL. Results There were 350 patients admitted for CO poisoning from 2011 to 2018. 72% of the patients received HBO treatment due to severity of their symptoms. The mean age was 47.3 years with 60% men, 89% of the admissions were accidental exposure. Cardiac biomarkers were elevated in 40% of the patients and with 21% having sinus tachycardia. 6% had ischemic EKG changes with 23% having regional wall motion abnormalities on echocardiogram. In terms of intervention, 83% of the patients with elevated cardiac biomarkers received HBO treatment, 9% underwent coronary angiogram out of which 50% were candidate for either percutaneous intervention (PCI) or coronary artery bypass graft (CABG). In hospital mortality amongst this population was 2%. Conclusion Myocardial injury is common and widely seen with CO poisoning as seen by elevated cardiac biomarkers in 40% of the tested population. Initial work up for patients with CO poisoning should include evaluation with an EKG and serial biomarkers. If an abnormality is detected, patient should undergo an echocardiogram. Further evaluation with coronary angiography may be warranted in patients with new left ventricular dysfunction or wall motion abnormalities, especially in patients with risk factors. Funding Acknowledgement Type of funding sources: None.

The predictive value of cardiac biomarkers and echocardiography in critical COVID-19

Abstract Background Coronavirus disease (COVID-19) continues to challenge healthcare systems worldwide. Adequate triage and divergence to an appropriate level of care are essential. Myocardial injury is a common finding in COVID-19 patients, while cardiac complications seem to occur only in a minority of patients. Purpose To evaluate cardiac biomarkers and echocardiographic findings in critical COVID-19 at time of ICU admission, and to assess their association with ICU mortality in comparison to other biomarkers and risk factors. Methods Prospective, single-center, cohort study in patients with PCR-confirmed COVID-19 admitted to the ICU. Laboratory assessment included high sensitive troponin T (hsTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP). Standard transthoracic echocardiographic evaluation was performed upon ICU admission. The primary outcome was ICU mortality. Statistical analysis was performed using SPSS statistics (Version 27.0, IBM Corp, Armonk, NY) with χ2 and Mann–Whitney U tests. Predictive markers for mortality were assessed by ROC analysis and cut-off values by the Youden Index. Results We included 86 patients. Transthoracic echocardiography was not feasible in 11 patients (12.8%) due to poor visualization or prone ventilation. Baseline characteristics are presented in the table. Left ventricular ejection fraction (LVEF) was below 50% in 18.7% of patients and 20% had an E/e' septal ratio above 14. Right ventricular function, evaluated with TAPSE, was normal (&amp;gt;14mm) in 94% of patients. Cardiac biomarkers were elevated in almost half of all patients (hsTnT ≥14 μg/L in 46.5%, and NT-proBNP ≥450 pg/mL in 44,2%), and in up to 30% of patients with normal LVEF. The level of these cardiac biomarkers was significantly higher in non-survivors, while other routinely used biomarkers (D-dimers, ferritin, C-reactive protein), and commonly used clinical scores indicating the severity of illness (SOFA score) were not. A cut-off value of 16.5 μg/L for hsTnT corresponded with sensitivity and specificity for mortality of resp. 75% and 74.2%. For NT-proBNP, a cut-off value of 760 pg/mL corresponded with sensitivity and specificity for mortality of resp. 60% and 83.3%. LVEF was significantly lower and E/e' ratio was significantly higher in non-survivors. Conclusion Echocardiographic abnormalities, especially left and not right ventricular dysfunction, were found in up to 20% of patients, whereas up to half of all patients had elevated cardiac biomarkers at time of ICU admission. This study highlights the strong predictive value of cardiac biomarkers for ICU mortality and their possible role for triage in critical COVID-19. They outperform routinely used biomarkers of inflammation as well as clinical indices of disease severity in ICU. Transthoracic echocardiography should only be considered if it is likely to impact therapeutic management given the potential hazard for sonographers and the scarcity of personal protective equipment. Funding Acknowledgement Type of funding sources: None.

COVID-19 and the Incidence of Acute Myocardial Injury.

Cardiovascular manifestations are frequent in COVID-19 infection and are predictive of adverse outcomes. Elevated cardiac biomarkers are common findings in patients with cardiovascular comorbidities and severe COVID-19 infection. Troponin, inflammatory and thrombotic markers may also improve risk prediction in COVID-19. In our comprehensive review, we provide an overview of the incidence, potential mechanisms and outcome of acute cardiac injury in COVID-19. Thereby, we discuss coagulation abnormalities in sepsis and altered immune response as contributing factors favoring myocardial injury. We further highlight the role of endothelial damage in the pathophysiological concepts. Finally, observational studies addressing the incidence of myocardial infarction during COVID-19 pandemic are discussed.

COVID-19-RELATED MYOCARDITIS RESULTING IN CARDIOGENIC SHOCK

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Coronavirus-19 (COVID-19) myocarditis showed increased mortality despite team work of experts. We present a case of a middle-aged male with COVID-19 related myocarditis leading to cardiogenic shock. CASE PRESENTATION: 64-year-old male with history of hypertension, hyperlipidemia, hypothyroidism and positive COVID-19 infection with related stroke presented with 2 weeks of myalgias, malaise, and dyspnea. He was tachycardic on exam with bibasilar crackles and mild pedal edema. Labs revealed elevated inflammatory markers, cardiac biomarkers and leukocytosis with peripheral eosinophilia. Pulse dose steroids were initiated for suspected vasculitis. Transthoracic echocardiogram (TTE) revealed global hypokinesis and cardiac catheterization revealed LVEDP of 28 mmHg, LVEF of 10%, and cardiac index of 1.7 L/min/m2 without ischemic disease. Inotropes were started, and the patient was transferred to the center for advanced heart failure and cardiac transplant evaluation. Cardiac MRI (CMRI) revealed late enhancing subendocardial myocardial scarring of anteroseptal segments and endomyocardial biopsy revealed focal ischemic injury suggestive of COVID-19 related myocarditis in the setting of multisystem inflammatory syndrome (MIS-A). DISCUSSION: MIS-A is a rare subacute complication of COVID-19, thought to be caused by direct cell injury from ACE2 upregulation and a dysregulated immune response resulting in acute myocarditis. Elevated troponins have been reported in these patients due to ventricular dilation and direct myocardial injury. Electrocardiograms have poor sensitivity for myocarditis, thus TTE is performed which reveals wall abnormalities with reduced ventricular function and has been reported in 60% of COVID-19 related myocarditis cases. CMRI is preferred to evaluate myocarditis and may reveal hyperemia, edema, and myocardial necrosis. Endomyocardial biopsy (EMB) is the gold standard for diagnosing myocarditis, but should be a shared decision due to lack of studies to support EMB diagnosis in suspected COVID-19 myocarditis. Patients with cardiogenic shock need vasopressors and inotropes, and mechanical circulatory support via extracorporeal membrane oxygenation or intra-aortic balloon pumps if needed. It is unclear if intravenous immunoglobulins or steroids have benefit treating COVID-19-related myocarditis and requires further evaluation. CONCLUSIONS: Myocarditis should be suspected in patients with COVID-19 infection presenting with acute heart failure. Given limited data for COVID-19 related myocarditis, we need more studies to better treat these patients. REFERENCE #1: Morris SB, Schwartz NG, Patel P, et al. Case series of multisystem inflammatory syndrome in adults associated with sars-cov-2 infection — united kingdom and united states, march–august 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1450–1456. REFERENCE #2: Sawalha K, Abozenah M, Kadado AJ, et al. Systematic review of COVID-19 related myocarditis: insights on management and outcome. Cardiovasc Revasc Med. 2021;23,107-113. REFERENCE #3: Siripanthong B, Nazarian S, Muser D, et al. Recognizing covid-19-related myocarditis: the possible pathophysiology and proposed guideline for diagnosis and management. Heart Rhythm. 2020;17(9):1463-1471. DISCLOSURES: No relevant relationships by Suong Nguyen, source=Web Response No relevant relationships by Nikola Perosevic, source=Web Response No relevant relationships by Evan Wasserman, source=Web Response

One-Year Committed Exercise Training Reverses Abnormal Left Ventricular Myocardial Stiffness in Patients With Stage B Heart Failure With Preserved Ejection Fraction.

Individuals with left ventricular (LV) hypertrophy and elevated cardiac biomarkers in middle age are at increased risk for the development of heart failure with preserved ejection fraction. Prolonged exercise training reverses the LV stiffening associated with healthy but sedentary aging; however, whether it can also normalize LV myocardial stiffness in patients at high risk for heart failure with preserved ejection fraction is unknown. In a prospective, randomized controlled trial, we hypothesized that 1-year prolonged exercise training would reduce LV myocardial stiffness in patients with LV hypertrophy. Forty-six patients with LV hypertrophy (LV septum >11 mm) and elevated cardiac biomarkers (N-terminal pro-B-type natriuretic peptide [>40 pg/mL] or high-sensitivity troponin T [>0.6 pg/mL]) were randomly assigned to either 1 year of high-intensity exercise training (n=30) or attention control (n=16). Right-heart catheterization and 3-dimensional echocardiography were performed while preload was manipulated using both lower body negative pressure and rapid saline infusion to define the LV end-diastolic pressure-volume relationship. A constant representing LV myocardial stiffness was calculated from the following: P=S×[Exp {a (V-V0)}-1], where "P" is transmural pressure (pulmonary capillary wedge pressure - right atrial pressure), "S" is the pressure asymptote of the curve, "V" is the LV end-diastolic volume index, "V0" is equilibrium volume, and "a" is the constant that characterizes LV myocardial stiffness. Thirty-one participants (exercise group [n=20]: 54±6 years, 65% male; and controls (n=11): 51±6 years, 55% male) completed the study. One year of exercise training increased max by 21% (baseline 26.0±5.3 to 1 year later 31.3±5.8 mL·min-1·kg-1, P<0.0001, interaction P=0.0004), whereas there was no significant change in max in controls (baseline 24.6±3.4 to 1 year later 24.2±4.1 mL·min-1·kg-1, P=0.986). LV myocardial stiffness was reduced (right and downward shift in the end-diastolic pressure-volume relationship; LV myocardial stiffness: baseline 0.062±0.020 to 1 year later 0.031±0.009), whereas there was no significant change in controls (baseline 0.061±0.033 to 1 year later 0.066±0.031, interaction P=0.001). In patients with LV hypertrophy and elevated cardiac biomarkers (stage B heart failure with preserved ejection fraction), 1 year of exercise training reduced LV myocardial stiffness. Thus, exercise training may provide protection against the future risk of heart failure with preserved ejection fraction in such patients. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03476785.