Characterizing Long COVID: Deep Phenotype of a Complex Condition

BACKGROUND

Numerous publications describe the clinical manifestations of post-acute sequelae of SARS-CoV-2 (PASC or "long COVID"), but they are difficult to integrate because of heterogeneous methods and the lack of a standard for denoting the many phenotypic manifestations. Patient-led studies are of particular importance for understanding the natural history of COVID-19, but integration is hampered because they often use different terms to describe the same symptom or condition. This significant disparity in patient versus clinical characterization motivated the proposed ontological approach to specifying manifestations, which will improve capture and integration of future long COVID studies.

METHODS

The Human Phenotype Ontology (HPO) is a widely used standard for exchange and analysis of phenotypic abnormalities in human disease but has not yet been applied to the analysis of COVID-19.

FUNDING

We identified 303 articles published before April 29, 2021, curated 59 relevant manuscripts that described clinical manifestations in 81 cohorts three weeks or more following acute COVID-19, and mapped 287 unique clinical findings to HPO terms. We present layperson synonyms and definitions that can be used to link patient self-report questionnaires to standard medical terminology. Long COVID clinical manifestations are not assessed consistently across studies, and most manifestations have been reported with a wide range of synonyms by different authors. Across at least 10 cohorts, authors reported 31 unique clinical features corresponding to HPO terms; the most commonly reported feature was Fatigue (median 45.1%) and the least commonly reported was Nausea (median 3.9%), but the reported percentages varied widely between studies.

INTERPRETATION

Translating long COVID manifestations into computable HPO terms will improve analysis, data capture, and classification of long COVID patients. If researchers, clinicians, and patients share a common language, then studies can be compared/pooled more effectively. Furthermore, mapping lay terminology to HPO will help patients assist clinicians and researchers in creating phenotypic characterizations that are computationally accessible, thereby improving the stratification, diagnosis, and treatment of long COVID.

FUNDING

U24TR002306; UL1TR001439; P30AG024832; GBMF4552; R01HG010067; UL1TR002535; K23HL128909; UL1TR002389; K99GM145411.

A New Method to Optimize Stent Deployment by High-Definition Intravascular Ultrasound

OBJECTIVES

Optimal stent deployment by intravascular ultrasound (IVUS) improves outcome, but it can only be achieved in 50% of patients. We investigated the feasibility and effect of a new method of stent optimization on optimal stent deployment.

METHODS

IVUS analyses of 168 coronary segments were performed after angiography-guided stenting (AGS) and stent optimization in 29 patients (30 lesions). Minimum stent area (MSA), stent volume index (SVI), lumen area, external elastic membrane (EEM), and plaque burden (PB) were measured. Stent optimization included post-stent dilation with a balloon sized by high-definition (HD)-IVUS to the distal reference EEM diameter for stent underexpansion or malapposition, and stenting of PB >50% or edge dissection.

RESULTS

After AGS, stent deployment was suboptimal in 77% of patients. After stent optimization, MSA and SVI were significantly larger than AGS. Adequate stent expansion - defined as MSA ≥5.4 mm² or ≥90% of distal reference lumen area - was significantly higher after stent optimization vs AGS (87% vs 56%, respectively; P=.02). Optimal stent deployment - a composite of adequate stent expansion, no malapposition, PB <50% at the stent edges, and no edge dissection - was markedly higher after stent optimization vs AGS (87% vs 35%, respectively; P<.01).

CONCLUSION

After stent deployment and postdilation, stent results were suboptimal in two-thirds of patients. This simple online stent optimization by HD-IVUS was feasible and resulted in optimal stent deployment in the majority of patients. Randomized studies are warranted to compare the rate of optimal stent deployment and outcomes of this strategy vs other techniques.

Ticagrelor monotherapy: When is mono-antiplatelet therapy (MAPT) equivalent or better?

Ischemic and bleeding events portend equivalently poor prognosis after percutaneous coronary intervention (PCI). Risk factors for these untoward events largely overlap limiting the "decoupling" of bleeding and ischemic risk. While individual patient risk scores inform the duration of guideline recommended dual antiplatelet therapy (DAPT) to strike the optimal balance between ischemic and bleeding risk, a promising additional approach is to tailor the regimens themselves. In higher risk patients, 1 month of aspirin plus ticagrelor followed by 23 months of ticagrelor monotherapy has equivalent bleeding and numerically improved ischemic risk than standard DAPT for 12 months followed by aspirin monotherapy in the GLOBAL LEADERS trial. In the TWILIGHT study of high ischemic and bleeding risk patients, 12 months of ticagrelor monotherapy had lower bleeding risk with equivalent ischemic risk as DAPT after 3 months of successful DAPT. Individual risk scores should be developed informing both optimal antiplatelet regimen such as ticagrelor monotherapy and treatment duration after PCI.

Systemic toxicities of trastuzumab-emtansine predict tumor response in HER2+ metastatic breast cancer

The mechanism by which trastuzumab-emtansine (T-DM1) causes systemic toxicities apart from trastuzumab alone is currently unknown. We hypothesized that the systemic toxicities from T-DM1 may have been caused by the free and active maytansine released from the lysed HER2+ tumor cells, and if so, they may correlate with the response to treatment and eventually disease-free survival or patient outcome. In a retrospective, observational study, we evaluated 73 patients from three centers in the United States and Canada with advanced HER2+ breast cancer that received at least one dose of T-DM1. Toxicity grades were summed to create a corresponding toxicity sum score (TSS), and its association with clinical outcomes was analyzed. A higher TSS was significantly associated with longer progression-free survival with an HR = 0.66 [95% confidence interval [CI]: 0.47-0.92], P = .014, for each 1-point increase in the TSS score. Adjusted for baseline platelet count, aspartate transaminase and alanine transaminase, higher TSS remains significantly associated with longer progression-free survival with adjusted HR = 0.67 [95% CI: 0.47-0.93], P = .020. The analysis suggests that the systemic toxicities of T-DM1 were significantly correlated with its clinical efficacy. This is the first report to correlate the systemic toxicities of T-DM1 with clinical outcome. Further, this suggests that systemic toxicities of antibody-drug conjugates (ADCs) may serve as a predictive biomarker, particularly if noncleavable linkers are used. If confirmed in larger prospective studies, the present finding is significant because most ADCs do not have a biomarker predictive of clinical outcome other than the presence or absence of the antibody target.

Everolimus eluting bioresorbable vascular scaffolds for infrapopliteal critical limb ischemia: Moving beyond grasping at metal straws

Consistent and durable patency and clinical benefit after initially successful infrapopliteal percutaneous balloon transluminal angioplasty (PTA) for critical limb ischemia remains an unmet need. Permanently implanted metallic stents for suboptimal initial infrapopliteal PTA results also have limited patency and clinical results as well as other drawbacks. In 48 critical limb ischemia patients with infrapopliteal lesions < 50 mm length, everolimus eluting bioresorbable vascular scaffolds (EEBVS) achieved 90% primary patency and freedom from clinically driven target lesion revascularization at 2 years follow-up with no late scaffold thrombosis.

Safety and efficacy of paclitaxel drug-coated balloon treatment of femoropopliteal claudicants: Data and analytic methods matter

Claudicants with femoropopliteal disease average 25% higher primary patency and reduced target lesion revascularization long term with crystalline paclitaxel eluting stent and balloon treatment compared to uncoated devices. In animal models, local and downstream tissues have detectable paclitaxel for greater than 180 days. Aggregate data meta-analyses of 28 randomized trials suggested 50-100% higher all-cause mortality with paclitaxel device treatment. In contrast, more complete ascertainment of follow-up and pooled individual patient data analyses do not find significantly increased mortality, a dose-mortality relationship, or an unexpected cause of death pattern with paclitaxel eluting device treatment in femoropopliteal claudicants.

Underutilization of Treatment for Black Adults With Apparent Treatment-Resistant Hypertension: JHS and the REGARDS Study

Resistant hypertension, defined as blood pressure levels above goal while taking ≥3 classes of antihypertensive medication or ≥4 classes regardless of blood pressure level, is associated with increased cardiovascular disease risk. The 2018 American Heart Association Scientific Statement on Resistant Hypertension recommends healthy lifestyle habits and thiazide-like diuretics and mineralocorticoid receptor antagonists for adults with resistant hypertension. The term apparent treatment-resistant hypertension (aTRH) is used when pseudoresistance cannot be excluded. We estimated the use of healthy lifestyle factors and recommended antihypertensive medication classes among US Black adults with aTRH. Data were pooled for Black participants in the JHS (Jackson Heart Study) in 2009 to 2013 (n=2496) and the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) in 2013 to 2016 (n=3786). Outcomes included lifestyle factors (not smoking, not consuming alcohol, ≥75 minutes of vigorous-intensity or ≥150 minutes of moderate or vigorous physical activity per week, and body mass index <25 kg/m²) and recommended antihypertensive medications (thiazide-like diuretics and mineralocorticoid receptor antagonists). Overall, 28.3% of participants who reported taking antihypertensive medication had aTRH. Among participants with aTRH, 14.5% and 1.2% had ideal levels of 3 and 4 of the lifestyle factors, respectively. Also, 5.9% of participants with aTRH reported taking a thiazide-like diuretic, and 9.8% reported taking a mineralocorticoid receptor antagonist. In conclusion, evidence-based lifestyle factors and recommended pharmacological treatment are underutilized in Black adults with aTRH. Increased use of lifestyle recommendations and antihypertensive medication classes specifically recommended for aTRH may improve blood pressure control and reduce cardiovascular disease-related morbidity and mortality among US Black adults. Graphic Abstract A graphic abstract is available for this article.

A step forward in predicting anterograde crossing success for infrapopliteal chronic total occlusions

Forty to fifty percent of critical limb ischemia patients have infrainguinal chronic total occlusions, frequently below-the-knee. With probabilities ranging from 21 to 90%, the Infrapop-CTO Score presented here in CCI predicts the likelihood of anterograde crossing of infrapopliteal chronic total occlusions (CTO). Based on cap morphology, occlusion length, calcification, and restenosis status, the score is easily assessed in the lab. An unfavorable Infrapop-CTO Score of 5 or 6, particularly coupled with convex proximal and distal caps (chronic total occlusion plaque [CTOP] Type IV), portends very low (21%) probability of successful anterograde crossing. An initial retrograde crossing strategy should be considered in these patients when technically feasible, followed by combined anterograde-retrograde intervention.

Clopidogrel pretreatment may reduce early acquired thrombocytopenia after transcatheter aortic valve replacement (TAVR)

Transcatheter aortic valve replacement (TAVR) causes early acquired thrombocytopenia on postoperative Days 1 and 2 in 30-50% of patients. While usually transient and rarely severe, early acquired thrombocytopenia is strongly associated with 30-day and 1-year post-TAVR outcomes, including mortality. Observation from a prospective registry suggests pretreatment with the P2Y₁₂ receptor inhibitor clopidogrel before TAVR reduces the frequency and magnitude of early acquired thrombocytopenia. If a protective effect of clopidogrel pretreatment on early thrombocytopenia can be confirmed, then further study to determine if this translates into improved TAVR outcomes is warranted.

Risk of Major Adverse Cardiovascular Events and Major Hemorrhage Among White and Black Patients Undergoing Percutaneous Coronary Intervention

Background

Data on racial disparities in major adverse cardiovascular events (MACE) and major hemorrhage (HEM) after percutaneous coronary intervention are limited. Factors contributing to these disparities are unknown.

Methods and Results

PRiME‐GGAT (Pharmacogenomic Resource to Improve Medication Effectiveness–Genotype‐Guided Antiplatelet Therapy) is a prospective cohort. Patients aged ≥18 years undergoing percutaneous coronary intervention were enrolled and followed for up to 1 year. Racial disparities in risk of MACE and HEM were assessed using an incident rate ratio. Sequential cumulative adjustment analyses were performed to identify factors contributing to these disparities. Data from 919 patients were included in the analysis. Compared with white patients, black patients (n=203; 22.1% of the cohort) were younger and were more likely to be female, to be a smoker, and to have higher body mass index, lower socioeconomic status, higher prevalence of diabetes mellitus and moderate to severe chronic kidney disease, and presentation with acute coronary syndrome and to undergo urgent percutaneous coronary intervention. The incident rates of MACE (34.1% versus 18.2% per 100 person‐years, P<0.001) and HEM (17.7% versus 10.3% per 100 person‐years, P=0.02) were higher in black patients. The incident rate ratio was 1.9 (95% CI, 1.3–2.6; P<0.001) for MACE and 1.7 (95% CI, 1.1–2. 7; P=0.02) for HEM. After adjustment for nonclinical and clinical factors, black race was not significantly associated with outcomes. Rather, differences in socioeconomic status, comorbidities, and coronary heart disease severity were attributed to racial disparities in outcomes.

Conclusions

Despite receiving similar treatment, racial disparities in MACE and HEM still exist. Opportunities exist to narrow these disparities by mitigating the identified contributors.

Costs of postoperative delirium with transcatheter aortic valve replacement: Improved yet still present

Transcatheter aortic valve replacement (TAVR) is associated with a lower risk of postoperative delirium (PD) than surgical aortic valve replacement (SAVR) in patients aged ≥80, based on billing codes. Postoperative delirium remains a frequent problem after both SAVR and TAVR in clinical series and is costly. Improved pre-procedural prediction of PD risk would improve targeting of clinical care and allow testing of preventative and management strategies.

Intravascular ultrasound of normal left main arteries: Insights for stent optimization and standardization

Left main (LM) lumen diameters >4 mm are the norm and diameter >4.5 mm is present in almost 50% of patients by intravascular ultrasound (IVUS). Normal LM minimum lumen area averages 14.1 mm² for women and 16.2 mm² for men, requiring an area stenosis of 57-63% for LM lesion to be hemodynamically significant using the prevailing criterion of 6 mm² as a cut-off for revascularization. Incomplete LM visualization with IVUS is common (68%) without dedicated and specific LM IVUS techniques.

The promise of effective P2Y12 platelet receptor pretreatment: Not crushed yet

Pre-treatment with intact oral clopidogrel and prasugrel tablets in a representative observational study is not associated with altered ischemic or bleeding outcomes in acute coronary syndrome (ACS) patients. Limited by cost, cangrelor, a rapidly acting intravenous P2Y₁₂ platelet receptor inhibitor, achieved meaningful reductions in major adverse cardiovascular events (MACE) and stent thrombosis (ST) compared to oral clopidogrel pretreatment. Crushed prasugrel and ticagrelor (CP&T) administered orally achieve accepted thresholds of therapeutic platelet inhibition in one hour in approximately 2/3rds of patients compared to 1/3rd with intact oral tablets. A large, simple randomized trial should test whether CP&T pre-treatment could capture some of the potential outcome benefit of rapid P2Y₁₂ inhibition at no incremental risk and cost.