Cardiovascular Disease in Hospitalized Patients With a Diagnosis of Coronavirus From the Pre-COVID-19 Era in United States: National Analysis From 2016-2017

Burden of cardiovascular disease on coronavirus disease 2019 hospitalizations in the USA

BACKGROUND

Patients with cardiovascular disease (CVD) and risk factors have increased rates of adverse events and mortality after hospitalization for coronavirus disease 2019 (COVID-19). In this study, we attempted to identify and assess the effects of CVD on COVID-19 hospitalizations in the USA using a large national database.

METHODS

The current study was a retrospective analysis of data from the US National (Nationwide) Inpatient Sample from 2020. All adult patients 18 years of age and older who were admitted with the primary diagnosis of COVID-19 were included. The primary outcome was in-hospital mortality, while secondary outcomes included prolonged hospital length of stay, mechanical ventilation, and disposition other than home. Prolonged hospital length of stay was defined as a length of stay greater than the 75 th percentile for the full sample. The diagnoses were identified using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes.

RESULTS

A total of 1 050 040 patients were included in the study, of which 454 650 (43.3%) had prior CVD. Patients with CVD had higher mortality during COVID-19 hospitalization (19.3 vs. 5.0%, P  < 0.001). Similarly, these patients had a higher rate of prolonged hospital length of stay (34.5 vs. 21.0%, P  < 0.001), required mechanical ventilation (15.4 vs. 5.6%, P  < 0.001), and were more likely to be discharged to a disposition other than home (62.5 vs. 32.3%, P  < 0.001). Mean hospitalization cost was also higher in patients with CVD during hospitalization ($24 023 vs. $15 320, P  < 0.001). Conditional logistic regression analysis showed that the odds of in-hospital mortality [odds ratio (OR), 3.23; 95% confidence interval (CI), 2.91-3.45] were significantly higher for COVID-19 hospitalizations with CVD, compared with those without CVD. Similarly, prolonged hospital length (OR, 1.82; 95% CI, 1.43-2.23), mechanical ventilation (OR, 3.31; 95% CI, 3.06-3.67), and disposition other than home (OR, 2.01; 95% CI, 1.87-2.21) were also significantly higher for COVID-19 hospitalizations with coronary artery disease.

CONCLUSION

Our study showed that the presence of CVD has a significant negative impact on the prognosis of patients hospitalized for COVID-19. There was an associated increase in mortality, length of stay, ventilator use, and adverse discharge dispositions among COVID-19 patients with CVD. Adjustment in treatment for CVD should be considered when providing care to patients hospitalized for COVID-19 to mitigate some of the adverse hospital outcomes.

Use of Real-Time Remote Tele-mentored Ultrasound Echocardiography for Cardiovascular Disease Diagnosis in Adults: A Systematic Review

Cardiovascular diseases remain a major health challenge, leading to high rates of death and hospitalization globally. In the battle against these ailments, echocardiography stands as the frontline tool for diagnosis. Pioneering the charge in innovation, real-time remote tele-mentored ultrasound echocardiography (RTMUS echo) has emerged. This cutting-edge technique facilitates the instant transmission of cardiac imaging from the patient's side to experts in far-off locations, enabling prompt diagnosis and expert consultation. To bridge this gap, a systematic review was conducted to understand RTMUS echo's current applications in diagnosing heart diseases. Searches across six databases, guided by strict inclusion and exclusion criteria, yielded nine relevant articles. These studies assessed the feasibility of RTMUS echo and the technology behind it, confirming its potential for high-quality cardiac imaging. The findings reveal that RTMUS echo could notably improve care for cardiac patients, especially those in resource-constrained settings or in isolation because of infection risks. This technology enables quick access to diagnostic expertise, which is otherwise unavailable in such areas. Future research should aim to optimize the cost-effectiveness and application of RTMUS echo to enhance its benefits for global healthcare.

Sex Differences in Outcomes of Percutaneous Pulmonary Artery Thrombectomy in Patients With Pulmonary Embolism

BACKGROUND

The sex differences in use, safety outcomes, and health-care resource use of patients with pulmonary embolism (PE) undergoing percutaneous pulmonary artery thrombectomy are not well characterized.

RESEARCH QUESTION

What are the sex differences in outcomes for patients diagnosed with PE who undergo percutaneous pulmonary artery thrombectomy?

STUDY DESIGN AND METHODS

This retrospective cross-sectional study used national inpatient claims data to identify patients in the United States with a discharge diagnosis of PE who underwent percutaneous thrombectomy between January 2016 and December 2018. We evaluated the demographics, comorbidities, safety outcomes (in-hospital mortality), and health-care resource use (discharge to home, length of stay, and hospital charges) of patients with PE undergoing percutaneous thrombectomy.

RESULTS

Among 1,128,904 patients with a diagnosis of PE between 2016 and 2018, 5,160 patients (0.5%) underwent percutaneous pulmonary artery thrombectomy. When compared with male patients, female patients showed higher procedural bleeding (16.9% vs 11.2%; P < .05), required more blood transfusions (11.9% vs 5.7%; P < .05), and experienced more vascular complications (5.0% vs 1.5%; P < .05). Women experienced higher in-hospital mortality (16.9% vs 9.3%; adjusted OR, 1.9; 95% CI, 1.2-3.0; P = .003) when compared with men. Although length of stay and hospital charges were similar to those of men, women were less likely to be discharged home after surviving hospitalization (47.9% vs 60.3%; adjusted OR, 0.7; 95% CI, 0.50-0.99; P = .04).

INTERPRETATION

In this large nationwide cohort, women with PE who underwent percutaneous thrombectomy showed higher morbidity and in-hospital mortality compared with men.

Characteristics and outcomes of severe COVID-19 in hospitalized patients with cardiovascular diseases in the Amazonian region of Brazil: a retrospective cohort

The northern region of Brazil is already vulnerable to other infectious diseases and it was no different in COVID-19. However, cardiovascular diseases still lead the causes of death. Thus, the objective of this study is to identify the clinical predictors and outcome of severe COVID-19 in hospitalized patients with and without CVD in this region of the Amazon. A retrospective cohort, referring to the notifications from January 1 to December 31, 2020, including cases confirmed by molecular testing. The study consisted of 9223 confirmed cases for COVID-19. Of these, 6011 (65.17%) did not have cardiovascular disease and 3212 (34.83%) had some cardiovascular disease. The significance of deaths was in the age group of < 1 to 59 CVD carriers (< 0.001). Predictor of mortality were invasive ventilation for patients with CVD, (OR 23,688 CI 18,180-30,866), followed by chronic kidney disease (OR 2442 CI 1568-3740), dyspnea (OR 2312 CI 1817-3941), respiratory distress (OR 1523 CI 1210-2919), cough (OR 1268 CI 1005-1599), Lower oxygen saturation 95% (OR 1281 CI 1039-1579), diabetes mellitus (OR 1267 CI 1050-1528) and age (OR 1051 CI 1044-1058). Carriers of CVD had a lower survival rate (< 0.0001). The order of the predictors of death differed among the non-carriers, as well as the high odds ratio in the predictors of CVD, only cough was an independent predictor. The age group under 59 years was associated with deaths. We also show the shorter survival in CVD carriers, as well as the higher cardiovascular morbidity rate than other studies in the literature.

Heterogeneity and Risk of Bias in Studies Examining Risk Factors for Severe Illness and Death in COVID-19: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis synthesized the evidence on the impacts of demographics and comorbidities on the clinical outcomes of COVID-19, as well as the sources of the heterogeneity and publication bias of the relevant studies. Two authors independently searched the literature from PubMed, Embase, Cochrane library, and CINAHL on 18 May 2021; removed duplicates; screened the titles, abstracts, and full texts by using criteria; and extracted data from the eligible articles. The variations among the studies were examined by using Cochrane, Q.; I2, and meta-regression. Out of 11,975 articles that were obtained from the databases and screened, 559 studies were abstracted, and then, where appropriate, were analyzed by meta-analysis (n = 542). COVID-19-related severe illness, admission to the ICU, and death were significantly correlated with comorbidities, male sex, and an age older than 60 or 65 years, although high heterogeneity was present in the pooled estimates. The study design, the study country, the sample size, and the year of publication contributed to this. There was publication bias among the studies that compared the odds of COVID-19-related deaths, severe illness, and admission to the ICU on the basis of the comorbidity status. While an older age and chronic diseases were shown to increase the risk of developing severe illness, admission to the ICU, and death among the COVID-19 patients in our analysis, a marked heterogeneity was present when linking the specific risks with the outcomes.

Asymptomatic hyponatremia precipitated by COVID-19 pneumonia

COVID-19, also known as SARS-CoV-2, which originated in China in late 2019, has spread rapidly resulting in a global pandemic. COVID-19 has been linked to many different clinical manifestations, including hyponatremia. The cause of hyponatremia in acute COVID-19 infection is speculated to be multifactorial, including syndrome of inappropriate antidiuretic hormone secretion (SIADH), thought to be a result of inflammatory cytokines (Interleukin-6) and/or related to the gastrointestinal symptoms of this infection. SIADH in the setting of COVID-19 pneumonia is an established complication of this disease. This is the case of an 81-year-old woman with a history of hypertension, on thiazide diuretic, initially presented after a fall in the setting of COVID-19 pneumonia. She was treated with remdesivir and dexamethasone and then discharged to a rehab facility with normal labwork, including a sodium of 137 mmol/L. Two weeks later, routine labwork identified hyponatremia of 111 mmol/L. Her vital signs were normal, she was euvolemic on exam and alert/oriented with no complaints. Investigations into the etiology of her hyponatremia included a urine sodium of 72 mmol/L, serum osmolality of 231 mOsm/kg, urine osmolality of 454 mOsm/kg. We diagnosed hypo-osmolar hyponatremia due to SIADH. Management included fluid restriction and then tolvaptan, which ultimately corrected the serum sodium to 134 mmol/L. As COVID-19 is a new infection, little is known regarding its impact on electrolyte imbalances. Our patient recovered from pneumonia, then later developed severe hyponatremia possibly secondary to the lasting effects of inflammation in her lungs.

Clinical and cardiac magnetic resonance findings in post-COVID patients referred for suspected myocarditis

Objectives

We assessed possible myocardial involvement in previously cardiac healthy post-COVID patients referred for persisting symptoms with suspected myocarditis.

Background

Prior studies suggested myocardial inflammation in patients with coronavirus-induced disease 2019 (COVID-19). However, the prevalence of cardiac involvement among COVID patients varied between 1.4 and 78%.

Methods

A total of 56 post-COVID patients without previous heart diseases were included consecutively into this study. All patients had positive antibody titers against SARS-CoV-2. Patients were referred for persistent symptoms such as chest pain/discomfort, shortness of breath, or intolerance to activity. All patients underwent standardized cardiac assessment including electrocardiogram (ECG), cardiac biomarkers, echocardiography, and cardiac magnetic resonance (CMR).

Results

56 Patients (46 ± 12 years, 54% females) presented 71 ± 66 days after their COVID-19 disease. In most patients, the course of COVID-19 was mild, with hospital treatment being necessary in five (9%). At presentation, patients most often reported persistent fatigue (75%), chest pain (71%), and shortness of breath (66%). Acute myocarditis was confirmed by T1/T2-weighed CMR and elevated NTpro-BNP levels in a single patient (2%). Left ventricular ejection fraction was 56% in this patient. Additional eight patients (14%) showed suspicious CMR findings, including myocardial edema without fibrosis (n = 3), or non-ischemic myocardial injury suggesting previous inflammation (n = 5). However, myocarditis could ultimately not be confirmed according to 2018 Lake Louise criteria; ECG, echo and lab findings were inconspicuous in all eight patients.

Conclusions

Among 56 post-COVID patients with persistent thoracic complaints final diagnosis of myocarditis could be confirmed in a single patient using CMR.

Graphic abstract

Effectiveness of real-time tele-ultrasound for echocardiography in resource-limited medical teams

BACKGROUND

Echocardiography is a first-line tool for the screening of patients with cardiac dysfunction. However, the mastery of echocardiography requires significant training, and not all medical teams involve an echocardiography specialist. Telemedicine approaches can potentially improve the quality of echocardiography in resource-limited situations.

METHODS

We used a novel tablet-based hand-held ultrasound device that enables tele-ultrasound- a real-time video telecommunication with remote control for ultrasound images. A trainee scanned patients with various cardiovascular diseases and interpreted the images. Subsequently, the same trainee re-scanned the same patients and re-interpreted the same images using tele-ultrasound with an echocardiography specialist. An examination on the same patients by a blinded specialist was considered the gold standard.

RESULTS

We included 31 patients (median 77 [interquartile range 68-84] years old, 42% women). Mean absolute errors in left ventricular (LV) end-diastolic and end-systolic diameters, visual LV ejection fraction, and tricuspid annular plane systolic excursion decreased significantly after tele-ultrasound advice (5.9 mm, 5.8 mm, 8.6%, and 4.5 to 1.6 mm, 2.8 mm, 0.7%, and 1.8 mm, respectively, all p < 0.001), and intra-class correlation coefficients improved (0.76, 0.84, 0.68, and 0.44 to 0.96, 0.93, 0.99, and 0.90, respectively). Notably, with tele-advice, the trainee's examination showed perfect agreement with that of the specialist in classifying LV ejection fraction (> 50%, 50-35%, or > 35%) and identifying significant valvular heart diseases.

CONCLUSION

Real-time tele-ultrasound improved a trainee's echocardiography results to those of a specialist-level examination. This approach might be helpful in resource-limited medical teams where echocardiographic specialists are not readily available.

The habit of finger-licking: getting a solution out of the pandemic

The habit of finger-licking is an insanitary habit observed everywhere including hospital wards and other medical facilities, among providers and other staff members. It is an enduring habit that has been present before and during the pandemic and will continue unless serious notice of it is taken. Herein, we illustrate the risks imposed by this everyday habit on individuals practicing it and on surrounding people, we describe the challenges with prior attempts to defeat this habit, and we explain how the face mask can eliminate this ever-lasting habit.

COVID-19 with non-obstructive coronary artery disease in a young adult

Systemic inflammatory response due to cytokine storm in severe COVID-19 cases can lead to acute myocardial infarction, also affecting the younger population, without significant risk factors. We present the case of a 36-year-old male with morbid obesity and well-controlled asthma who had developed COVID-19-induced acute respiratory distress syndrome requiring mechanical ventilation and, subsequently, extracorporeal membrane oxygenation (ECMO) who developed myocardial infarction on Day 10 of admission and died on Day 15 of admission due to sequelae of severe COVID-19 infection. In young patients with COVID-19-induced respiratory infection, severe inflammatory response can lead to acute coronary syndrome in absence of obstructive lesions or plaque ruptures.