Cardiac complications in patients with community-acquired pneumonia: incidence, timing, risk factors, and association with short-term mortality

Time-dependent cardiovascular risks following pneumonia in inpatient and outpatient settings: A register-based cohort study

Background

The elevated long-term cardiovascular disease (CVD) risks associated with pneumonia have been observed among inpatients, yet the risks associated with outpatients are less understood.

Methods

We used register-based data and a matched cohort design, including 98,354 pneumonia inpatients and 44,486 outpatients, as well as a 5-fold number of matched healthy controls. Associations between pneumonia presentation (in inpatient and outpatient settings) and long-term CVD risks were measured by rate difference and hazard ratio (HR) using Poisson and Cox regressions in a time-dependent manner.

Results

During a maximum follow-up period of 5.7 years of ischemic heart disease (IHD), heart failure (HF), and stroke were documented among pneumonia inpatients.Relative to healthy controls, pneumonia patients showed increased risks of IHD, HF, and stroke. Women and young inpatients demonstrated stronger associations of CVD with pneumonia; inpatients aged 60 years or older showed the highest excessive CVD risks.

Conclusions

Pneumonia demanding outpatient and inpatient cares are intermediate-term and long-term risk factors of incident CVDs respectively, underscoring the need to plan setting-specific and time-dependent CVD-preventive cares following pneumonia presentation.

Role of lifestyle factors on the development and long-term prognosis of pneumonia and cardiovascular disease in the Chinese population

BACKGROUND

Whether adherence to a healthy lifestyle is associated with a lower risk of developing pneumonia and a better long-term prognosis remains unclear. This study aimed to investigate associations of individual and combined lifestyle factors (LFs) with the incidence risk and long-term prognosis of pneumonia hospitalization.

METHODS

Using data from the China Kadoorie Biobank study, we used the multistate models to investigate the role of five high-risk LFs, including smoking, excessive alcohol drinking, unhealthy dietary habits, physical inactivity, and unhealthy body shape, alone or in combination in the transitions from a generally healthy state at baseline to pneumonia hospitalization or cardiovascular disease (CVD, regarded as a reference outcome), and subsequently to mortality.

RESULTS

Most of the five high-risk LFs were associated with increased risks of transitions from baseline to pneumonia and from pneumonia to death, but with different risk estimates. The greater the number of high-risk LFs, the higher the risk of developing pneumonia and long-term mortality risk after pneumonia, with the strength of associations comparable to that of LFs and CVD. Compared to participants with 0-1 high-risk LF, the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for transitions from baseline to pneumonia and from pneumonia to death in those with five high-risk LFs were 1.43 (1.28-1.60) and 1.98 (1.61-2.42), respectively. Correspondingly, the respective HRs (95% CIs) for transitions from baseline to CVD and from CVD to death were 2.00 (1.89-2.11) and 1.44 (1.30-1.59), respectively. The risk estimates changed slightly when further adjusting for the presence of major chronic diseases.

CONCLUSION

In this Chinese population, unhealthy LFs were associated with an increased incidence and long-term mortality risk of pneumonia.

Impact of early myocardial injury on patients with severe pneumonia

Pneumonia often causes myocardial damage. This study sought to understand how early myocardial injury affects severe pneumonia patients' prognoses. This multi-center prospective cohort study from March 2020 to October 2023 comprised severe pneumonia patients. Binary logistic regression analysis examined how myocardial damage affects cardiac complications and acute renal injury (AKI). We used Spearman correlation analysis to examine the relationship between troponin I levels and the vasoactive inotropic score (VIS) in shock patients with myocardial injury. We used the Kaplan-Meier survival curve to evaluate the impact of myocardial injury on 30-day and 1-year survival rates. Mediation investigations examined how AKI and cardiac complications mediate myocardial injury and death. This study included 363 severe pneumonia patients, of whom 204 (56.2%) developed myocardial damage, 132 (36.4%) had cardiac problems, and 146 (40.2%) had AKI. Myocardial damage independently elevated the incidence of cardiac complications (OR = 2.548, 95% CI = 1.404-4.303, P = 0.002) and AKI (OR = 1.946, 95% CI = 1.177-3.219, P = 0.009). There was a positive link between troponin I and VIS in myocardial injury and shock patients (r = 0.43, P < 0.001). COX regression found myocardial injury to be a death risk (HR = 1.472, 95% CI = 1.043-2.077, P = 0.028). Adjusted Kaplan-Meier survival analysis showed significantly decreased short-term and long-term survival rates with myocardial injury (log-rank test P < 0.05). The mediation study showed that cardiac complications and AKI mediated myocardial injury and death by 19.30% and 17.18%, respectively. Early myocardial injury in severe pneumonia patients raises the likelihood of cardiac problems, AKI, and refractory shock, reducing short- and long-term survival.

Diagnosis and Vulnerability Risk Assessment of Atherosclerotic Plaques Using an Amino Acid-Assembled Near-Infrared Ratiometric Nanoprobe

To reduce the risk of atherosclerotic disease, it is necessary to not only diagnose the presence of atherosclerotic plaques but also assess the vulnerability risk of plaques. Accurate detection of the reactive oxygen species (ROS) level at plaque sites represents a reliable way to assess the plaque vulnerability. Herein, through a simple one-pot reaction, two near-infrared (NIR) fluorescent dyes, one is ROS responsive and the other is inert to ROS, are coassembled in an amphiphilic amino acid-assembled nanoparticle. In the prepared NIR fluorescent amino acid nanoparticle (named FANP), the fluorescent properties and ROS-responsive behaviors of the two fluorescent dyes are well maintained. Surface camouflage through red blood cell membrane (RBCM) encapsulation endows the finally obtained FANP@RBCM nanoprobe with not only further reduced cytotoxicity and improved biocompatibility but also increased immune escape capability, prolonged blood circulation time, and thus enhanced accumulation at atherosclerotic plaque sites. In vitro and in vivo experiments demonstrate that FANP@RBCM not only works well in probing the occurrence of atherosclerotic plaques but also enables plaque vulnerability assessment through the accurate detection of the ROS level at plaque sites in a reliable ratiometric mode, thereby holding great promise as a versatile tool for the diagnosis and risk assessment of atherosclerotic disease.

Giant Left Ventricular Thrombus Rapidly Developing in an Extremely Short Period of Time in a Patient With Severe Systolic Dysfunction

Although left ventricular thrombi (LVTs) are closely related to the prognosis of patients with systolic dysfunction, anticoagulation therapy is not recommended for the primary prevention of LVTs in patients with sinus rhythm heart failure. We report a case of a patient with systolic dysfunction who developed a giant LVT in an extremely short period of time (one month) after an infection. The LVT led to acute limb ischemia, gangrene, and death. Additionally, we incidentally detected pulmonary thrombosis in this patient.

Long-Term Outcomes in Severe Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) is globally one of the major causes of hospitalization and mortality. Severe CAP (sCAP) presents great challenges and need a comprehensive understanding of its long-term outcomes. Cardiovascular events and neurological impairment, due to persistent inflammation and hypoxemia, contribute to long-term outcomes in CAP, including mortality. Very few data are available in the specific population of sCAP. Multiple studies have reported variable 1-year mortality rates for patients with CAP up to 40.7%, with a clear influence by age, comorbidities, and disease severity. In terms of treatment, the potential protective role of macrolides in reducing mortality emphasizes the importance of appropriate empiric antibiotic therapy. This narrative review explores the growing interest in the literature focusing on the long-term implications of sCAP. Improved understanding of long-term outcomes in sCAP can facilitate targeted interventions and enhance posthospitalization care protocols.

Lung endothelium, tau, and amyloids in health and disease

Lung endothelia in the arteries, capillaries, and veins are heterogeneous in structure and function. Lung capillaries in particular represent a unique vascular niche, with a thin yet highly restrictive alveolar-capillary barrier that optimizes gas exchange. Capillary endothelium surveys the blood while simultaneously interpreting cues initiated within the alveolus and communicated via immediately adjacent type I and type II epithelial cells, fibroblasts, and pericytes. This cell-cell communication is necessary to coordinate the immune response to lower respiratory tract infection. Recent discoveries identify an important role for the microtubule-associated protein tau that is expressed in lung capillary endothelia in the host-pathogen interaction. This endothelial tau stabilizes microtubules necessary for barrier integrity, yet infection drives production of cytotoxic tau variants that are released into the airways and circulation, where they contribute to end-organ dysfunction. Similarly, beta-amyloid is produced during infection. Beta-amyloid has antimicrobial activity, but during infection it can acquire cytotoxic activity that is deleterious to the host. The production and function of these cytotoxic tau and amyloid variants are the subject of this review. Lung-derived cytotoxic tau and amyloid variants are a recently discovered mechanism of end-organ dysfunction, including neurocognitive dysfunction, during and in the aftermath of infection.

Definition, Epidemiology, and Pathogenesis of Severe Community-Acquired Pneumonia

The clinical presentation of community-acquired pneumonia (CAP) can vary widely among patients. While many individuals with mild symptoms can be managed as outpatients with excellent outcomes, there is a distinct subgroup of patients who present with severe CAP. In these cases, the mortality rate can reach approximately 25% within 30 days and even up to 50% within a year. It is crucial to focus attention on these patients who are at higher risk. Among the various definitions of severe CAP found in the literature, one commonly used criterion is the requirement for admission to intensive care unit. Notable epidemiological characteristics of these patients include the impact of acute cardiovascular diseases on clinical outcomes and the enduring, independent effect of pneumonia on long-term outcomes. Factors such as pathogen virulence, the presence of comorbidities, and the host response are important contributors to the pathogenesis of severe CAP. In these patients, the host response may be dysregulated and compartmentalized. Gaining a better understanding of the epidemiology and pathogenesis of severe CAP will provide a foundation for the development of new therapies for this condition. This manuscript aims to review the definition, epidemiology, and pathogenesis of severe CAP, shedding light on important aspects that can aid in the improvement of patient care and outcomes.

Protective effect and mechanism of Qingfei Paidu decoction on myocardial damage mediated by influenza viruses

Introduction: Significant attention has been paid to myocardial damage mediated by the single-stranded RNA virus. Qingfei Paidu decoction (QFPDD) has been proved to protect the damage caused by the influenza virus A/PR/8/1934 (PR8), but its specific mechanism is unclear. Methods: Molecular biological methods, together with network pharmacology, were used to analyze the effects and underlying mechanism of QFPDD treatment on PR8-induced myocardial damage to obtain insights into the treatment of COVID-19-mediated myocardial damage. Results: Increased apoptosis and subcellular damage were observed in myocardial cells of mice infected by PR8. QFPDD treatment significantly inhibited the apoptosis and subcellular damage induced by the PR8 virus. The inflammatory factors IFN-β, TNF-α, and IL-18 were statistically increased in the myocardia of the mice infected by PR8, and the increase in inflammatory factors was prevented by QFPDD treatment. Furthermore, the expression levels or phosphorylation of necroptosis-related proteins RIPK1, RIPK3, and MLKL were abnormally elevated in the group of infected mice, while QFPDD restored the levels or phosphorylation of these proteins. Our study demonstrated that HIF-1α is a key target of QFPDD in the treatment of influenza virus-mediated injury. The HIF-α level was significantly increased by PR8 infection. Both the knockdown of HIF-1α and treatment of the myocardial cell with QFPDD significantly reversed the increased inflammatory factors during infection. Overexpression of HIF-1α reversed the inhibition effects of QFPDD on cytokine expression. Meanwhile, seven compounds from QFPDD may target HIF-1α. Conclusion: QFPDD can ameliorate influenza virus-mediated myocardial damage by reducing the degree of cell necroptosis and apoptosis, inhibiting inflammatory response and the expression of HIF-1α. Thus, our results provide new insights into the treatment of respiratory virus-mediated myocardial damage.

Exposome in ischaemic heart disease: beyond traditional risk factors

Ischaemic heart disease represents the leading cause of morbidity and mortality, typically induced by the detrimental effects of risk factors on the cardiovascular system. Although preventive interventions tackling conventional risk factors have helped to reduce the incidence of ischaemic heart disease, it remains a major cause of death worldwide. Thus, attention is now shifting to non-traditional risk factors in the built, natural, and social environments that collectively contribute substantially to the disease burden and perpetuate residual risk. Of importance, these complex factors interact non-linearly and in unpredictable ways to often enhance the detrimental effects attributable to a single or collection of these factors. For this reason, a new paradigm called the 'exposome' has recently been introduced by epidemiologists in order to define the totality of exposure to these new risk factors. The purpose of this review is to outline how these emerging risk factors may interact and contribute to the occurrence of ischaemic heart disease, with a particular attention on the impact of long-term exposure to different environmental pollutants, socioeconomic and psychological factors, along with infectious diseases such as influenza and COVID-19. Moreover, potential mitigation strategies for both individuals and communities will be discussed.

Retrospective computed tomography assessment of chemotherapy-related pneumonia with severity screening in pediatric acute lymphoblastic leukemia by radiological imaging

Objectives

To evaluate the radiological imaging-guided severity along the pneumonia course and evaluate the chest computed tomography (CT) findings of chemotherapy-related pneumonia in children with acute lymphoblastic leukemia (ALL).

Materials and methods

A retrospective database review of children with ALL was conducted from March 2016 to August 2021 to identify cases with CT images who developed pneumonia during the chemotherapy course. A total of 51 children with ALL developed pneumonia were ultimately included (31 boys and 20 girls, mean age: 6 ± 4 years [standard deviation]). Each child's demographics, medical records, and laboratory results were collected. The CT images were then reviewed and the radiologic severity index (RSI) was calculated based on the regional opacity and implicated volume. A t-test, U test, Pearson's Chi-square test, and Fisher's exact test were performed to compare the clinical or radiologic features between the severe and moderate cases. The linear regression models were employed to analyze the correlation of RSIs with other clinical features.

Results

Eleven children (22 %, 11/51) displayed severe phenotypes associated with respiratory failure. The ground glass opacity (GGO) frequently appeared (65 % of CT images). The baseline RSI was positively associated with the lowest lymphocyte (p = .003), neutrophil (p = .01) counts, and the highest C-reactive protein level (p = .04). The peak RSI may predict severe phenotypes at a cutoff of 4.5 (AUC 0.76 [0.61, 0.91]) with 73 % sensitivity and 63 % specificity.

Conclusion

The chest CT images of children with chemotherapy-related pneumonia displayed clinically related baseline RSI and a peak RSI of >4.5 of 36 predicted severe phenotypes.

Vaccines in cardiology, an underutilized strategy to reduce the residual cardiovascular risk

Cardiovascular diseases stand as the leading cause of mortality among adults globally. For decades, comprehensive evidence has underscored the correlation between infections, particularly those involving the respiratory system, and an elevated risk of cardiovascular and cerebrovascular events, as well as all-cause mortality. The mechanisms through which infections heighten cardiovascular events are intricate, encompassing immune system activation, systemic inflammation, hypercoagulable states, sympathetic system activation, and increased myocardial oxygen demand. Respiratory infections further contribute hypoxemia to this complex interplay. These mechanisms intertwine, giving rise to endothelial dysfunction, plaque ruptures, myocardial depression, and heart failure. They can either instigate de novo cardiovascular events or exacerbate pre-existing conditions. Compelling evidence supports the safety of influenza, pneumococcal, herpes zoster, COVID-19 and respiratory syncytial virus vaccines in individuals with cardiovascular risk factors or established cardiovascular disease. Notably, the influenza vaccine has demonstrated safety even when administered during the acute phase of a myocardial infarction in individuals undergoing angioplasty. Beyond safety, these vaccinations significantly reduce the incidence of cardiovascular events in individuals with an augmented cardiovascular risk. Nevertheless, vaccination rates remain markedly suboptimal. This manuscript delves into the intricate relationship between infections and cardiovascular events. Additionally, we highlight the role of vaccinations as a tool to mitigate these occurrences and reduce residual cardiovascular risk. Finally, we emphasize the imperative need to optimize vaccination rates among individuals with heart diseases.

Phase 3 trial to evaluate the safety, tolerability, and immunogenicity of V114, a 15-valent pneumococcal conjugate vaccine, followed by 23-valent pneumococcal polysaccharide vaccine 6 months later, in at-risk adults 18-49 years of age (PNEU-DAY): A subgroup analysis by baseline risk factors

Immunocompetent adults with certain medical and behavioral factors are at increased risk of pneumococcal disease. In some countries, sequential vaccination with 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) is recommended for at-risk adults. This subgroup analysis from a phase 3 study evaluated the safety, tolerability, and immunogenicity of sequential administration of either V114 (a 15-valent PCV containing serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F, and 33F) or PCV13, followed 6 months later by PPSV23, in immunocompetent adults 18-49 years of age with pre-defined risk factors for pneumococcal disease. Safety and immunogenicity post-vaccination were analyzed by type and baseline number of risk factors for pneumococcal disease (1 and ≥2 risk factors). This analysis included 1,131 participants randomized 3:1 to receive either V114 or PCV13, followed by PPSV23. The majority (73.1%) of participants had at least one risk factor. Safety and tolerability profiles of V114 and PCV13 were similar across risk factor groups. V114 administered either alone or sequentially with PPSV23 6 months later was immunogenic for all 15 serotypes, including those not contained in PCV13, regardless of the number of baseline risk factors. V114 has the potential to broaden serotype coverage for at-risk adults.

Major adverse cardiovascular events (MACE) in patients with severe COVID-19 registered in the ISARIC WHO clinical characterization protocol: A prospective, multinational, observational study

PURPOSE

To determine its cumulative incidence, identify the risk factors associated with Major Adverse Cardiovascular Events (MACE) development, and its impact clinical outcomes.

MATERIALS AND METHODS

This multinational, multicentre, prospective cohort study from the ISARIC database. We used bivariate and multivariate logistic regressions to explore the risk factors related to MACE development and determine its impact on 28-day and 90-day mortality.

RESULTS

49,479 patients were included. Most were male 63.5% (31,441/49,479) and from high-income countries (84.4% [42,774/49,479]); however, >6000 patients were registered in low-and-middle-income countries. MACE cumulative incidence during their hospital stay was 17.8% (8829/49,479). The main risk factors independently associated with the development of MACE were older age, chronic kidney disease or cardiovascular disease, smoking history, and requirement of vasopressors or invasive mechanical ventilation at admission. The overall 28-day and 90-day mortality were higher among patients who developed MACE than those who did not (63.1% [5573/8829] vs. 35.6% [14,487/40,650] p < 0.001; 69.9% [6169/8829] vs. 37.8% [15,372/40,650] p < 0.001, respectively). After adjusting for confounders, MACE remained independently associated with higher 28-day and 90-day mortality (Odds Ratio [95% CI], 1.36 [1.33-1.39];1.47 [1.43-1.50], respectively).

CONCLUSIONS

Patients with severe COVID-19 frequently develop MACE, which is independently associated with worse clinical outcomes.

Stattic ameliorates the cecal ligation and puncture-induced cardiac injury in septic mice via IL-6-gp130-STAT3 signaling pathway

AIM

Sepsis-induced cardiac dysfunction is the leading cause of higher morbidity and mortality with poor prognosis in septic patients. Our recent previous investigation provides evidence of the hallmarks of signal transducer and activator of transcription3 (STAT3) activation in sepsis and targeting of STAT3 with Stattic, a small-molecule inhibitor of STAT3, has beneficial effects in various septic tissues. We investigated the possible cardioprotective effects of Stattic on cardiac inflammation and dysfunction in mice with cecal ligation and puncture (CLP)-induced sepsis.

MAIN METHODS

A polymicrobial sepsis model was induced by CLP in mice and Stattic (25 mg/kg) was intraperitoneally given at one and twelve hours after CLP operation. The cecum was exposed in sham-control mice without CLP. After 18 h of surgery, electrocardiogram (ECG) for anaesthized mice was registered followed by collecting of samples of blood and tissues for bimolecular and histopathological assessments. Myeloperoxidase, a marker of neutrophil infiltration, was assessed immunohistochemically.

KEY FINDINGS

CLP profoundly impaired cardiac functions as evidenced by ECG changes in septic mice as well as elevation of cardiac enzymes, and inflammatory markers with myocardial histopathological and immunohistochemical alterations. While, Stattic markedly reversed the CLP-induced cardiac abnormalities and restored the cardiac function by its anti-inflammatory activities.

SIGNIFICANCE

Stattic treatment had potential beneficial effects against sepsis-induced cardiac inflammation, dysfunction and damage. Its cardioprotective effects were possibly attributed to its anti-inflammatory activities by targeting STAT3 and downregulation of IL-6 and gp130. Our investigations suggest that Stattic could be a promising target for management of cardiac sepsis and inflammation-related cardiac damage.

Predictors and prognostic implications of hospital-acquired pneumonia in patients admitted for acute heart failure

Introduction

Data on predictors and prognosis of hospital acquired pneumonia (HAP) in patients admitted for acute heart failure (AHF) to intensive care units (ICU) are scarce. Better knowledge of these factors may inform management strategies. This study aimed to assess the incidence and predictors of HAP and its impact on management and outcomes in patients hospitalised for AHF in the ICU.

Methods

this was a retrospective single-centre observational study. Patient-level and outcome data were collected from an anonymized registry-based dataset. Primary outcome was in-hospital all-cause mortality and secondary outcomes included length of stay (LOS), requirement for inotropic/ventilatory support, and prescription patterns of heart failure (HF) drug classes at discharge.

Results

Of 638 patients with AHF (mean age, 71.6 ± 12.7 years, 61.9% male), HAP occurred in 137 (21.5%). In multivariable analysis, HAP was predicted by de novo AHF, higher NT proB-type natriuretic peptide levels, pleural effusion on chest x-ray, mitral regurgitation, and a history of stroke, diabetes, and chronic kidney disease. Patients with HAP had a longer LOS, and a greater likelihood of requiring inotropes (adjusted odds ratio, OR, 2.31, 95% confidence interval, CI, 2.16-2.81; p < 0.001) or ventilatory support (adjusted OR 2.11, 95%CI, 1.76-2.79, p < 0.001). After adjusting for age, sex and clinical covariates, all-cause in-hospital mortality was significantly higher in patients with HAP (hazard ratio, 2.10; 95%CI, 1.71-2.84; p < 0.001). Patients recovering from HAP were less likely to receive HF medications at discharge.

Discussion

HAP is frequent in AHF patients in the ICU setting and more prevalent in individuals with de novo AHF, mitral regurgitation, higher burden of comorbidities, and more severe congestion. HAP confers a greater risk of complications and in-hospital mortality, and a lower likelihood of receiving evidence-based HF medications at discharge.

The Global Burden of Community-Acquired Pneumonia in Adults, Encompassing Invasive Pneumococcal Disease and the Prevalence of Its Associated Cardiovascular Events, with a Focus on Pneumolysin and Macrolide Antibiotics in Pathogenesis and Therapy

Despite innovative advances in anti-infective therapies and vaccine development technologies, community-acquired pneumonia (CAP) remains the most persistent cause of infection-related mortality globally. Confronting the ongoing threat posed by Streptococcus pneumoniae (the pneumococcus), the most common bacterial cause of CAP, particularly to the non-immune elderly, remains challenging due to the propensity of the elderly to develop invasive pneumococcal disease (IPD), together with the predilection of the pathogen for the heart. The resultant development of often fatal cardiovascular events (CVEs), particularly during the first seven days of acute infection, is now recognized as a relatively common complication of IPD. The current review represents an update on the prevalence and types of CVEs associated with acute bacterial CAP, particularly IPD. In addition, it is focused on recent insights into the involvement of the pneumococcal pore-forming toxin, pneumolysin (Ply), in subverting host immune defenses, particularly the protective functions of the alveolar macrophage during early-stage disease. This, in turn, enables extra-pulmonary dissemination of the pathogen, leading to cardiac invasion, cardiotoxicity and myocardial dysfunction. The review concludes with an overview of the current status of macrolide antibiotics in the treatment of bacterial CAP in general, as well as severe pneumococcal CAP, including a consideration of the mechanisms by which these agents inhibit the production of Ply by macrolide-resistant strains of the pathogen.

γ' fibrinogen levels as a biomarker of COVID-19 respiratory disease severity

Coronavirus disease 2019 (COVID-19) is characterized by a pro-inflammatory state associated with organ failure, thrombosis, and death. We investigated a novel inflammatory biomarker, γ' fibrinogen (GPF), in 103 hospitalized patients with COVID-19 and 19 healthy controls. We found significant associations between GPF levels and the severity of COVID-19 as judged by blood oxygen saturation (SpO2). The mean level of GPF in the patients with COVID-19 was significantly higher than in controls (69.8 (95 % CI 64.8-74.8) mg/dL compared with 36.9 (95 % CI 31.4-42.4) mg/dL, p < 0.0001), whereas C-reactive protein (CRP), lactate dehydrogenase (LDH), and total fibrinogen levels were not significantly different between groups. Mean GPF levels were significantly highest in patients with severe COVID-19 (SpO2 ≤ 93 %, GPF 75.2 (95 % CI 68.7-81.8) mg/dL), compared to mild/moderate COVID-19 (SpO2 > 93 %, GPF 62.5 (95 % CI 55.0-70.0) mg/dL, p = 0.01, AUC of 0.68, 95 % CI 0.57-0.78; Youden's index cutpoint 62.9 mg/dL, sensitivity 0.64, specificity 0.63). In contrast, CRP, interleukin-6, ferritin, LDH, D-dimers, and total fibrinogen had weaker associations with COVID-19 disease severity (all ROC curves with lower AUCs). Thus, GPF may be a useful inflammatory marker of COVID-19 respiratory disease severity.

Risk of Acute Myocardial Infarction Among Patients With Laboratory-Confirmed Invasive Pneumococcal Disease: A Self-Controlled Case Series Study

BACKGROUND

Acute myocardial infarction (AMI) events have been reported among patients with certain viral and bacterial infections. Whether invasive pneumococcal disease (IPD) increases the risk of AMI remains unclear. We examined whether laboratory-confirmed IPD was associated with the risk of AMI.

METHODS

We conducted a self-controlled case series analysis among adult Tennessee residents with evidence of an AMI hospitalization (2003-2019). Patient follow-up started 1 year before the earliest AMI and continued through the date of death, 1 year after AMI, or study end (December 2019). Periods for AMI assessment included the 7 to 1 days before IPD specimen collection (pre-IPD detection), day 0 through day 7 after IPD specimen collection (current IPD), day 8 to 28 after IPD specimen collection (post-IPD), and a control period (all other follow-up). We used conditional Poisson regression to calculate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) for each risk period compared with control periods using within-person comparisons.

RESULTS

We studied 324 patients hospitalized for AMI with laboratory-confirmed IPD within 1 year before or after the AMI hospitalization. The incidence of AMI was significantly higher during the pre-IPD detection (IRR, 10.29; 95% CI: 6.33-16.73) and the current IPD (IRR, 92.95; 95% CI: 72.17-119.71) periods but nonsignificantly elevated in the post-IPD risk period (IRR, 1.83; 95% CI: .86-3.91) compared with control periods. The AMI incidence was higher in the post-IPD control period (29 to 365 days after IPD; IRR, 2.95; 95% CI: 2.01-4.32).

CONCLUSIONS

Hospitalizations with AMI were strongly associated with laboratory-confirmed IPD.

Acute Coronary Syndrome, Stroke, and Mortality after Community-Acquired Pneumonia: Systematic Review and Meta-Analysis

One-third of adult inpatients with community-acquired pneumonia (CAP) develop acute coronary syndrome (ACS), stroke, heart failure (HF), arrhythmias, or die. The evidence linking CAP to cardiovascular disease (CVD) events is contradictory. We aimed to systematically review the role of CAP as a CVD risk factor. We registered the protocol (CRD42022352910) and searched for six databases from inception to 31 December 2022. We included 13 observational studies, 276,109 participants, 18,298 first ACS events, 12,421 first stroke events, 119 arrhythmic events, 75 episodes of new onset or worsening HF, 3379 deaths, and 218 incident CVD events. CAP increased the odds of ACS (OR 3.02; 95% CI 1.88–4.86), stroke (OR 2.88; 95% CI 2.09–3.96), mortality (OR 3.22; 95% CI 2.42–4.27), and all CVD events (OR 3.37; 95% CI 2.51–4.53). Heterogeneity was significant (I2 = 97%, p < 0.001). Subgroup analysis found differences according to the continent of origin of the study, the follow-up length, and the sample size (I2 > 40.0%, p < 0.10). CAP is a significant risk factor for all major CVD events including ACS, stroke, and mortality. However, these findings should be taken with caution due to the substantial heterogeneity and the possible publication bias.

Transient increase in atherosclerotic plaque macrophage content following Streptococcus pneumoniae pneumonia in ApoE-deficient mice

Introduction

Despite epidemiological associations between community acquired pneumonia (CAP) and myocardial infarction, mechanisms that modify cardiovascular disease during CAP are not well defined. In particular, largely due to a lack of relevant experimental models, the effect of pneumonia on atherosclerotic plaques is unclear. We describe the development of a murine model of the commonest cause of CAP, Streptococcus pneumoniae pneumonia, on a background of established atherosclerosis. We go on to use our model to investigate the effects of pneumococcal pneumonia on atherosclerosis.

Methods

C57BL/6J and ApoE-/- mice were fed a high fat diet to promote atherosclerotic plaque formation. Mice were then infected with a range of S. pneumoniae serotypes (1, 4 or 14) with the aim of establishing a model to study atherosclerotic plaque evolution after pneumonia and bacteremia. Laser capture microdissection of plaque macrophages enabled transcriptomic analysis.

Results

Intratracheal instillation of S. pneumoniae in mice fed a cholate containing diet resulted in low survival rates following infection, suggestive of increased susceptibility to severe infection. Optimization steps resulted in a final model of male ApoE-/- mice fed a Western diet then infected by intranasal instillation of serotype 4 (TIGR4) S. pneumoniae followed by antibiotic administration. This protocol resulted in high rates of bacteremia (88.9%) and survival (88.5%). Pneumonia resulted in increased aortic sinus plaque macrophage content 2 weeks post pneumonia but not at 8 weeks, and no difference in plaque burden or other plaque vulnerability markers were found at either time point. Microarray and qPCR analysis of plaque macrophages identified downregulation of two E3 ubiquitin ligases, Huwe1 and Itch, following pneumonia. Treatment with atorvastatin failed to alter plaque macrophage content or other plaque features.

Discussion

Without antibiotics, ApoE-/- mice fed a high fat diet were highly susceptible to mortality following S. pneumoniae infection. The major infection associated change in plaque morphology was an early increase in plaque macrophages. Our results also hint at a role for the ubiquitin proteasome system in the response to pneumococcal infection in the plaque microenvironment.

Pneumonia-Induced Inflammation, Resolution and Cardiovascular Disease: Causes, Consequences and Clinical Opportunities

Pneumonia is inflammation in the lungs, which is usually caused by an infection. The symptoms of pneumonia can vary from mild to life-threatening, where severe illness is often observed in vulnerable populations like children, older adults, and those with preexisting health conditions. Vaccines have greatly reduced the burden of some of the most common causes of pneumonia, and the use of antimicrobials has greatly improved the survival to this infection. However, pneumonia survivors do not return to their preinfection health trajectories but instead experience an accelerated health decline with an increased risk of cardiovascular disease. The mechanisms of this association are not well understood, but a persistent dysregulated inflammatory response post-pneumonia appears to play a central role. It is proposed that the inflammatory response during pneumonia is left unregulated and exacerbates atherosclerotic vascular disease, which ultimately leads to adverse cardiac events such as myocardial infarction. For this reason, there is a need to better understand the inflammatory cross talk between the lungs and the heart during and after pneumonia to develop therapeutics that focus on preventing pneumonia-associated cardiovascular events. This review will provide an overview of the known mechanisms of inflammation triggered during pneumonia and their relevance to the increased cardiovascular risk that follows this infection. We will also discuss opportunities for new clinical approaches leveraging strategies to promote inflammatory resolution pathways as a novel therapeutic target to reduce the risk of cardiac events post-pneumonia.

Acute organ injury and long-term sequelae of severe pneumococcal infections

Streptococcus pneumoniae (Spn) is a major public health problem, as it is a main cause of otitis media, community-acquired pneumonia, bacteremia, sepsis, and meningitis. Acute episodes of pneumococcal disease have been demonstrated to cause organ damage with lingering negative consequences. Cytotoxic products released by the bacterium, biomechanical and physiological stress resulting from infection, and the corresponding inflammatory response together contribute to organ damage accrued during infection. The collective result of this damage can be acutely life-threatening, but among survivors, it also contributes to the long-lasting sequelae of pneumococcal disease. These include the development of new morbidities or exacerbation of pre-existing conditions such as COPD, heart disease, and neurological impairments. Currently, pneumonia is ranked as the 9^th leading cause of death, but this estimate only considers short-term mortality and likely underestimates the true long-term impact of disease. Herein, we review the data that indicates damage incurred during acute pneumococcal infection can result in long-term sequelae which reduces quality of life and life expectancy among pneumococcal disease survivors.

A multiple comorbidities mouse lung infection model in ApoE‑deficient mice

Acute pneumonia is characterised by a period of intense inflammation. Inflammation is now considered to be a key step in atherosclerosis progression. In addition, pre-existing atherosclerotic inflammation is considered to play a role in pneumonia progression and risk. In the present study, a multiple comorbidities murine model was used to study respiratory and systemic inflammation that results from pneumonia in the setting of atherosclerosis. Firstly, a minimal infectious dose of Streptococcus pneumoniae (TIGR4 strain) to produce clinical pneumonia with a low mortality rate (20%) was established. C57Bl/6 ApoE ^-/- mice were fed a high-fat diet prior to administering intranasally 10⁵ colony forming units of TIGR4 or phosphate-buffered saline (PBS). At days 2, 7 and 28 post inoculation (PI), the lungs of mice were imaged by magnetic resonance imaging (MRI) and positron emission tomography (PET). Mice were euthanised and investigated for changes in lung morphology and changes in systemic inflammation using ELISA, Luminex assay and real-time PCR. TIGR4-inoculated mice presented with varying degrees of lung infiltrate, pleural effusion and consolidation on MRI at all time points up to 28 days PI. Moreover, PET scans identified significantly higher FDG uptake in the lungs of TIGR4-inoculated mice up to 28 days PI. The majority (90%) TIGR4-inoculated mice developed pneumococcal-specific IgG antibody response at 28 days PI. Consistent with these observations, TIGR4-inoculated mice displayed significantly increased inflammatory gene expression [interleukin (IL)-1β and IL-6] in the lungs and significantly increased levels of circulating inflammatory protein (CCL3) at 7 and 28 days PI respectively. The mouse model developed by the authors presents a discovery tool to understand the link between inflammation related to acute infection such as pneumonia and increased risk of cardiovascular disease observed in humans.

Baseline physical activity and the risk of severe illness and mortality from COVID-19: A dose-response meta-analysis

To provide a scientific basis for improved exercise-based immunity, a meta-analysis was used to explore the dose-response relationship between physical activity (PA) and the risk of severe illness and mortality related to COVID-19 (coronavirus disease 2019). To this end, we searched PubMed, Web of Science databases from January 2020 through April 2022. 14 observational studies met the criteria for inclusion in the meta-analysis, including 2840 cases of severe illness and death from COVID-19. Categorical dose-relationship analysis showed that the risks of severe illness and mortality from COVID-19 were, respectively, 46% (risk ratio (RR): 0.54; confidence intervals (CIs): 0.41-0.68) and 59% (RR = 0.41; 95%CI: 0.23-0.58) lower for the highest dose of PA compared with the lowest dose of PA. The results of the continuous dose-response analysis show an inverse nonlinear relationship (P_{non-linearity} < 0.05) between PA and both the risk of severe illness and mortality from COVID-19. For PA below 10 MET-h/week (MET-h/week: metabolic equivalent of task-hours/week), an increase of 4 MET-h/week (1 h of moderate-intensity or 0.5 h of high-intensity PA) was associated with 8% and 11% reductions in the risk of severe illness and mortality from COVID-19. PA above 10 MET-h/week lowered the risk of severe illness and mortality from COVID-19 by 7% and 9%, respectively, for each 4 MET-h/week increase. Doses of WHO-recommended PA levels (10 MET-h/week) may be required for more substantial reductions in the risk of severe illness and mortality from COVID-19.

Prevalence of new-onset atrial fibrillation in hospitalized patients with community-acquired pneumonia: a systematic review and meta-analysis

Community-acquired pneumonia (CAP) is a common lower respiratory tract infection, often complicated by cardiovascular events, including cardiac arrhythmias. New-onset atrial fibrillation (newAF) has been associated with increased mortality in CAP patients, especially in those critically ill; however, limited data on the prevalence of newAF in patients with CAP are available. We aim to estimate the pooled prevalence of newAF and its impact on adverse outcomes in patients with CAP, through a systematic review and meta-analysis. MEDLINE and EMBASE were systematically searched from inception to 27 January 2022. All studies reporting the prevalence of newAF in CAP patients were included and all-cause mortality was extracted when available. The pooled prevalence of newAF, 95% Confidence Intervals (CI), and 95% Prediction Intervals (PI) were computed. The inconsistency index (I²) was calculated to measure heterogeneity. Subgroup analyses were also performed. A protocol for this study was registered on PROSPERO (CRD42022307422). Among 7,655 records retrieved, 10 studies were included, with a total of 280,589 CAP patients. Pooled prevalence of newAF in CAP patients was 7.6% (95% CI 6.4-9.0%, 95% PI 4.3-13.1%, I² = 95%). Subgroup analyses showed no significant differences according to geographical location or study design. Patients with newAF had a higher risk of mortality among the studies included in the systematic review. NewAF is a common complication, occurring in 7.6% of CAP patients, with prediction intervals suggesting an even higher burden. CAP patients who develop newAF during hospitalization may be at higher risk of mortality in both short- and long-term follow-up.

The value of modified Ross score in the evaluation of children with severe lower respiratory tract infection admitted to the pediatric intensive care unit

Heart failure (HF) represents an important cause of morbidity and mortality in children. It is mostly caused by congenital heart disease (CHD) and cardiomyopathy. The Ross HF classification was developed to assess severity in infants and has subsequently been modified to apply to all pediatric ages. The modified Ross classification for children provides a numeric score comparable with the New York Heart Association (NYHA) HF classification for adults. The aim of this work is to investigate the role of modified Ross score in the evaluation of children with severe lower respiratory tract infection admitted to the pediatric intensive care unit (PICU). One hundred and sixty-four children with severe LRTI admitted to the PICU were enrolled in this prospective cohort study, which was carried out at Assiut University Children Hospital, from the start of July 2021 up to the end of December 2021. Sixty patients (36.6%) of studied cases with severe LRTI admitted to PICU had HF. Out of these, 37 (61.7%) had mild HF; 17 (28.3%) had moderate HF, while six cases (10%) had severe HF according to the modified Ross score. The value of modified Ross score was significantly higher in children with heart failure with sensitivity and specificity 100% with cutoff value of 2. Admission to NICU, history of previous ventilation, and prematurity were higher in patients who developed HF. Patients with pulmonary hypertension (PH) and those with raised neutrophil lymphocyte ratio were significantly higher in the group of patients with moderate and severe degree of HF.   Conclusion: Modified Ross score is a simple clinical score which may help in assessing and predicting children with severe LRTI. What is Known: • Hear failure is common complication to lower respiratory tract infection. • Modified Ross score was used to predict and classify heart failure in adult with lower respiratory infection. What is New: • Modified Ross score found to be of value in prediction of heart failure in children with lower respiratory tract infection.

Pathophysiological mechanisms of thrombosis in acute and long COVID-19

COVID-19 patients have a high incidence of thrombosis, and thromboembolic complications are associated with severe COVID-19 and high mortality. COVID-19 disease is associated with a hyper-inflammatory response (cytokine storm) mediated by the immune system. However, the role of the inflammatory response in thrombosis remains incompletely understood. In this review, we investigate the crosstalk between inflammation and thrombosis in the context of COVID-19, focusing on the contributions of inflammation to the pathogenesis of thrombosis, and propose combined use of anti-inflammatory and anticoagulant therapeutics. Under inflammatory conditions, the interactions between neutrophils and platelets, platelet activation, monocyte tissue factor expression, microparticle release, and phosphatidylserine (PS) externalization as well as complement activation are collectively involved in immune-thrombosis. Inflammation results in the activation and apoptosis of blood cells, leading to microparticle release and PS externalization on blood cells and microparticles, which significantly enhances the catalytic efficiency of the tenase and prothrombinase complexes, and promotes thrombin-mediated fibrin generation and local blood clot formation. Given the risk of thrombosis in the COVID-19, the importance of antithrombotic therapies has been generally recognized, but certain deficiencies and treatment gaps in remain. Antiplatelet drugs are not in combination with anticoagulant treatments, thus fail to dampen platelet procoagulant activity. Current treatments also do not propose an optimal time for anticoagulation. The efficacy of anticoagulant treatments depends on the time of therapy initiation. The best time for antithrombotic therapy is as early as possible after diagnosis, ideally in the early stage of the disease. We also elaborate on the possible mechanisms of long COVID thromboembolic complications, including persistent inflammation, endothelial injury and dysfunction, and coagulation abnormalities. The above-mentioned contents provide therapeutic strategies for COVID-19 patients and further improve patient outcomes.

Risk of cardiovascular events leading to hospitalisation after Streptococcus pneumoniae infection: a retrospective cohort LIFE Study

OBJECTIVES

To elucidate the risk of cardiovascular event occurrence following Streptococcus pneumoniae infection.

DESIGN

Retrospective cohort study using a LIFE Study database.

SETTING

Three municipalities in Japan.

PARTICIPANTS

Municipality residents who were enrolled in either National Health Insurance or the Latter-Stage Elderly Healthcare System from April 2014 to March 2020.

EXPOSURE

Occurrence of S. pneumoniae infection.

PRIMARY OUTCOME MEASURES

Occurrence of one of the following cardiovascular events that led to hospitalisation after S. pneumoniae infection: (1) coronary heart disease (CHD), (2) heart failure (HF), (3) stroke or (4) atrial fibrillation (AF).

RESULTS

S. pneumoniae-infected patients were matched with non-infected patients for each cardiovascular event. We matched 209 infected patients and 43 499 non-infected patients for CHD, 179 infected patients and 44 148 non-infected patients for HF, 221 infected patients and 44 768 non-infected patients for stroke, and 241 infected patients and 39 568 non-infected patients for AF. During follow-up, the incidence rates for the matched infected and non-infected patients were, respectively, 38.6 (95% CI 19.9 to 67.3) and 30.4 (29.1 to 31.8) per 1000 person-years for CHD; 69.6 (41.9 to 108.8) and 50.5 (48.9 to 52.2) per 1000 person-years for HF; 75.4 (48.3 to 112.2) and 35.5 (34.1 to 36.9) per 1000 person-years for stroke; and 34.7 (17.9 to 60.6) and 11.2 (10.4 to 12.0) per 1000 person-years for AF. Infected patients were significantly more likely to develop stroke (adjusted HR: 2.05, 95% CI 1.22 to 3.47; adjusted subdistribution HR: 1.94, 95% CI 1.15 to 3.26) and AF (3.29, 1.49 to 7.26; 2.74, 1.24 to 6.05) than their non-infected counterparts.

CONCLUSIONS

S. pneumoniae infections elevate the risk of subsequent stroke and AF occurrence. These findings indicate that pneumococcal infections have short-term effects on patients' health and increase their midterm to long-term susceptibility to serious cardiovascular events.

Cardiovascular Complications in Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) is accountable for high mortality in both pediatric and adult populations worldwide, about one-third of hospitalized patients pass away within a year of being discharged from the facility. The high mortality and morbidity rates are closely related to cardiovascular complications that are consequent or concomitant to the acute episode of pneumonia. An updated perspective on the major pathophysiological mechanisms, prevalence, risk factors, outcomes, and relevant treatments of cardiovascular events in CAP patients is provided in the current study. It is possible to evaluate the pathophysiology of cardiac disease in this population based on plaque-related events, such as acute myocardial infarction, or events unrelated to plaque, such as arrhythmias and heart failure. With an absolute rate of cardiovascular problems ranging broadly from 10% to 30%, CAP raises the risk of both plaque-related and plaque-unrelated events. Both in- and out-patients may experience these issues at admission, throughout hospitalization, or even up to a year following discharge. At long-term follow-up, cardiac events account for more than 30% of deaths in CAP patients, making them a significant cause of mortality. If patients at risk for cardiac events are stratified, diagnostic tools, monitoring, and preventive measures may be applied to these patients. A prospective evaluation of cardioprotective treatments is urgently required from a research point of view.

Gamma' fibrinogen levels as a biomarker of COVID-19 respiratory disease severity

Coronavirus disease 2019 (COVID-19) is characterized by a pro-inflammatory state associated with organ failure, thrombosis, and death. We investigated a novel inflammatory biomarker, γ' fibrinogen (GPF), in 103 hospitalized patients with COVID-19 and 19 healthy controls. We found significant associations between GPF levels and the severity of COVID-19 as judged by blood oxygen saturation (SpO ₂ ). The mean level of GPF in the patients with COVID-19 was significantly higher than in controls (69.8 (95% CI 64.8-74.8) mg/dL compared with 36.9 (95% CI 31.4-42.4) mg/dL, p < 0.0001), whereas C-reactive protein (CRP), lactate dehydrogenase (LDH), and total fibrinogen levels were not significantly different between groups. Mean GPF levels were significantly highest in patients with severe COVID-19 (SpO ₂  ≤ 93%, GPF 75.2 (95% CI 68.7-81.8) mg/dL), compared to mild/moderate COVID-19 (SpO ₂  > 93%, GPF 62.5 (95% CI 55.0-70.0) mg/dL, p = 0.01, AUC of 0.68, 95% CI 0.57-0.78; Youden's index cutpoint 62.9 mg/dL, sensitivity 0.64, specificity 0.63). In contrast, CRP, interleukin-6, ferritin, LDH, D-dimers, and total fibrinogen had weaker associations with COVID-19 disease severity (all ROC curves with lower AUCs). Thus, GPF may be a useful inflammatory marker of COVID-19 respiratory disease severity.

Habitual Exercise, Air Pollution, and Pneumonia Mortality: A Longitudinal Cohort Study of Approximately 0.4 Million Adults

In this study, we aimed to examine the combined associations of particulate matter with an aerodynamic diameter less than or equal to 2.5 μm (PM2.5) and habitual exercise with pneumonia mortality. We included 384,130 persons aged ≥18 years from Taiwan, Republic of China, during 2001-2016. We followed participants until May 31, 2019, to obtain information on vital status. A time-dependent Cox regression model was used for statistical analysis. We found that risks of pneumonia mortality were reduced by 55% (hazard ratio (HR) = 0.45, 95% confidence interval (CI): 0.36, 0.55) and 36% (HR = 0.64, 95% CI: 0.52, 0.80) in participants who engaged in high and moderate levels of exercise, respectively, as compared with inactive persons. By contrast, each 10-μg/m3 increase in chronic PM2.5 exposure was associated with a 30% (HR = 1.30, 95% CI: 1.17, 1.45) higher risk of pneumonia mortality. Risk of pneumonia death was 72% lower (HR = 0.28, 95% CI: 0.20, 0.41) for persons with a high exercise level and a low PM2.5 level. Lower risk of pneumonia mortality was associated with both higher exercise and lower PM2.5 air pollution levels. For adults exposed to different levels of PM2.5, exercise benefits remained. Our findings suggest that engaging in exercise is a safe and effective strategy for alleviating the burden of pneumonia mortality, even for people who reside in a moderately polluted area.

A nationwide cohort study suggests clarithromycin-based therapy for Helicobacter pylori eradication is safe in patients with stable coronary heart disease and subsequent peptic ulcer disease

Background

Clarithromycin-based therapy is important for Helicobacter pylori eradication treatment. However, clarithromycin may increase cardiovascular risk. Hence, we investigated the association between clarithromycin use and outcomes in adults with stable coronary heart disease (CHD) and subsequent peptic ulcer disease (PUD).

Methods

This nationwide cohort study used a national health insurance database to screen 298,417 Taiwanese residents who were diagnosed with coronary heart disease from 2001 to 2015 for eligibility in the study and to evaluate select eligible patients with CHD–PUD from 2004 to 2015. Data were obtained from new users of clarithromycin (n = 4183) and nonusers of clarithromycin (n = 24,752) during follow-up. A total of 4070 eligible clarithromycin users and 4070 nonusers were subject to final analysis by 1:1 propensity score matching. Participants were followed up after receiving clarithromycin or at the corresponding date until the occurrence of cardiovascular morbidity in the presence of competing mortality, overall mortality and cardiovascular mortality, or through the end of 2015. The incidence rates and risks of overall mortality and cardiovascular outcomes were evaluated. The associations between clarithromycin and arrhythmia risk, as well as its dose and duration and overall mortality and cardiovascular outcomes were also addressed.

Results

Clarithromycin users were associated with adjusted hazard ratios of 1.08 (95% confidence interval, 0.93–1.24; 21.5 compared with 21.2 per 1000 patient-years) for overall mortality, 0.95 (0.57–1.59; 1.5 compared with 1.8 per 1000 patient-years) for cardiovascular mortality, and 0.94 (0.89–1.09; 19.6 compared with 20.2 per 1000 patient-years) for cardiovascular morbidity in the presence of competing mortality, as compared with nonusers. We found no relationship between dose and duration of clarithromycin and overall mortality and cardiovascular outcomes and no increased risk of arrhythmia during follow-up period. After inclusion of arrhythmia events to re-estimate the risks of all study outcomes, the results remained insignificant.

Conclusion

Concerning overall mortality, cardiovascular mortality, and cardiovascular morbidity, our results suggest clarithromycin-based therapy for Helicobacter pylori eradication may be safe in patients with stable CHD and subsequent PUD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02498-1.

Ventilatory efficiency is superior to peak oxygen uptake for prediction of lung resection cardiovascular complications

Introduction

Ventilatory efficiency (V_E/VCO₂ slope) has been shown superior to peak oxygen consumption (VO₂) for prediction of post-operative pulmonary complications in patients undergoing thoracotomy. V_E/VCO₂ slope is determined by ventilatory drive and ventilation/perfusion mismatch whereas VO₂ is related to cardiac output and arteriovenous oxygen difference. We hypothesized pre-operative VO₂ predicts post-operative cardiovascular complications in patients undergoing lung resection.

Methods

Lung resection candidates from a published study were evaluated by post-hoc analysis. All of the patients underwent preoperative cardiopulmonary exercise testing. Post-operative cardiovascular complications were assessed during the first 30 post-operative days or hospital stay. One-way analysis of variance or the Kruskal–Wallis test, and multivariate logistic regression were used for statistical analysis and data summarized as median (IQR).

Results

Of 353 subjects, 30 (9%) developed pulmonary complications only (excluded from further analysis), while 78 subjects (22%) developed cardiovascular complications and were divided into two groups for analysis: cardiovascular only (n = 49) and cardiovascular with pulmonary complications (n = 29). Compared to patients without complications (n = 245), peak VO₂ was significantly lower in the cardiovascular with pulmonary complications group [19.9 ml/kg/min (16.5–25) vs. 16.3 ml/kg/min (15–20.3); P<0.01] but not in the cardiovascular only complications group [19.9 ml/kg/min (16.5–25) vs 19.0 ml/kg/min (16–23.1); P = 0.18]. In contrast, V_E/VCO₂ slope was significantly higher in both cardiovascular only [29 (25–33) vs. 31 (27–37); P = 0.05] and cardiovascular with pulmonary complication groups [29 (25–33) vs. 37 (34–42); P<0.01)]. Logistic regression analysis showed V_E/VCO₂ slope [OR = 1.06; 95%CI (1.01–1.11); P = 0.01; AUC = 0.74], but not peak VO₂ to be independently associated with post-operative cardiovascular complications.

Conclusion

V_E/VCO₂ slope is superior to peak VO₂ for prediction of post-operative cardiovascular complications in lung resection candidates.

Preexisting coronary artery disease among coronavirus disease 2019 patients: a systematic review and meta-analysis

AIMS

The prevalence and prognostic implications of coronary artery disease (CAD) in patients infected by the novel coronavirus 2019 (COVID-19) disease remain unclear.

METHODS

We conducted a systematic review and meta-analysis to investigate the prevalence and mortality risk in COVID-19 patients with preexisting CAD. We searched Medline and Scopus to locate all articles published up to December 8, 2021, reporting data of COVID-19 survivors and nonsurvivors with preexisting CAD. Data were pooled using the Mantel-Haenszel random effects models with odds ratio (OR) as the effect measure with the related 95% confidence interval (CI).

RESULTS

Thirty-eight studies including 27 435 patients (mean age 61.5 and 70.9 years) were analysed. The pooled prevalence of preexisting CAD was 12.6% (95% CI: 11.2-16.5%, I2 : 95.6%), and resulted as higher in intensive care unit patients (17.5%, 95% CI: 11.9-25.1, I2 : 88.4%) and in European cohorts (13.1%, 95% CI: 7.8-21.6%, P  < 0.001, I2 : 98.4%). COVID-19 patients with preexisting CAD had a two-fold risk of short-term mortality (OR 2.61, 95% CI 2.10-3.24, P  < 0.001, I2  = 73.6%); this risk was higher among Asian cohorts (OR: 2.66, 95% CI: 1.79-3.90, P  < 0.001, I2 : 77.3%) compared with European (OR: 2.44, 95% CI: 1.90-3.14, P  < 0.001, I2 : 56.9%) and American (OR: 1.86, 95% CI: 1.41-2.44, P  < 0.001, I2 : 0%) populations. The association between CAD and poor short-term prognosis was influenced by age, prevalence of hypertension (HT), DM and CKD.

CONCLUSIONS

Preexisting CAD is present in approximately 1 in 10 patients hospitalized for COVID-19 and significantly associated with an increased risk of short-term mortality, which is influenced by age, HT, DM and CKD.

Acetylsalicylic acid use is associated with improved survival in bacteremic pneumococcal pneumonia: A long-term nationwide study

BACKGROUND

Pneumonia is commonly caused by Streptococcus pneumoniae (pneumococcus) and associated with subsequent cardiovascular complications and increased mortality. Potential short-term survival benefits conferred by acetylsalicylic acid (ASA) use in pneumonia remain controversial, and long-term outcomes have not been studied.

OBJECTIVES

To evaluate the association between ASA use and survival for up to 1 year following bacteremic pneumococcal pneumonia.

METHODS

All bacteremic pneumococcal episodes in Iceland from 1975 to 2019 were reviewed. The study cohort consisted of individuals at least 18 years of age with symptoms and imaging results consistent with pneumonia. Differences in survival were assessed at 30 days, 90 days and 1 year using propensity score weighting (inverse probability weighting). Splitting and stratifying on survival at 7 days was done for the 30-day survival, because of nonproportionality.

RESULTS

In total, 815 bacteremic pneumococcal pneumonia episodes (median age 67 years, females 48%) were identified. Cox regression using propensity score weighting on the association of ASA with survival at 30 days showed an average hazard ratio (HR) of 0.60 (95% confidence interval [CI] 0.34-1.05). A significantly improved survival was observed within 7 days (HR = 0.42, 95% CI 0.19-0.92) but not during days 7-30 (HR = 1.08, 95% CI 0.46-2.55). ASA was associated with survival at 90 days (HR = 0.53, 95% CI 0.32-0.87) and 1 year (HR = 0.48, 95% CI 0.31-0.75).

CONCLUSION

Use of ASA upon admission for bacteremic pneumococcal pneumonia is associated with significantly reduced mortality for up to 1 year after diagnosis. ASA therapy in patients with pneumonia and other infectious syndromes warrants further study.

Advancing Lung Immunology Research: An Official American Thoracic Society Workshop Report

The mammalian airways and lungs are exposed to a myriad of inhaled particulate matter, allergens, and pathogens. The immune system plays an essential role in protecting the host from respiratory pathogens, but a dysregulated immune response during respiratory infection can impair pathogen clearance and lead to immunopathology. Furthermore, inappropriate immunity to inhaled antigens can lead to pulmonary diseases. A complex network of epithelial, neural, stromal, and immune cells has evolved to sense and respond to inhaled antigens, including the decision to promote tolerance versus a rapid, robust, and targeted immune response. Although there has been great progress in understanding the mechanisms governing immunity to respiratory pathogens and aeroantigens, we are only beginning to develop an integrated understanding of the cellular networks governing tissue immunity within the lungs and how it changes after inflammation and over the human life course. An integrated model of airway and lung immunity will be necessary to improve mucosal vaccine design as well as prevent and treat acute and chronic inflammatory pulmonary diseases. Given the importance of immunology in pulmonary research, the American Thoracic Society convened a working group to highlight central areas of investigation to advance the science of lung immunology and improve human health.

Cardiovascular changes after pneumonia in a dual disease mouse model

Residual inflammation in cardiovascular organs is thought to be one of the catalysts for the increased risk of cardiovascular complications seen following pneumonia. To test this hypothesis, we investigated changes in plaque characteristics and inflammatory features in ApoE-/- mouse aorta and heart following pneumonia. Male ApoE-/- mice were fed a high fat diet for 8 weeks before intranasal inoculation with either Streptococcus pneumoniae serotype 4 (test group) or phosphate buffered saline (control group). Mice were sacrificed at 2-, 7- and 28-days post-challenge. Changes in plaque burden and characteristics in aortic root and thoracic aorta were characterized by Oil red O and Trichrome stains. Inflammatory changes were investigated by FDG-PET imaging and immunofluorescence staining. We found TIGR4-infected mice present with increased plaque presence in the aortic root and thoracic aorta at 2- and 28-days post-inoculation, respectively. Aortic wall remodelling was also more pronounced in mice challenged with pneumococci at 28 days post-inoculation. Aortic root plaques of infected mice had reduced collagen and smooth muscle cells, consistent with an unstable plaque phenotype. Pneumonia alters plaque burden, plaque characteristics, and aortic wall remodelling in ApoE-/- mice. These effects caused by Streptococcus pneumoniae TIGR4, may contribute to the increased risk of cardiovascular complications seen in survivors of this infection.

Unmasking Myocardial Dysfunction in Patients Hospitalized for Community-Acquired Pneumonia Using a 4-Chamber 3-Dimensional Volume/Strain Analysis

Lower respiratory infection was reported as the most common fatal infectious disease. Community-acquired pneumonia (CAP) and myocardial injury are associated; yet, true prevalence of myocardial injury is probably underestimated. We assessed the rate and severity of myocardial dysfunction in patients with CAP. Admitted patients diagnosed with CAP were prospectively recruited. All the patients had C-reactive protein (CRP), brain natriuretic peptide (BNP), and high-sensitivity cardiac troponin (hs-cTnl) tests added to their routine workup. 2D/3D Doppler echocardiography was done on a Siemens Acuson SC2000 machine ≤ 24 h of diagnosis. 3D datasets were blindly analyzed for 4-chamber volumes/strains using EchobuildR 3D-Volume Analysis prototype software, v3.0 2019, Siemens-Medical Solutions. Volume/strain parameters were correlated with admission clinical and laboratory findings. The cohort included 34 patients, median age 60 years (95% CI 55-72). The cohort included 18 (53%) patients had hypertension, 9 (25%) had diabetes mellitus, 7 (21%) were smokers, 7 (21%) had previous myocardial infarction, 4 (12%) had chronic renal failure, and 1 (3%) was on hemodialysis treatment. 2D/Doppler echocardiography findings showed normal ventricular size/function (LVEF 63 ± 9%), mild LV hypertrophy (104 ± 36 g/m²), and LA enlargement (41 ± 6 mm). 3D volumes/strains suggested bi-atrial and right ventricular dysfunction (global longitudinal strain RVGLS =  - 8 ± 4%). Left ventricular strain was normal (LVGLS =  - 18 ± 5%) and correlated with BNP (r = 0.40, p = 0.024). The patients with LVGLS >  - 17% had higher admission blood pressure and lower SaO₂ (144 ± 33 vs. 121 ± 20, systolic, mmHg, p = 0.02, and 89 ± 4 vs. 94 ± 4%, p = 0.006, respectively). hs-cTnl and CRP were not different. Using novel 3D volume/strain software in CAP patients, we demonstrated diffuse global myocardial dysfunction involving several chambers. The patients with worse LV GLS had lower SaO₂ and higher blood pressure at presentation. LV GLS correlated with maximal BNP level and did not correlate with inflammation or myocardial damage markers.

The effect of community-acquired pneumonia on myocardial injury in systemic lupus erythematosus: Insights from cardiac magnetic resonance

OBJECTIVES

Myocardial injury (MInj) in systemic lupus erythematosus (SLE) has been observed in several studies. However, clinical predictors of MInj remain unclear. We aim to explore the effects of community-acquired pneumonia (CAP) on MInj in SLE patients according to cardiac magnetic resonance (CMR) T1 mapping.

METHODS

SLE patients with or without CAP and healthy controls underwent CMR screening. The CMR protocol included: cines, T1- and T2 mapping, and late gadolinium enhancement (LGE). Clinical characteristics, CMR findings, and T1 mapping measuremments were compared between subgroups. Clinical assessment was performed on the subjects.

RESULTS

Thirty-eight SLE patients were screened, including 18 patients with CAP (CAP group) and 20 age- and gender-matched patients without CAP (non-CAP group) as well as 26 healthy controls. The platelet count of CAP group was higher than the non-CAP group (p = 0.015). Compared with the health control group, native T1 was higher in the CAP group (p < 0.001) and the non-CAP group (p = 0.002). ECV was higher in the CAP group (p < 0.001) and the non-CAP group (p = 0.002). The LV ejection fraction (p = 0.049) and RV ejection fraction (p = 0.026) of the CAP group was lower than that of the healthy control group, whereas no significant difference was observed between non-CAP and healthy control groups.

CONCLUSIONS

This is the first study that assesses the effects of CAP on MInj of SLE patients by CMRI T1 mapping. We highlight SLE patients with CAP who are at increased risk of MInj, manifesting as myocardial inflammation, diffuse myocardial fibrosis, and decreased ventricular function.

European Society of Cardiology guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 1-epidemiology, pathophysiology, and diagnosis

AIMS

Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two-part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular disease (CVD) in association with COVID-19.

METHODS AND RESULTS

A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, reported here, focuses on the epidemiology, pathophysiology, and diagnosis of cardiovascular (CV) conditions that may be manifest in patients with COVID-19. The second part, which will follow in a later edition of the journal, addresses the topics of care pathways, treatment, and follow-up of CV conditions in patients with COVID-19.

CONCLUSION

This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.

Sepsis, cardiovascular events and short-term mortality risk in critically ill patients

INTRODUCTION

There is paucity of data on the occurrence of cardiovascular events (CVEs) in critically ill patients with sepsis. We aimed to describe the incidence, risk factors and impact on mortality of CVEs in these patients.

METHODS

This was a retrospective cohort study of critically ill patients admitted to the medical intensive care unit (ICU) between July 2015 and October 2016. The primary outcome was intra-hospital CVEs, while the secondary outcomes were in-hospital mortality, ICU and hospital length of stay.

RESULTS

Patients with sepsis (n=662) had significantly more CVEs compared to those without (52.9% versus 23.0%, P<0.001). Among sepsis patients, 350 (52.9%) had 1 or more CVEs: 59 (8.9%) acute coronary syndrome; 198 (29.9%) type 2 myocardial infarction; 124 (18.7%) incident atrial fibrillation; 76 (11.5%) new or worsening heart failure; 32 (4.8%) cerebrovascular accident; and 33 (5.0%) cardiovascular death. Factors associated with an increased risk of CVEs (adjusted relative risk [95% confidence interval]) included age (1.013 [1.007-1.019]); ethnicity-Malay (1.214 [1.005-1.465]) and Indian (1.240 [1.030-1.494]) when compared to Chinese; and comorbidity of ischaemic heart disease (1.317 [1.137-1.527]). There were 278 patients (79.4%) who developed CVEs within the first week of hospitalisation. Sepsis patients with CVEs had a longer median (interquartile range [IQR]) length of stay in the ICU (6 [3-12] vs 4 [2-9] days, P<0.001), and hospital (21 [10-42] vs 15 [7-30] days, P<0.001) compared to sepsis patients without CVEs. There was no difference in in-hospital mortality between the 2 groups (46.9% vs 45.8%, P=0.792).

CONCLUSION

CVEs complicate half of the critically ill patients with sepsis, with 79.4% of patients developing CVEs within the first week of hospitalisation, resulting in longer ICU and hospital length of stay.

Prognostic Accuracy of Presepsis and Intrasepsis Characteristics for Prediction of Cardiovascular Events After a Sepsis Hospitalization

Sepsis survivors face increased risk for cardiovascular complications; however, the contribution of intrasepsis events to cardiovascular risk profiles is unclear.

Dose-response relationship between risk factors and incidence of COVID-19 in 325 hospitalized patients: A multicenter retrospective cohort study

BACKGROUND

The epidemiological and clinical characteristics of coronavirus disease 2019 (COVID-19) patients have been widely reported, but the assessment of dose-response relationships and risk factors for mortality and severe cases and clinical outcomes remain unclear.

AIM

To determine the dose-response relationship between risk factors and incidence of COVID-19.

METHODS

In this retrospective, multicenter cohort study, we included patients with confirmed COVID-19 infection who had been discharged or had died by February 6, 2020. We used multivariable logistic regression and Cox proportional hazard models to determine the dose-response relationship between risk factors and incidence of COVID-19.

RESULTS

It clarified that increasing risk of in-hospital death were associated with older age (HR: 1.04, 95%CI: 1.01-1.09), higher lactate dehydrogenase [HR: 1.04, 95% confidence interval (CI): 1.01-1.10], C-reactive protein (HR: 1.10, 95%CI: 1.01-1.23), and procalcitonin (natural log-transformed HR: 1.88, 95%CI: 1.22-2.88), and D-dimer greater than 1 μg/mL at admission (natural log transformed HR: 1.63, 95%CI: 1.03-2.58) by multivariable regression. D-dimer and procalcitonin were logarithmically correlated with COVID-19 mortality risk, while there was a linear dose-response correlation between age, lactate dehydrogenase, D-dimer and procalcitonin, independent of established risk factors.

CONCLUSION

Higher lactate dehydrogenase, D-dimer, and procalcitonin levels were independently associated with a dose-response increased risk of COVID-19 mortality.

European Society of Cardiology guidance for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic: part 1-epidemiology, pathophysiology, and diagnosis

AIMS

Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two-part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular disease (CVD) in association with COVID-19.

METHODS AND RESULTS

A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, reported here, focuses on the epidemiology, pathophysiology, and diagnosis of cardiovascular (CV) conditions that may be manifest in patients with COVID-19. The second part, which will follow in a later edition of the journal, addresses the topics of care pathways, treatment, and follow-up of CV conditions in patients with COVID-19.

CONCLUSION

This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.

Immunogenicity, Safety, and Tolerability of V114, a 15-Valent Pneumococcal Conjugate Vaccine, in Immunocompetent Adults Aged 18-49 Years With or Without Risk Factors for Pneumococcal Disease: A Randomized Phase 3 Trial (PNEU-DAY)

BACKGROUND

Adults with certain medical and behavioral factors are at increased risk for pneumococcal disease (PD). Sequential vaccination with 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) is recommended for at-risk adults in some countries.

METHODS

This phase 3 trial evaluated the safety, tolerability, and immunogenicity of sequential administration of either V114 (a 15-valent PCV containing serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 22F, 23F, and 33F) or PCV13, followed 6 months later by PPSV23, in immunocompetent adults aged 18-49 years with or without predefined risk factors for PD (NCT03547167). Overall, 1515 participants were randomized 3:1 to receive either V114 or PCV13, followed by PPSV23.

RESULTS

Most common solicited adverse events (AEs) following administration of V114 or PCV13 as well as PPSV23 were injection-site pain and fatigue. The proportion of participants with AEs was comparable in both groups. V114 and PCV13 were immunogenic based on opsonophagocytic activity (OPA) geometric mean titers (GMTs) 30 days postvaccination for all serotypes contained in each respective vaccine. OPA GMTs to the 2 unique serotypes in V114 were robust in the V114 group. PPSV23 was immunogenic for all 15 serotypes contained in V114 in both vaccination groups, including 22F and 33F.

CONCLUSIONS

V114 administered alone or sequentially with PPSV23 is well tolerated and immunogenic for all 15 serotypes, including those not contained in PCV13, in immunocompetent adults aged 18-49 years with or without certain medical or behavioral risk factors for PD.

CLINICAL TRIALS REGISTRATION

NCT03547167 and EudraCT 2017-004915-38.

Type 2 MI and Myocardial Injury in the Era of High-sensitivity Troponin

Troponin has been the cornerstone of the definition of MI since its introduction to clinical practice. High-sensitivity troponin has allowed clinicians to detect degrees of myocardial damage at orders of magnitude smaller than previously and is challenging the definitions of MI, with implications for patient management and prognosis. Detection and diagnosis are no doubt enhanced by the greater sensitivity afforded by these markers, but perhaps at the expense of specificity and clarity. This review focuses on the definitions, pathophysiology, prognosis, prevention and management of type 2 MI and myocardial injury. The five types of MI were first defined in 2007 and were recently updated in 2018 in the fourth universal definition of MI. The authors explore how this pathophysiological classification is used in clinical practice, and discuss some of the unanswered questions in this era of availability of high-sensitivity troponin.

Effects of fluid and drinking on pneumonia mortality in older adults: A systematic review and meta-analysis

Background and aims

Methods

Results

Conclusions