History Of Systemic Hypertension Research Articles

Endoscopic Ultrasound-Guided Rendezvous Pancreatic Duct Stenting in Pancreas Divisum Using Modified Cannula

AbstractThis video is of a 65 year old female patient with history of systemic hypertension, type 2 diabetes and coronary artery disease on medical management. She presented with features of acute pancreatitis which was managed conservatively and imaging showed features of chronic pancreatitis with dilated pancreatic duct and pancreas divisum was suggested. She had two further episodes of acute pancreatitis and was managed conservatively. Pancreatic stenting was suggested but during ERCP minor papillae couldn't be identified. Hence, EUS guided Rendez - vous pancreatic duct puncture and minor papillae stenting was done with the help of a modified cannula.

C62 CHALLENGING DIAGNOSIS OF A TRIPLE CARDIAC PATHOLOGY: TRANSTHYRETIN AMYLOIDOSIS WITH ASPECTS OF HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY AND ANOMALOUS CORONARY ARTERY

Abstract A 70 years–old man with a history of systemic hypertension and surgically treated bilateral carpal tunnel was referred for dyspnea on exertion for few months. At physical examination a systolic heart murmur exacerbated by Valsalva maneuver was appreciated; no signs of heart failure. EKG with low–voltage QRS is shown in Fig.1A. Blood tests showed elevated NT–proBNP (1434 pg/ml). Transthoracic echo (ETT) revealed hyperdynamic left ventricle (LV) with severe asymmetric hypertrophy (interventricular septum 23 mm, posterior wall 17 mm), ‘granular sparkling’ appearance of myocardium, grade 2 diastolic dysfunction and ‘apical sparing’ pattern at global longitudinal strain (GLS, Fig.1B). Moreover, elongated mitral leaflets, anomalies of mitral sub–valvular apparatus with apically displaced papillary muscles and systolic anterior motion of the mitral valve (SAM) with dynamic outflow tract obstruction (20 mmHg at rest and 90–100 mmHg with Valsalva maneuver) were seen (Fig. 2A–B–C). For ETT suspicion of a coronary artery anomaly (Fig.3A), the patient underwent coronary CT angiography that confirmed a separate origin of left anterior descending artery (LAD) from right coronary sinus with a long mid–proximal intramyocardial bridge (Fig.3B–C). As a part of evaluation of the hypertrophic phenotype, a 99mTC–HDP bone scintigraphy was performed with high–grade of cardiac uptake (Perugini Score 2, Fig.1C). Screening for monoclonal gammopathy and genetic testing for hereditary amyloidosis resulted negative. Cardiac MRI revealed late gadolinium enhancement (LGE) in midwall septum, diffuse endocardial LGE in the LV basal inferior and posterolateral walls (Fig.1D), elevated T1 mapping and ECV (40–42%) and confirmed the asymmetric hypertrophy with apically displaced papillary muscles (Fig.2D) and SAM. These clinical, EKG and imaging features led to a non–invasive diagnosis of wild–type transthyretin cardiac amyloidosis (ATTRwt) with aspects of hypertrophic obstructive cardiomyopathy (HOCM). The patient started a disease–modifying therapy with Tafamidis and, cautiously, Metoprolol tartrate, with good tolerance and relevant reduction of LVOT obstruction at follow–up. Genetic testing for HCM was also performed. In conclusion, in rare cases hypertrophic phenotype may be challenging, showing features overlap between ATTR and HOCM. Multimodality evaluation is crucial for a correct diagnosis, thus identifying the most effective target–therapy for the underlying hypertrophic phenotype.

P316 CHEST PAIN: ONE, NONE AND A HUNDRED THOUSAND DIAGNOSES. A CASE REPORT

Abstract A 62–year–old woman, with a history of systemic hypertension, smoking habit and paroxysmal atrial fibrillation treated with Flecainide, was admitted to the ER of our Hospital for chest pain. She reported that the symptoms appeared after an emotional stress at work. Troponin I was of 895 pg/mL. The electrocardiogram showed: negative T waves in the inferior leads and an early repolarization pattern/ ST elevated in the antero–lateral leads. The patient underwent transthoracic echocardiography which showed: EF 45%, akinesia of the posterior and inferior segments of the septum. Invasive coronary angiography showed absence of lesions. CMR presented: EF 51% and mild hypokinesia of the mid septum and inferior segment; signs of oedema affecting the left ventricular myocardium in the apex, the mid inferior segment and in the lower apical wall, with subendocardial hypoperfusion layer in the mid inferior septum (microvascular dysfunction?). The patient was dismissed with the diagnosis of M.I.N.O.C.A. A month later, she was admitted again to our ER suffering from a new episode of acute chest pain; she also reported a short episode of atrial fibrillation (documented by an EKG) lasting about 10 minutes occurred the day before. The EKG showed: negative T waves in anterolateral leads. TnI was of 2052,5 pg/ml. The patient underwent a transthoracic echocardiogram which demonstrated: reduced global systolic function (EF 35%), akinesia of the apex, mid–anterior septum and mid– anterior wall. The day after the echo was repeated and it demonstrated a gaining of Vsx EF which was of approximately of 50%. Invasive coronary angiography showed absence of lesions. A methylergometrine test was negative for vasospasm on anterior descending artery. The CMR showed: EF 58%, signs of oedema in the basal and mid anterior wall, mid–anterior septum. LGE intra wall of the apical septum and of the basal part of the anterior wall (coronary spasm? Vasculitis?) Absence of edema. The final diagnosis was of Tako Tsubo. Discussion and conclusions This case offers the inspiration to reflect on differential diagnosis of chest pain with undamaged coronary arteries. In addition to this, it should be considered coronary emboli arisen through various mechanisms including left atrial appendage thrombi due to atrial fibrillation, so that also anticoagulation therapy is suggested as discharge treatment.

A case report of cardiac tamponade as a result of pericardial damage from chest compression

Background: It is well-recognized that manual chest compression could cause a number of internal injuries, many of which are fatal. Similar to this, many type A acute aortic dissection (AAD) patients who develop cardiac tamponade die before reaching the hospital. This study presented a case in which pericardial laceration brought on by chest compressions has unintentionally caused cardiac tamponade by AAD. Case Presentation: A 65-year-old woman with a history of systemic hypertension was presented who fainted shortly after complaining of terrible epigastric discomfort. Paramedics started manual chest compressions on the patient, as soon as they realized they were dealing with a cardiopulmonary arrest. The pericardial laceration brought on by chest compressions might have unintentionally freed cardiac tamponade caused by AAD, perhaps sparing the patient's life. During surgery, a hemothorax and pericardial laceration connected to the left pleural space were found, but no heart injury was seen. There were no indications of the ruptured aortic aneurysm or any intra-thoracic injuries that would have caused the hemothorax. Hemiarch replacement was successfully accomplished, but the patient died from multi-organ failure 31 days after the operation. Conclusion: An instance of non-fractured pericardial injury caused by chest compression was presented. The pericardial laceration, which also afforded the patient enough time for surgery, have accidentally eased the hemothorax brought on by the AAD.

COUNTERPOINT: Pulmonary Vascular Resistance 2.0— Shedding Light or Casting Shadows?

COUNTERPOINT: Pulmonary Vascular Resistance 2.0— Shedding Light or Casting Shadows?

Low Back Pain: An Unusual Presentation of Non-Hodgkin Lymphoma

Abstract Non-Hodgkin lymphoma (NHL) is a lymphoid tissue neoplasm originating from B- and T-cells and usually presents with fever, lymphadenopathy, and hepatosplenomegaly. Here is a case of NHL who presented to us with low backache. We describe a patient 63 year old female who had a known history of systemic hypertension, presented with spasmodic low back pain. On examination, she had a single right lymph node 1 cm × 2 cm palpable with spinal tenderness. Her blood reports were all within normal limits with slightly elevated inflammatory markers. Magnetic resonance imaging of the spine revealed multiple enlarged lymph nodes in the abdomen, which were compressing the celiac plexus. After a lymph node biopsy, it was revealed that she had follicular NHL. On the initiation of steroids and chemotherapy, her pain subsided. NHL has a variety of presentations. It is not necessary always fever should be a part of the presentation. Physicians should have a suspicion of lymphoma also in patients presenting with low backache.

Are choroidal vascularity parameters influenced by age, hypertension and visual acuity in pachychoroid spectrum diseases?

AbstractPurpose: To identify correlations of subfoveal choroidal thickness (SFCT) and choroidal vascularity index (CVI) with age and best corrected visual acuity in eyes with pachychoroid spectrum diseases (PSD) and their association to systemic hypertension using a retrospective study design.Methods: Our study included 82 eyes of 45 patients with PSD: 15 eyes had uncomplicated pachychoroid (UCP), 27 had pachychoroid pigment epitheliopathy (PPE), 32 had central serous chorioretinopathy (CSC) and 8 had pachychoroid neovasculopathy (PNV). All patients underwent DRI TRITON Swept‐Source Optical Coherence Tomography (SS‐OCT). A 1500 mm width subfoveal choroidal area was defined in SS‐OCT B‐scans and divided into luminal area (LA) and stromal area (SA) by the imageJ binarization technique. CVI was defined as the ratio of LA to the total subfoveal choroidal area (TCA).Results: The mean SFCT was 393, 23 ± 95, 65 μm and it was correlated negatively with age (p = 0.003, R = −0.326). We found a negative correlation of TCA and LA with age (p = 0.043, r = −0.227, p = 0.04, r = −0.230). Mean choroidal vascularity index was 64.45 ± 2, 74% with no correlation with age (p = 0.169, R = −0.155). No parameter among SFCT, CVI, TCA, LA and SA had a significant correlation with BCVA or spherical equivalent. Patients with essential hypertension were found to have significantly thinner SFCT when compared with healthy controls (374, 49 ± 83 141 μm vs. 423, 98 ± 130 466 μm, p = 0.046). CVI was not affected by a history of systemic hypertension (64.05 ± 1.97 vs. 64.83 ± 3.3, p = 0.207). The total choroidal area, luminal area, and stromal area, as well as the CVI correlated with SFCT (p < 0.001, r = 0.817, p < 0.001, r = 0.821, p < 0.001, r = 0.750 and p < 0.001, r = 0.371 respectively).Conclusions: SFCT and CVI are dynamic parameters that are affected in patients with pachychoroid diseases. Unlike CVI, SFCT is also affected by age, ocular and systemic factors like hypertension. CVI may be a more specific biomarker for PSD.

Abstract 11629: Multicenter Development and Validation of a Machine Learning Risk Model to Predict Right Ventricular Failure Following Mechanical Circulatory Support: The STOP-RVF Score

Introduction: Existing models predicting right ventricular failure (RVF) after durable left ventricular assist device (LVAD) support are limited due to lack of multicenter validation, absence of intraoperative characteristics, and marginal predictive power. We sought to derive and validate a risk model to predict post-LVAD RVF. Methods: Advanced heart failure (HF) patients (N=798) requiring continuous-flow LVAD were enrolled at the Utah Transplant Affiliated Hospitals (n=477), Inova Heart & Vascular Institute (n=183), and Henry Ford Medical Center (n=138). Baseline clinical and intraoperative characteristics were recorded. The primary outcome was RVF incidence, defined as the need for right VAD (RVAD) or intravenous inotropes for >14 days. Bootstrap imputation and lasso variable selection were used to derive a predictive model which was then validated. A risk calculator was developed classifying patients into risk groups, and survival was compared. Results: Patients were predominantly white (72%), males (84%), aged 56±13 years. Patients in the RVF and non-RVF groups were comparable in terms of sex, age, and LVAD indication, while RVF patients more commonly had a history of systemic hypertension, non-ischemic cardiomyopathy, lower INTERMACS profiles, and more commonly required inotropic or temporary circulatory support pre-LVAD. Overall, 193 (24.2%) patients developed RVF with 109 (56.5%) requiring inotropes and 84 (43.5%) an RVAD. Multivariable predictors for RVF are shown in the Figure and achieved a c-statistic of 0.74 (95% CI: 0.70-0.78). Inclusion of intraoperative characteristics did not improve model performance. Cumulative survival was higher in the minimal risk group compared to low, moderate, and high. Conclusions: The STOP-RVF calculator effectively stratifies the risk for RVF after LVAD support by implementing routinely collected clinical data. It could impact patient selection and peri-operative management of advanced HF patients.

Retinal Manifestations in Patients with COVID-19: A Prospective Cohort Study

The recent outbreak of the Coronavirus SARS-CoV-2 has been declared a worldwide pandemic. Within various multi-organ involvement, several ocular manifestations have been described, such as conjunctivitis and retinopathy. The prevalence and severity of retinal lesions and their relation to the severity of the systemic disease are unknown. We performed a prospective, observational study on 172 consecutively hospitalized patients with acute confirmed COVID-19 infection. All patients underwent screening widefield fundus photography at the time of hospital admission. Despite no ocular or vision-related symptoms, we found cotton wool spots (CWS) and/or hemorrhages in 19/172 patients (11%). Diabetes history, overweight, and elevated C-reactive protein were more frequently observed among patients with retinal abnormalities, while a history of systemic hypertension was more frequently observed among patients without retinal findings. At a 3-month follow-up visit, CWS had subsided in all patients.

Delayed lung function testing after COVID-19 to detect persistent lung function abnormalities - The DELTA - COVID-19 lung function study.

Coronavirus disease 2019 (COVID-19) has made its presence felt as the worst pandemic witnessed till date in the 21st century. The mortality and morbidity associated with COVID-19 does not end with the acute pneumonia and respiratory failure and consequences extend well into the subsequent weeks to months in a minority. After recovery from severe disease, symptoms, lung function abnormalities and radiological changes are known to persist for varying length of time in a small proportion of patients. Various studies report different incidences of lung function abnormalities post-COVID-19. The present study describes the occurrence, severity, pattern and risk factors for persistent lung function abnormalities post-COVID-19 patients. The present study was aimed to find out the occurrence of persistent lung function abnormalities in patients hospitalised with COVID-19 at three months of discharge who had normal previous lung function prior to COVID-19. In those with persisting abnormal lung function, the severity, pattern and risk factors for persistent lung function abnormalities were also studied. The present study was a retrospective study in patients hospitalised with COVID-19 who had radiological evidence of pneumonia at admission. Patients with prior abnormal lung function were excluded from the study. Lung function was analysed with spirometry, 6-min walk test and diffusion capacity between day 85 and 95 of hospital discharge and the occurrence, severity and pattern of impairment was described. Lung function impairment was correlated with baseline characteristics and univariate regression analysis was done to identify risk factors for persisting functional impairment. 39 patients were included in the study. Spirometry at follow up showed a restrictive ventilatory defect in 26 out of 39 patients (64%) and a normal study was noted in 12 patients. One patient had an obstructive ventilatory defect. Diffusion impairment was present in 27 patients and normal transfer factor was seen in 12 patients. The degree of diffusion impairment was mild in 16 patients and moderate in 11 patients. Univariate regression analysis revealed that age, history of systemic hypertension, severe hypoxia at presentation, and extent of lung involvement by CT chest were associated with lung function impairment. Almost two-thirds of patients hospitalised with COVID-19 pneumonia have persistent lung function abnormalities at three months post-discharge. Advanced age, severe disease and medical comorbidities increase the risk of persistent functional abnormalities.

CORRELATION OF INTRAOCULAR PRESSURE WITH SYSTEMIC HYPERTENSION

BACKGROUND: Systemic hypertension is one of the key modiable risk factors for the rise in intraocular pressure which leads to glaucoma. This study was undertaken to see the relationship between intraocular pressure and systemic hypertension in adults aged >40yrs, to diagnose ocular hypertension and its consequences at the earliest. AIM:To study the relationship between intraocular pressure and systemic hypertension among adults aged >40 yrs. METHOD: Ahospital-based cross-sectional study was done between February 2021 to November 2021. It included 50 subjects with more than ve years history of systemic hypertension. The subjects having increased central corneal thickness (>560µm), obesity and myopia were excluded from the study. The study subjects underwent routine ophthalmic examination, intraocular pressure was measured with Goldmann's applanation tonometer before pupil dilatation and blood pressure measured by sphygmomanometer after 10 minutes of rest. The variables were analysed using percentages and mean ± standard deviation. RESULTS:Intraocular pressure increases with age up to 60 years, later on intraocular pressure decreases with further increase in age. In subjects aged 40- 60years intraocular pressure increases with systemic blood pressure (p<0.001). CONCLUSION: Hypertension was a contributing factor for raised intraocular pressure in subjects aged 40-60yrs. So, routine assessment for raised blood pressure is required for screening glaucoma.

Multimodal imaging in retinal artery macroaneurysms

AbstractPurposeTo describe multimodal imaging features in eyes with retinal artery macroaneurysms (RAM).MethodsA retrospective case series of 4 eyes diagnosed with RAM. All patients underwent a detailed ophthalmic examination, fundus photography, fluorescein angiography, swept source optical coherence tomography (SS‐OCT) and swept source optical coherence tomography angiography (SS‐OCTA).ResultsAll patients were females with a mean age of 57‐year‐old. There was a history of systemic hypertension in 3 patients. An acute vision loss was reported in 2 cases. The best corrected visual acuity at presentation ranged between +1.7 and +0.1 LogMar. RAM was single and unilateral in all cases. The RAM were seen in the temporal half of the retina in all cases and were localized in the superior temporal arcade in 2 cases and in the inferior temporal arcade in 2 cases. Fluorescein angiography allowed for the visualization of the RAM in 3 cases. SS‐OCT visualized the RAM in all cases and their consequences on the surrounding area and on the macula. SS‐OCTA allowed observation of blood flow in each layer of the RAM. En face OCT permitted delineation of the macroaneurysm wall in 2 cases.ConclusionsRetinal artery macroaneurysm is an acquired rare vascular disease that may mimic a variety of other conditions. Multimodal imaging approach is very useful for planning and assessing therapy.

Risk factors for periorbital dermatitis in patients using dorzolamide/timolol eye drops

This study assessed the clinical risk factors for periorbital dermatitis (PD) after using dorzolamide/timolol eye drops in a total of 1282 glaucoma patients. Both the PD(+) group and the PD(−) group were evaluated using clinical data such as age, sex, dosing duration, presence of benzalkonium chloride (BAK) in the formulation, ocular surgery history (e.g. cataract or glaucoma operations), height, weight, personal history of systemic hypertension, smoking, alcohol consumption, intraocular pressure, best-corrected visual acuity (BCVA), central corneal thickness, axial length, and visual field index (VFI). Univariate analyses showed that shorter dosing duration, higher rate of BAK-included cases, worse BCVA, worse VFI, more systemic hypertension history, and more ocular surgery history were more associated with the PD(+) group than the PD(−) group. The BAK(−) group showed a lower PD rate than the BAK-included group, which was supported by the Kaplan–Meier analysis (log-rank test, p = 0.0014). Multivariate analyses revealed that the probability of PD increased by 8 times if they had a history of ocular surgery and increased by 2.3% when the VFI decreased by 1% (Cox’s hazard regression test, p < 0.001). Therefore, a preservative-free dorzolamide/timolol can benefit the subjects for those who had ocular surgery or who have worse VFI.

Experience of cardiac implantable electronic device lead removal from a South African tertiary referral centre.

The rate of cardiac implantable electronic device (CIED) implantation in low- and middle-income countries is increasing. Patients recieving these devices are frequently older and with multiple co-morbidities, which may later lead to complications requiring CIED removal. CIED removals are associated with life-threatening complications. However, high sucesss rates are reported in high-income countries. The purpose of this study was to report on the experience of CIED removal in a resource-constrained setting. In this retrospective study, we included consecutive adult patients admitted to Groote Schuur Hospital and the University of Cape Town Private Academic Hospital for CIED removal from 1 January 2008 to 31 December 2019. During the study period, 53 patients underwent CIED removal (26 extractions and 27 explants). The patients had a mean (standard deviation) age of 59.1 (16.0) years. A history of systemic hypertension was present in 50.9% of patients, diabetes mellitus in 30.2% and dilated cardiomyopathy in 47.2%. Complete heart block was the leading indication for CIED implantation (37.7%), and device infection was the leading indication for removal (69.2%). CIEDs were removed after a median (interquantile range) of 243 (53-831) days. There were 40 leads extracted and 35 explants. Lead extractions were perfomed in the cardiac catheterisation laboratory under general anaesthesia via a percutaneous transvenous superior approach. There was one major and one minor complication related to lead extraction. CIED infections were the primary indication for CIED removal in a tertiary referral centre in South Africa. Despite being a low-volume centre, we report a high percutaneous transvenous extraction success rate with low complication rate; results which are comparable to high-volume centres.

Association of foveal avascular zone area withstructural and functional progression in glaucoma patients

BackgroundTo investigate whether quantitative optical coherence tomography angiography (OCTA) metrics of the superficial/deep macular retina and optic disc are associated with glaucoma progression risk.MethodsA total of 238 eyes from 119...

Risk Factors of the First-Time Stroke in the Southwest of Saudi Arabia: A Case-Control Study.

Worldwide, stroke is the second leading cause of death and a frequent cause of permanent disability. The objective was to identify the first-time stroke modifiable risk factors in the Aseer region, southwest Saudi Arabia. In a multicenter hospital-based case-control study design, all first stroke patients admitted to hospitals in the Aseer region were included consecutively over one year. Age, sex, and geographical residence-matched controls were selected and included in a ratio of 1:1. Data collected included altitude (low or high), nationality, marital status, educational level, family history of stroke, history of diabetes mellitus, history of systemic hypertension, high cholesterol level, current smoking, obesity, and regular exercise practice. The study included 1249 first-time stroke patients and 1249 age, sex, and residence-matched controls. Hypertension, diabetes mellitus, obesity, and high cholesterol were significantly highly prevalent among cases (57.7%, 49.4%, 42.0%, 29.4%, respectively) compared to controls (31.8%, 25.9%, 30.8%, 12.1%, respectively). Practicing regular exercise was significantly highly prevalent among controls (29.9%) compared to cases (13.1%). Multivariable logistic regression analysis revealed that systemic hypertension (adjusted odds ratio (aOR) = 2.12, 95%CI: 1.74–2.57), diabetes mellitus (aOR = 1.73, 95%CI: 1.41–2.21), obesity (aOR = 1.95, 95%CI: 1.61–2.28) and high cholesterol (aOR = 1.64, 95%CI: 1.28–2.10) were significant risk factors, while regular exercise practice was a significant protective factor (aOR = 0.12, 95%CI: 0.05–0.26) for stroke. Hypertension, diabetes mellitus, obesity, and high cholesterol are major risk factors for stroke in the Aseer region of southwest Saudi Arabia. The protective role of regular physical activity in reducing the risk of stroke is evident. The observed higher prevalence of potentially modifiable risk factors among stroke cases encourages an urgent need to develop and implement a national program to control these factors.

An unusual cause of "reverse batwing" sign.

An unusual cause of "reverse batwing" sign.

Bilateral chorioretinal folds in patients with central serous chorioretinopathy

Abstract Introduction: Chorioretinal folds accompanied by central serous chorioretinopathy (CSC) are relatively uncommon. Here, we report CARE-compliant 2 patients with bilateral CSC chorioretinal folds and CSC that was followed-up for 2 years. Patient concerns: Case 1 was a 68-year-old female who complained of central visual field disturbance in her left eye. At the initial visit, her visual acuity (VA) was 20/20 in her right eye and 20/40 in her left. She had a history of systemic hypertension and an optic neuropathy in her left eye 20 years previously. Case 2 was a 63-year-old female with CSC in her right eye. Her VA at her first visit was 20/200 in her right eye and 20/20 in her left. Diagnosis: In case 1, an examination revealed serous retinal detachment (SRD) in the macula and optic disc atrophy in her left eye and both fundi showed chorioretinal folds. Fluorescein angiography showed a fluorescein leakage area in her left eye. In case 2, examination of fundus showed marked SRD in her right macula and both fundi had chorioretinal folds. fluorescein angiography showed a fluorescein leakage area and indocyanine green angiography showed vascular hyperpermeability, but no choroidal neovascularization. Interventions and outcomes: In case 1, the patient rejected the photocoagulation treatment. Her SRD resolved spontaneously and the VA improved to 20/20 in her left eye nine months after the first visit. But the chorioretinal folds in both eyes remain till date. In case 2, photodynamic therapy was planned; however, her SRD disappeared spontaneously. Photocoagulation therapy was performed at the leak point and her VA improved to 20/20, but the bilateral chorioretinal folds remain till date. There has been no recurrence of CSC in both the patients in the 2 year follow-up. Conclusions: The exact mechanism of CSC remains uncertain. Choroidal vascular abnormalities, such as choroidal hyperpermeability and dilated choroidal vessels associated with congested vortex veins, have been previously reported even in the unaffected eye of CSC patients. We theorize that the bilateral chorioretinal folds in CSC patients were possibly induced by the outflow congestion of the vortex vein due to the marked CSC and choroidal dysregulation. As the choroid expanded due to CSC, the overlying Bruch membrane was forced into folds. Further investigation of the pathophysiology of CSC is needed.

Tendências na hospitalização de pacientes com Insuficiência Cardíaca Aguda

Objetivo: Identificar as causas de descompensação e as tendências na classificação e tratamento de pacientes internados com Insuficiência cardíaca. Métodos: Estudo observacional, realizado em um hospital privado de referência em cardiologia na cidade de Aracaju/SE. Foram analisados prontuários de junho de 2015 à agosto de 2018 e aplicou-se questionários em pacientes acima de 18 anos, que deram entrada com quadro de Insuficiência Cardíaca Aguda ou Crônica agudizada. Resultados: Incluíram-se 180 pacientes, com média de 73 anos e prevalência do sexo masculino (52,2%). Identificou-se que 94,4% dos pacientes apresentavam dispneia, 86,1% tinha história de Hipertensão arterial sistêmica, arritmia (33,3%) foi a principal causa de descompensação e a etiologia hipertensiva foi reconhecida em 39,4% dos casos. A Insuficiência Cardíaca com fração de ejeção reduzida foi identificada em 50,7%, tendo uma maior tendência no sexo masculino (p&lt;0,0001) e nos mais jovens (p=0,001). Os diuréticos (82,3%) e betabloqueadores (58,3%) foram as principais medicações usadas cronicamente e durante a internação 83,9% usaram diurético de alça para melhoria sintomática. O tempo médio de internação foi 12,45 dias e dos 6,1% que foram a óbito, 72,7% necessitaram de cuidados intensivos. Conclusão: As características identificadas nos pacientes com Insuficiência Cardíaca, como a associação de diversas comorbidades e o crescente diagnóstico de pacientes com fração de ejeção preservada, demonstram a necessidade de novas estratégias para o enfrentamento dessa síndrome.

COVID-19 Pneumonia in Patients With HIV: A Case Series

To the Editors: As our understanding of the coronavirus disease 2019 (COVID-19) improves through emerging data from the general population affected with COVID-19, there is a paucity of information regarding the management and prognosis of patients with HIV infection who may be at an increased risk for morbidity and mortality.1 Here, we describe our experience with the management of COVID-19 in patients with HIV at a health care facility in Newark, the center of the HIV epidemic of New Jersey.2 We included all patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection defined as a positive result on a reverse transcriptase polymerase chain reaction assay of a specimen collected on a nasopharyngeal swab. We identified 27 patients who had a known history of HIV at the time of presentation. Of these, 51% (n = 14) were managed in the ambulatory setting, whereas the rest were hospitalized. The median age was 58 years, there were 15 men and 12 women, and 93% (n = 25) were black or African Americans. The top 4 common symptoms at presentation were fever (67%), cough (63%), dyspnea (63%), and fatigue (48%), which had started over a median duration of 3 days before presentation. More than half of the patients had a history of systemic hypertension (59%), and about one-third reported diabetes mellitus (33%) or chronic kidney disease (27%) (Table 1).TABLE 1.: Demographic, Clinical Characteristics, and Outcomes of HIV Patients With COVID-19 (n = 27)TABLE 1-A.: Demographic, Clinical Characteristics, and Outcomes of HIV Patients With COVID-19 (n = 27)Ambulatory patients were hemodynamically stable at the time of presentation and demonstrated an oxygen saturation of 94–100% on ambient air. They were discharged home with no medical therapy but with the following recommendations: (1) self-quarantine for at least 2 weeks, (2) return to the emergency department for management in case of new-onset symptoms such as fever and dyspnea, and (3) adherence to antiretroviral therapy. Ambulatory patients were followed up with phone calls through a telemedicine platform over a median duration of 14 days. Patients were hospitalized and managed in the inpatient setting if they (1) had signs of sepsis or septic shock defined by the 2016 Third International Consensus Definitions for Sepsis and Septic Shock3 and (2) reported dyspnea requiring a step up in oxygenation therapy to maintain an oxygen saturation between 88% and 94%. Major laboratory markers and immunological data of their HIV status are given in Table 1. The median lymphocyte count was 17%, with a serum d-dimer and procalcitonin of 1.9 ng/mL and 0.26 μ/L, respectively. Patients reported a median CD4 count of 551, and the viral load was <120 in 96% (n = 26) of the patients. Data on antiretroviral regimen before presentation were unavailable in 15% (n = 4) of the patients. Among those with full data, integrase-based regimen was used in 33% (n = 9), nonnucleoside reverse transcriptase inhibitor (NNRTI) in 19% (n = 7), protease inhibitor (PI) + integrase in 19% (n = 7), NNRTI + integrase in 7% (n = 3), and PI based in only 1 patient. Of the hospitalized patients, 26% (n = 7) received hydroxychloroquine and 30% (n = 6) were managed with empiric antibiotics for suspected community-acquired pneumonia. Antiretroviral therapy was held during hospitalization. None of the patients had a superimposed infection, defined as an isolated organism in a positive sputum, urine, or blood culture. After a median hospital course of 10 days, 3 patients required intensive unit level of care and 2 of them had died. The deceased subjects were elderly patients, with multiple coexisting conditions whose course was complicated by septic shock and multiorgan dysfunction syndrome. There were no cases of hospital admission for patients who were managed in the ambulatory setting. In this series of HIV patients with COVID-19, we found a similarity in presentation with what has been reported for the general population. Half of the patients were managed in the ambulatory setting with no reported mortality or morbidity. In-hospital survival was 85% and 23% required intensive care unit admission. Of note, all 27 patients had well-controlled HIV infection evidenced by elevated CD4 count levels and low viral loads. As the challenge involving the management of COVID-19 evolves, large-scale studies are necessary to better understand the management and prognosis of patients with HIV who present with COVID-19.