Evidence of Pulmonary Hypertension after SARS-CoV-2 Infection in Subjects without Previous Significant Cardiovascular Pathology

BACKGROUND

Coronavirus (Covid-19) infection represents a serious medical condition, often associated with cardiovascular complications, pulmonary hypertension (PH), and right ventricle dysfunction (RVD). The aim of this study is to show, by means of transthoracic echocardiography (TTE), the presence of an increased estimated systolic pressure in the pulmonary artery (esPAP) and altered right ventricular global longitudinal strain (RV-GLS) in patients without history of PH.

METHODS

In a group of 91 patients, aged under 55 years, hospitalized for a moderate Covid-19 infection, a thorough cardiologic and TTE examination were performed two months after discharge. Their initial thorax computer-tomography (TCT) images and laboratory data were accessed from the electronic data base of the hospital.

RESULTS

We observed an increased prevalence of PH (7.69%) and RVD (10.28%), significantly correlated with the initial levels of the TCT score and inflammatory factors (p ˂ 0.001), but borderline changes were observed in more patients. Multivariate regression analysis showed that these factors and RV-GLS explain 89.5% of elevated esPAP.

CONCLUSIONS

In COVID-19 infection, PH and RVD are common complications, being encountered after the recovery even in moderate cases. It appears to be a connection between their severity and the extent of the initial pulmonary injury and of the inflammatory response.

Platelet Aggregation Inhibitors and Anticoagulants Delay Surgery for Hip Fractures

Background: we aimed to analyze the influence of antithrombotic medication in delaying surgery for fragility hip fractures; Method: a total of 312 consecutive hip fracture cases over 55 years who underwent surgery in our Orthopedic Clinic; Results: of these, 90 patients received chronic antithrombotic medication. There were no differences between the medicated group and controls (n = 222) regarding age, gender, type of fracture and haemoglobin at admittance. However, median time to surgery was significantly longer in the medicated group: 4(3–6) days compared to 2(1–4) (p < 0.0001). By type of medication, time to surgery was: 3(1–4) days for acetylsalicylic acid (n = 44), 6(5.25–7.75) days for clopidogrel (n = 15), 4.5(4–7) days for acenocoumarin (n = 18) and 5(4–7.25) days for novel direct oral anticoagulants (n = 13). The Charlson comorbidity index was significantly higher in the medicated group: 5 [4–5] versus 4 [3–5]. There were no differences in transfusions except for fresh frozen plasma, which was administered more in the medicated patients; Conclusions: the prevalence of platelet aggregation inhibitors and anticoagulant use among fragility hip fracture patients is high, with almost a third using some form of antithrombotic medication. This may significantly lengthen time to surgery.

Evolution of Heart Rate Variability and Heart Rate Turbulence in Patients with Depressive Illness Treated with Selective Serotonin Reuptake Inhibitors

Background and objectives: Major depressive disorder (MDD) and cardiovascular diseases (CVDs) represent serious and prevalent medical conditions. Autonomic nervous system (ANS) dysfunctions, expressed by parameters of heart rate variability (HRV) and heart rate turbulence (HRT), have been repeatedly associated with depression. The aim of our study was to identify potential HRV and HRT alterations in patients with MDD, before and after selective serotonin reuptake inhibitor (SSRI) therapy, and to observe any correlations between these parameters and the severity of depressive symptoms. Another aim was to evidence if there was a normalization or improvement of HRV and HRT parameters that paralleled the reduction of the intensity of depressive symptoms. Materials and Methods: We studied heart rate variability (HRV) and heart rate turbulence (HRT) in a sample of 78 patients, aged under 51 years, who were referred to our outpatient clinic between June 2017 and December 2019, for complaints in the context of a new onset major depressive disorder (MDD), before and after therapy with SSRIs. Results: By using 24 h Holter ECG monitoring, we evidenced alterations of HRV and HRT parameters, significantly correlated with the severity of depressive symptoms (p < 0.001), as assessed by the Montgomery-Åsberg Depression Rating Scale (MADRS). Our results indicated that these parameters improved following one and six months of SSRI therapy, when a partial or total remission of depressive symptoms was achieved (p < 0.001). Changes in HRV parameters were correlated with the reduction of the severity of depression. Conclusions: In our study group, we highlighted, through 24 h ECG Holter monitoring, frequent and clear HRV and HRT abnormalities that were statistically correlated with the severity of depressive symptoms. Furthermore, we were able to document a progressive improvement of these parameters, which corresponded with the improvement of depressive symptoms under SSRI therapy, when compared to the values measured before the commencement of antidepressant pharmacotherapy.

Research on the Effect of Aortic Valve Replacement with Mechanical Prosthesis on the Evolution of Ventricular Hypertrophy in Patients with Degenerative Aortic Stenosis

Aortic valvulopathies, and especially aortic stenosis (AS), are the most common valvular disorders. Untreated, 50% of patients with severe AS will die within 2-3 years from the onset of symptomatology. The standard treatment consists in the surgical replacement of the aortic valve with mechanical or biological prosthesis. 40 patients were included in the study after replacement of the aortic valve with double disc mechanical prosthesis for severe degenerative AS. The disks of the prosthesis are made of pyrolytic carbon characterized by extreme hardness, which provides wear protection over the years. The ring is composed of a graphite substrate coated with pyrolytic carbon and attached to a suture collar made of polyethylene (polytetrafluoroethylene - PTFE) or polyester (Dacron� or Teflon�). This study evaluates mass regression and left ventricular mass index at three months and one year postoperatively. The regression of the left ventricular mass at 3 months after the surgery is 25.86%, and at one year after the surgery this regression was reduced - 15.11%. The regression of the mass of the left ventricle and especially the premature regression, correlated with the degree of hypertrophy of the left ventricle preoperatively, highlight the beneficial effect of the double disc mechanical prosthesis.

Pulmonary hypertension in patients with end stage renal disease undergoing hemodialysis

Background

Pulmonary hypertension (PH) is a serious cardiovascular complication in patients with end stage renal disease (ESRD) undergoing hemodialysis (HD) via arterio-venous fistulas (AVF).

Aim

The aim of this study was to assess pulmonary vascular resistance (PVR), AVF flow volume (AVF-FV) and cardiac output (CO) and to highlight the impact of their augmentation, as well as of the duration of HD, on the occurrence of PH in patients with ESRD.

Methods

Our study group consisted of 51 dialyzed patients, with ESRD, without history of PH. We determined by ultrasonography the systolic pulmonary arterial pressure (PAPs), the left ventricular ejection fraction (EF), the cardiac output (CO), PVR and AVF-FV.

Results

We documented PH in 27 (52.94%) patients. All had elevated PVR, higher AVF-FV and CO comparing to patients without PH. They were undergoing HD for a longer period and had lower EF than those without PH. For all patients, we documented strong correlations between PAPs and PVR (r = 0.933, P < 0.001) and the duration of HD (r = 0.702, P < 0.001), but moderate ones with AVF-FV (r = 0.583, P < 0.001) and CO (r = 0.519, P < 0.001).

Conclusion

In patients with ESRD undergoing HD, PH was a common finding being associated with increased PVR, a longer duration of HD and chronic glomerulonephritis as etiology for ESRD. The majority of patients with PH had altered left ventricular systolic function, predisposing them to an increased risk to develop heart failure.

Impact of Elevated Parathormone Levels on the Severity of Pulmonary Hypertension in Patients with End Stage Renal Disease Undergoing Hemodialysis

One of the most severe cardiovascular complications encountered in patients with end stage renal disease (ESRD) undergoing hemodialysis (HD) is pulmonary hypertension (PH). Secondary hyperparathyroidism (SHPTH) is supposed to be one of the contributing mechanisms responsible for the occurrence of PH in these patients.The aim of our study is to determine if the elevated values of intact parathormone (iPTH) are correlated with increased pulmonary vascular resistance (PVR) in patients ESRD undergoing HD.Our study was conducted on 51 patients with ESRD undergoing HD. We assessed in all patients the levels of iPTH, as well as the systolic pulmonary arterial pressure (PAPs) and PVR by means of echocardiography. According to the levels of PAPs, patients were classified into two subgroups: 27 with 24 without PH.We documented a moderate correlation between iPTH and systolic pulmonary artery pressure (PAPs), respectively PVR in patients with PH. In patients without PH there were no significant correlations between iPAH and PVR, respectively PAPs.

Aspects of diastolic dysfunction in patients with new and recurrent depression

Objective

The main objective of this study was to evidence the potential impact of the intensity, duration and recurrence of depression on the development of arterial stiffness (AS) leading to left ventricular hypertrophy (LVH) and diastolic dysfunction (DD) in patients with new onset depression (NOD) and recurrent depression (RD) in comparison to 33 control subjects without depression. Another aim was to identify potential predictive factors regarding the occurrence of diastolic dysfunction (DD).

Methods

Our study group included 58 patients diagnosed with NOD and 128 diagnosed with RD, without any previously diagnosed significant heart diseases. The intensity of depression was evaluated by means of the Montgomery-Asberg Depression Rating Scale (MADRS). Assessment of pulse wave velocity (PWV), left ventricular mass index (LVMI) and echocardiographic parameters characterizing DD were performed for each patient.

Results

The cardiology evaluations suggested an increased prevalence of AS in all patients, of significantly higher rate than in controls (p<0.001), which was statistically correlated with the severity and duration of depression. Another significant finding was an increased prevalence of DD (29.31% and 63.28%, respectively; p<0.001) correlated with the MADRS score, total duration and number of recurrences/relapses. The multivariate logistic regression analysis identified PWV, the intensity and duration of depression as significant predictive factors for the occurrence of DD.

Conclusions

In our study, diastolic dysfunction was a common finding among patients with RD, but it was also noted, to a lesser extent, in those suffering with NOD. DD was associated with altered AS, and strongly correlated with the intensity and the duration of depressive symptoms. The two latter factors, together with an increased PWV, were strong predictors for the occurrence of DD.

Timely-Automatic Procedure for Estimating the Endocardial Limits of the Left Ventricle Assessed Echocardiographically in Clinical Practice

In this paper, we propose an analytical rapid method to estimate the endocardial borders of the left ventricular walls on echocardiographic images for prospective clinical integration. The procedure was created as a diagnostic support tool for the clinician and it is based on the use of the anisotropic generalized Hough transform. Its application is guided by a Gabor-like filtering for the approximate delimitation of the region of interest without the need for computing further anatomical characteristics. The algorithm is applying directly a deformable template on the predetermined filtered region and therefore it is responsive and straightforward implementable. For accuracy considerations, we have employed a support vector machine classifier to determine the confidence level of the automated marking. The clinical tests were performed at the Cardiology Clinic of the County Emergency Hospital Timisoara and they improved the physicians perception in more than 50% of the cases. The report is concluded with medical discussions.

Alterations of heart rate variability and turbulence in female patients with hyperthyroidism of various severities

Objective

The objective of the this study is to document the existence of statistically significant differences between parameters of heart rate variability (HRV) and heart rate turbulence (HRT), determined in women with overt hyperthyroidism (hT), compared to controls and to highlight their correlations with the level of thyroid hormones and the incidence of arrhythmias.

Methods

We studied the HRV in time and frequency domain, and the HRT in a group of 113 women with overt hT, without other cardiovascular risk factors or comorbidities, admitted to the endocrinology clinic of our hospital, between 2012 and 2016. Depending on the severity and duration of hT and levels of thyroid hormones, the patients were assigned to three groups: mild and moderate forms, severe hT with thyrotoxicosis and persistent cases with a relapse of hT. We performed 24 h Holter monitoring in all patients.

Results

HRV parameters in time domain (TD) were significantly depressed in patients comparing to controls. All patients had abnormal, positive values of turbulence onset (TO) with significant statistically differences (P < 0.0001) comparing to controls. Although positive, the values of turbulence slope (TS) decreased according to the severity of hT.

Conclusion

Patients with hT had depressed values of HRV parameters in TD, correlated with the severity of the thyroid disease and with the incidence of arrhythmias. All patients presented pathological values of TO. TS values were positive, but lower compared to controls.

Influences of Thyroid Hormones on the Alteration of Autonomic Nervous System in Female Patients with Overt Hyperthyroidism

The aim of this study is to document the impact of thyroid hormones on the autonomic nervous system (ANS), expressed by heart rate variability (HRV) and heart rate turbulence (HRT), in patients with hyperthyroidism, compared to controls. Another purpose is to determine if HRV and HRT parameters are significantly correlated with the levels of thyroid hormones and the duration of hyperthyroidism. We studied HRV, in time and frequency domain, and HRT in a group of 113 premenopausal women, with still untreated overt hyperthyroidism, without cardiovascular diseases or risk factors for atherosclerosis, admitted between 2015 and 2018 in the Endocrinology Clinic of our hospital and compared the results with data obtained in 29 healthy controls. Depending on the severity and duration of hyperthyroidism and levels of thyroid hormones, patients were assigned to three groups: mild and moderate hyperthyroidism, severe and recurrent forms. We performed 24 hours Holter monitoring in patients and controls. Regarding HRV parameters in time domain, they were significantly depressed in patients comparing to controls. Referring to HRT, all patients had abnormal, positive values of turbulence onset (TO) and we documented statistically significant differences (p[0.001) when compared to controls. All patients had normal positive values of turbulence slope (TS), which decreased parallel with the severity of hyperthyroidism. In patients with hyperthyroidism, we documented depressed values of HRV parameters in time domain, correlated with the duration and severity of the thyroid disease. Our patients had pathologic values of TO. Although positive, TS values were lower when compared to controls.

Advantages of Intra-cardiac Polymer Coated Electrodes Leads in Patients with Diabetes Mellitus and Cardiovascular Implantable Electronic Devices

Diabetes mellitus (DM) and cardiovascular diseases (CVD) represent worldwide, major health problems. Frequently, diabetic patients may require therapy with implantable intra-cardiac electronic devices. In this article, we analysed the complications related to the presence of polymer-coated electrodes leads occurred among 351 patients, carriers of implantable electronic intra-cardiac devices: permanent pacemakers (PPM), cardiac resynchronisation therapy (CRT) or implantable cardioverter-defibrillators (ICD). Of all these patients, 99 (28.20%) had type 2 DM (p=0.022), double than the prevalence of DM in the general population (11%). Only two patients with PPM and DM had fractures of electrodes leads and one was diagnosed with right heart infective endocarditis, but no non-diabetic patient developed any complications related to the presence of polymer coated electrodes leads.

Dacron Reconstruction of Aortic Aneurysm and Long Term Patients Evolution

Aortic aneurysm (AA) and especially dissecting aneurism (DAA) represent life threatening medical conditions and vascular reconstruction surgery with the insertion of a vascular prosthetic grafts is often required to save patients life. In this paper we debate over the long term outcome of 23 patients who underwent five to eight years ago an aortic reconstruction surgery with insertion of Dacron grafts. They attended, during 2018, the emergency room of the County Emergency Hospital Pius Brinzeu of Timisoara in terms of patency complications of the prosthesis. Despite slight dilatation of the Dacron graft and of the native aorta, presence of mural thrombi and/or progress of aortic regurgitation, their evolution was satisfactory, without severe complications.

Impact of Therapy with Selective Serotonine-Reuptake Inhibitors on the Evolution of Subclinical Atherosclerosis in Patients with Depressive Disorder

The aim of this study is to highlight the impact of therapy with Sertraline on the AS alterations, in a group of 128 patients with MDD, but without significant CVD or risk factors for atherosclerosis. A secondary goal was to analyze whether there are statistically significant correlations between AS and the intensity of the current depressive episode, as assessed by using the Montgomery-Asberg Depression Rating Scale (MADRS), while also taking into account the duration of MDD.

Impact of Therapy with L-Thyroxine on the Evolution of Arterial and Aortic Stiffness in Female Patients with Overt and Subclinical Hypothyroidism

The objective of this study is to highlight the impact of therapy with L-thyroxine on the altered arterial stiffness (AS) and reduced aortic distensibility (AoD), as well as on the left ventricular (LV) hypertrophy (LVH) and diastolic dysfunction (DD) in hypothyroid female patients.

Factors Influencing the Evolution of Pulmonary Hypertension in Patients with Hyperthyroidism

The aim of this study is to document the impact of thyroid hormones on pulmonary hypertension (PH). In two groups of hyperthyroid patients, one with Graves� disease and other with non-autoimmune aetiology, we have determined, by means of echocardiography, the estimated systolic pulmonary artery pressure (PAPs). We have documented an increased incidence of PH and statistically significant correlations between PAPs levels and free thyroxine (FT4), thyroid stimulating hormone (TSH) and TSH receptor antibodies (TRAb) and with the duration of hyperthyroidism. The severity of PH correlates with the severity and duration of hyperthyroidism. PAPs levels declined gradually, under specific therapy.

Aspects of Heart Failure in Patients with Ischemic Heart Disease after Percutaneous Coronary Revascularization with Polymer-coated Drug-Eluting Stents versus Bare-Metal Stents

Percutaneous coronary revascularization (PCR) with polymer-coated drug-eluting stents (DES) or bare-metal stents (BMS) is considered the standard therapy in advanced ischemic heart disease (IHD). Despite revascularisation, many of these patients subsequently develop heart failure with reduced ejection fraction (HFrEF). We analysed 51 patients with IHD, treated by PCR and insertion of DES and/or BMS who later developed HFrEF. Patients with DES where more likely women, of younger age and a higher incidence of diabetes mellitus compared to patients with BMS who were generally men, of older age and had more frequently acute ST-elevation myocardial infarction (STEMI) as indication for PCR. Although patients with DES had more severe IHD, their EF was higher, possibly due to the benefits offered by the DES.

Echocardiographic evolution of pulmonary hypertension in female patients with hyperthyroidism

Objective:

The objective of this study was to highlight the impact of increased cardiac output (CO) and/or pulmonary vascular resistance (PVR) on the occurrence and evolution of pulmonary hypertension (PH) in hyperthyroidism and to follow their evolution in patients under therapy.

Methods:

Our study group consisted of 142 women with hyperthyroidism of different severities and etiologies. We divided our patients into three groups: groups A (overt hyperthyroidism), B (recurrent disease), and C (subclinical forms). We performed echocardiography to determine echocardiographically estimated systolic pulmonary arterial pressure (eePAP), CO, and PVR before and at 3, 6, and 12 months after treatment with thyroid suppression therapy and beta-blockers.

Results:

In our study group we documented PH of various severities in 73 patients (51.4%). Increased CO, induced mostly by hyperthyroidism-specific tachycardia, was frequently detected in overt hyperthyroidism and also augmented PVR, as documented in 43.66% of patients with severe and recurrent forms. For all patients with PH, we emphasized a strong correlation between eePAP and PVR level (r=0.854, p<0.0001) and a moderate one with CO (r=0.437, p<0.0001) and with hyperthyroidism duration (r=0.545, p<0.0001). Under therapy, CO rapidly normalized and PVR significantly decreased in groups A and C. In group B, the reduction was modest and statistically significant.

Conclusion:

The pathophysiological mechanisms responsible for the occurrence of PH are elevated CO and PVR. While increased CO is rapidly alleviated under therapy, elevated eePAP and PVR persist in recurrent cases and are responsible for the perpetuation of PH.

High-risk pulmonary embolism in a patient with acute dissecting aortic aneurysm

In the last decades, an increased incidence of pulmonary embolism (PE) and acute dissection (AD) of aortic aneurysms has been registered mostly due to increased availability of advanced imaging techniques. They seldom occur concomitantly in the same patient. In this paper, we present the clinical challenges and controversies of diagnosis and therapy in a 70-year-old male patient with an atypical presentation of high-risk PE occurring concomitantly with a silent AD of a thoracic aortic aneurysm.

Hyperthyroidism and sick sinus syndrome, a rare but challenging association: A study of three cases

Hyperthyroidism is usually associated with sinus tachycardia or supraventricular tachyarrhythmias, but rarely with dysfunction of the sinus node or other conduction disturbances. Evidence of bradyarrhythmia in patients with hyperthyroidism is clinically relevant, but the fact that several drugs with negative chronotropic effects (beta-blockers and calcium channel antagonists) are frequently used in the management of these patients must be taken into account. In the presence of sick sinus syndrome (SSS) or other conductance disturbances, therapy with agents that delay the activity of sinus node or atrioventricular conduction can lead to extreme bradycardia with syncope. In this paper, aspects of diagnosis and therapy in three patients with SSS and hyperthyroidism, admitted in the Clinic of Endocrinology or/and Cardiology of the County Hospital, Timisoara, have been presented.

Edoxaban versus warfarin in patients with atrial fibrillation

BACKGROUND

Edoxaban is a direct oral factor Xa inhibitor with proven antithrombotic effects. The long-term efficacy and safety of edoxaban as compared with warfarin in patients with atrial fibrillation is not known.

METHODS

We conducted a randomized, double-blind, double-dummy trial comparing two once-daily regimens of edoxaban with warfarin in 21,105 patients with moderate-to-high-risk atrial fibrillation (median follow-up, 2.8 years). The primary efficacy end point was stroke or systemic embolism. Each edoxaban regimen was tested for noninferiority to warfarin during the treatment period. The principal safety end point was major bleeding.

RESULTS

The annualized rate of the primary end point during treatment was 1.50% with warfarin (median time in the therapeutic range, 68.4%), as compared with 1.18% with high-dose edoxaban (hazard ratio, 0.79; 97.5% confidence interval [CI], 0.63 to 0.99; P<0.001 for noninferiority) and 1.61% with low-dose edoxaban (hazard ratio, 1.07; 97.5% CI, 0.87 to 1.31; P=0.005 for noninferiority). In the intention-to-treat analysis, there was a trend favoring high-dose edoxaban versus warfarin (hazard ratio, 0.87; 97.5% CI, 0.73 to 1.04; P=0.08) and an unfavorable trend with low-dose edoxaban versus warfarin (hazard ratio, 1.13; 97.5% CI, 0.96 to 1.34; P=0.10). The annualized rate of major bleeding was 3.43% with warfarin versus 2.75% with high-dose edoxaban (hazard ratio, 0.80; 95% CI, 0.71 to 0.91; P<0.001) and 1.61% with low-dose edoxaban (hazard ratio, 0.47; 95% CI, 0.41 to 0.55; P<0.001). The corresponding annualized rates of death from cardiovascular causes were 3.17% versus 2.74% (hazard ratio, 0.86; 95% CI, 0.77 to 0.97; P=0.01), and 2.71% (hazard ratio, 0.85; 95% CI, 0.76 to 0.96; P=0.008), and the corresponding rates of the key secondary end point (a composite of stroke, systemic embolism, or death from cardiovascular causes) were 4.43% versus 3.85% (hazard ratio, 0.87; 95% CI, 0.78 to 0.96; P=0.005), and 4.23% (hazard ratio, 0.95; 95% CI, 0.86 to 1.05; P=0.32).

CONCLUSIONS

Both once-daily regimens of edoxaban were noninferior to warfarin with respect to the prevention of stroke or systemic embolism and were associated with significantly lower rates of bleeding and death from cardiovascular causes. (Funded by Daiichi Sankyo Pharma Development; ENGAGE AF-TIMI 48 ClinicalTrials.gov number, NCT00781391.).