Inpatient and Outpatient Infection as a Trigger of Cardiovascular Disease: The ARIC Study

From cardiovascular system to brain, the potential protective role of Mas Receptors in COVID-19 infection

Coronavirus disease 2019 (COVID-19) has been declared a new pandemic in March 2020. Although most patients are asymptomatic, those with underlying cardiovascular comorbidities may develop a more severe systemic infection which is often associated with fatal pneumonia. Nonetheless, neurological and cardiovascular manifestations could be present even without respiratory symptoms. To date, no COVID-19-specific drugs are able for preventing or treating the infection and generally, the symptoms are relieved with general anti-inflammatory drugs. Angiotensin-converting-enzyme 2 (ACE2) may function as the receptor for virus entry within the cells favoring the progression of infection in the organism. On the other hand, ACE2 is a relevant enzyme in renin angiotensin system (RAS) cascade fostering Ang1-7/Mas receptor activation which promotes protective effects in neurological and cardiovascular systems. It is known that RAS is composed by two functional countervailing axes the ACE/AngII/AT1 receptor and the ACE/AngII/AT2 receptor which counteracts the actions mediated by AngII/AT1 receptor by inducing anti-inflammatory, antioxidant and anti-growth functions. Subsequently an "alternative" ACE2/Ang1-7/Mas receptor axis has been described with functions similar to the latter protective arm. Here, we discuss the neurological and cardiovascular effects of COVID-19 highlighting the role of the stimulation of the RAS "alternative" protective arm in attenuating pulmonary, cerebral and cardiovascular damages. In conclusion, only two clinical trials are running for Mas receptor agonists but few other molecules are in preclinical phase and if successful these drugs might represent a successful strategy for the treatment of the acute phase of COVID-19 infection.

The trends and determinants of seasonal influenza vaccination after cardiovascular events in Canada: a repeated, pan-Canadian, cross-sectional study

INTRODUCTION

Annual influenza vaccination is recommended for individuals with a history of cardiovascular disease (CVD) events. We aimed to examine (1) the time trends for influenza vaccination among Canadians with a CVD event history between 2009 and 2018, and (2) the determinants of receiving the vaccination in this population over the same period.

METHODS

We used data from the Canadian Community Health Survey (CCHS). The study sample included respondents from 2009 to 2018 who were 30 years of age or more with a CVD event (heart attack or stroke) and who indicated their flu vaccination status. Weighted analysis was used to determine the trend of vaccination rate. We used linear regression analysis to examine the trend and multivariate logistic regression analysis to examine determinants of influenza vaccination, including sociodemographic factors, clinical characteristics, health behaviour and health system variables.

RESULTS

Over the study period, in our sample of 42 400, the influenza vaccination rate was overall stable around 58.9%. Several determinants for vaccination were identified, including older age (adjusted odds ratio [aOR] = 4.28; 95% confidence interval [95% CI]: 4.24-4.32], having a regular health care provider (aOR = 2.39; 95% CI: 2.37-2.41), and being a nonsmoker (aOR = 1.48; 95% CI: 1.47-1.49). Factors associated with decreased likelihood of vaccination included working full time (aOR = 0.72; 95% CI: 0.72-0.72).

CONCLUSION

Influenza vaccination is still at less than the recommended level in patients with CVD. Future research should consider the impact of interventions to improve vaccination uptake in this population.

Incidence of Dementia Following Hospitalization With Infection Among Adults in the Atherosclerosis Risk in Communities (ARIC) Study Cohort

Importance

Factors associated with the risk of dementia remain to be fully understood. Systemic infections are hypothesized to be such factors and may be targets for prevention and screening.

Objective

To investigate the association between hospitalization with infection and incident dementia.

Design, Setting, and Participants

Data from the community-based Atherosclerosis Risk in Communities (ARIC) study, a prospective cohort study, were used. Enrollment occurred at 4 research centers in the US, initiated in 1987 to 1989. The present study includes data up to 2019, for 32 years of follow-up. Data analysis was performed from April 2021 to June 2022.

Exposures

Hospitalizations with infections were identified via medical record review for selected International Classification of Diseases, Ninth Revision (ICD-9) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes, from baseline until administrative censoring or dementia diagnosis. Participants were considered unexposed until first hospitalization with infection and exposed thereafter. Selected infection subtypes were also considered.

Main Outcomes and Measures

Incident dementia and time-to-event data were identified through surveillance of ICD-9 and ICD-10 hospitalization and death certificate codes, in-person assessments, and telephone interviews. A sensitivity analysis was conducted excluding cases occurring within 3 years or beyond 20 years from exposure. Data were collected before study hypothesis formulation.

Results

Of the 15 792 ARIC study participants, an analytical cohort of 15 688 participants who were dementia free at baseline and of Black or White race were selected (8658 female [55.2%]; 4210 Black [26.8%]; mean [SD] baseline age, 54.7 [5.8] years). Hospitalization with infection occurred among 5999 participants (38.2%). Dementia was ascertained in 2975 participants (19.0%), at a median (IQR) of 25.1 (22.2-29.1) years after baseline. Dementia rates were 23.6 events per 1000 person-years (95% CI, 22.3-25.0 events per 1000 person-years) among the exposed and 5.7 events per 1000 person-years (95% CI, 5.4-6.0 events per 1000 person-years) among the unexposed. Patients hospitalized with infection were 2.02 (95% CI, 1.88-2.18; P < .001) and 1.70 (95% CI, 1.55-1.86; P < .001) times more likely to experience incident dementia according to unadjusted and fully adjusted Cox proportional hazards models compared with individuals who were unexposed. When excluding individuals who developed dementia less than 3 years or more than 20 years from baseline or the infection event, the adjusted hazard ratio was 5.77 (95% CI, 4.92-6.76; P < .001). Rates of dementia were significantly higher among those hospitalized with respiratory, urinary tract, skin, blood and circulatory system, or hospital acquired infections. Multiplicative and additive interactions were observed by age and APOE-ε genotype.

Conclusions and Relevance

Higher rates of dementia were observed among participants who experienced hospitalization with infection. These findings support the hypothesis that infections are factors associated with higher risk of dementias.

[COVID-induced facial bones necrosis]

The article focuses on the clinical manifestation of inflammatory and destructive lesions of the bones of the midface, nose and paranasal sinuses as a long-term complication of COVID-19 with clinical examples provided.

Cardio-cerebrovascular complications in COVID-19 patients: A retrospective cohort study

Background

Recent studies have highlighted the cardio-cerebrovascular manifestations of coronavirus disease 2019 (COVID-19).

Objective

This study aimed to analyze the likelihood of cardiovascular and cerebrovascular manifestations among patients with COVID-19-positive individuals in South Korea.

Methods

A cohort database for COVID-19 from the National Health Insurance Service was used which included patients diagnosed with COVID-19 between January 1 and June 4, 2020. Individuals who tested COVID-19 positive, notwithstanding the severity of the disease, were designated as cases. COVID-19- negative individuals were used as controls for the study. The exclusion criteria included people who had a history of cardiovascular and cerebrovascular diseases between 2015 and 2019. A new diagnosis of cardiovascular and cerebrovascular complications was considered the primary endpoint. The adjusted incidence rate ratio (IRR) of development of complications was estimated using log-link Poisson regression. The model was adjusted at two levels, the first one included age and sex while the second included age, sex, residence area, and level of income. The hazard ratio (HR) was estimated using Cox-proportional hazard regression analysis while adjusting for all demographic variables and covariates.

Results

Significant results were obtained for acute conditions, such as ischemic heart disease and cerebral hemorrhage. The IRR of COVID-19- positive individuals compared with that of controls for the diagnosis of ischemic heart disease was 1.78 (1.57-2.02; 95% confidence interval [CI]) when adjusted for age and sex. HR was calculated as 3.02 (2.19-4.17; 95% CI) after adjusting for the covariates. In case of cerebral hemorrhage, the adjusted IRR was 2.06 (1.25-3.40; 95% CI) and the adjusted HR was 4.08 (0.90-19.19; 95% CI).

Conclusion

The findings of our study suggest that COVID-19 infection can be a significant risk factor for acute cardiovascular complications, such as ischemic heart disease and acute cerebrovascular complications, such as cerebral infarction, after properly adjusting for covariates.

Blood Endothelial-Cell Extracellular Vesicles as Potential Biomarkers for the Selection of Plasma in COVID-19 Convalescent Plasma Therapy

Despite the advancement of vaccination and therapies currently available, deaths due to the coronavirus disease 2019 (COVID-19) are still heavily documented. Severely infected individuals experience a generalized inflammatory storm, caused by massive secretion of pro-inflammatory cytokines that can lead to endothelial dysfunction, cardiovascular disease, multi-organ failure, and even death. COVID-19 convalescent plasma (CCP) therapy, selected primarily based on anti-SARS-CoV-2 antibody levels, has not been as convincing as expected in the fight against COVID-19. Given the consequences of a dysfunctional endothelium on the progression of the disease, we propose that the selection of plasma for CCP therapy should be based on more specific parameters that take into consideration the effect on vascular inflammation. Thus, in the present study, we have characterized a subset of CCP that have been used for CCP therapy and measured their anti- or pro-inflammatory effect on human coronary artery endothelial cells (HCAECs). Our data revealed that the longer the time lapse between the onset of symptoms and the plasma donation, the more mitochondrial dysfunction can be evidenced. The concentration of blood endothelial cell extracellular vesicles (BEC-EVs) was increased in the plasma of young individuals with mild symptoms. This type of selected convalescent plasma promoted the activation of the blood vascular endothelium, as reflected by the overexpression of ICAM1 and NFκB1 and the downregulation of VE-Cadherin. We propose this mechanism is a warning signal sent by the injured endothelium to trigger self-defense of peripheral blood vessels against excessive inflammation. Therefore, these results are in line with our previous data. They suggest that a more specific selection of COVID-19 convalescent plasma should be based on the time of donation following the onset of the clinical symptoms of the donor, the severity of the symptoms, and the age of the donor. These characteristics are relatively easy to identify in any hospital and would reflect the concentration of plasma BEC-EVs and be optimal in CCP therapy.

Human circulating bacteria and dysbiosis in non-infectious diseases

Blood microorganisms were once thought to indicate infection. Blood in healthy people appears to be devoid of growing bacteria; nonetheless, intracellular dormant forms of bacteria have been reported previously. With breakthroughs in sequencing and bioinformatics, the presence of bacterial DNA in healthy human blood initiated the controversy of human blood microbiota (HBM). Recently, bacteria-specific DNA and culturable bacteria were found in healthy human blood. Researchers wanted to study the phenomena of a "healthy blood microbiota" by providing a thorough description of bacterially produced nucleic acids using many complementing molecular and traditional microbiological approaches. Because blood is a relatively limited and particular environment, culturability and plate count issues can be overcome using enhanced cultured procedures. However, more evidence is required to confirm that healthy human blood contains normal microbiota. Cavities, mouth and intestinal microbiota, trauma, surgery, and animal/insect bites can introduce bacteria into human blood. All these factors strengthen the concept of transient blood bacteria too. The presence of blood bacteria may be caused by temporary immunological clearance and absorption by dendritic or M cells. This review provides an extensive and comprehensive analysis that suggests that healthy blood bacteria may not be typical microbiota but transient circulatory microorganisms. In this study, we look at how contaminants (Escherichia, Shigella, Pseudomonads, etc.) from the skin, laboratory environments, and reagents can affect the interpretation of blood-derived microbial information and the relationship between the circulating bacteria and non-communicable diseases. Circulating transient bacteria may play a role in the pathogenesis of non-infectious diseases such as diabetes and CVD. Contamination-free hematological studies can aid in understanding the disease mechanisms, therapy, and biomarkers.

The role and mechanisms of gut microbiota in diabetic nephropathy, diabetic retinopathy and cardiovascular diseases

Type 2 diabetes mellitus (T2DM) and T2DM-related complications [such as retinopathy, nephropathy, and cardiovascular diseases (CVDs)] are the most prevalent metabolic diseases. Intriguingly, overwhelming findings have shown a strong association of the gut microbiome with the etiology of these diseases, including the role of aberrant gut bacterial metabolites, increased intestinal permeability, and pathogenic immune function affecting host metabolism. Thus, deciphering the specific microbiota, metabolites, and the related mechanisms to T2DM-related complications by combined analyses of metagenomics and metabolomics data can lead to an innovative strategy for the treatment of these diseases. Accordingly, this review highlights the advanced knowledge about the characteristics of the gut microbiota in T2DM-related complications and how it can be associated with the pathogenesis of these diseases. Also, recent studies providing a new perspective on microbiota-targeted therapies are included.

Incidence and Predictors of Cardiac Arrhythmias in Patients With COVID-19

Background

Coronavirus disease 2019 (COVID-19) is a systemic disease caused by severe acute respiratory syndrome coronavirus 2. Arrhythmias are frequently associated with COVID-19 and could be the result of inflammation or hypoxia. This study aimed to define the incidence of arrhythmias in patients with COVID-19 and to correlate arrhythmias with pulmonary damage assessed by computed tomography (CT).

Methods

All consecutive patients with a COVID-19 diagnosis hospitalized at Universitair Ziekenhuis Brussel, Belgium, between March 2020 and May 2020, were screened. All included patients underwent a thorax CT scan and a CT severity score, a semiquantitative scoring system of pulmonary damage, was calculated. The primary endpoint was the arrhythmia occurrence during follow-up.

Results

In this study, 100 patients were prospectively included. At a mean follow-up of 19.6 months, 25 patients with COVID-19 (25%) experienced 26 arrhythmic episodes, including atrial fibrillation in 17 patients, inappropriate sinus tachycardia in 7 patients, atrial flutter in 1 patient, and third-degree atrioventricular block in 1 patient. No ventricular arrhythmias were documented. Patients with COVID-19 with arrhythmias showed more often need for oxygen, higher oxygen maximum flow, longer QTc at admission, and worse damage at CT severity score. In univariate logistic regression analysis, significant predictors of the primary endpoint were: the need for oxygen therapy (odds ratio [OR] 4.59, 95% CI 1.44–14.67, p = 0.01) and CT severity score of pulmonary damage (OR per 1 point increase 1.25, 95% CI 1.11–1.4, p < 0.001).

Conclusions

In a consecutive cohort of patients with COVID-19 the incidence of cardiac arrhythmias was 25%. The need for oxygen therapy and CT severity score were predictors of arrhythmia occurrence during follow-up.

Early life infection and proinflammatory, atherogenic metabolomic and lipidomic profiles in infancy: a population-based cohort study

Background:

The risk of adult onset cardiovascular and metabolic (cardiometabolic) disease accrues from early life. Infection is ubiquitous in infancy and induces inflammation, a key cardiometabolic risk factor, but the relationship between infection, inflammation, and metabolic profiles in early childhood remains unexplored. We investigated relationships between infection and plasma metabolomic and lipidomic profiles at age 6 and 12 months, and mediation of these associations by inflammation.

Methods:

Matched infection, metabolomics, and lipidomics data were generated from 555 infants in a pre-birth longitudinal cohort. Infection data from birth to 12 months were parent-reported (total infections at age 1, 3, 6, 9, and 12 months), inflammation markers (high-sensitivity C-reactive protein [hsCRP]; glycoprotein acetyls [GlycA]) were quantified at 12 months. Metabolic profiles were 12-month plasma nuclear magnetic resonance metabolomics (228 metabolites) and liquid chromatography/mass spectrometry lipidomics (776 lipids). Associations were evaluated with multivariable linear regression models. In secondary analyses, corresponding inflammation and metabolic data from birth (serum) and 6-month (plasma) time points were used.

Results:

At 12 months, more frequent infant infections were associated with adverse metabolomic (elevated inflammation markers, triglycerides and phenylalanine, and lower high-density lipoprotein [HDL] cholesterol and apolipoprotein A1) and lipidomic profiles (elevated phosphatidylethanolamines and lower trihexosylceramides, dehydrocholesteryl esters, and plasmalogens). Similar, more marked, profiles were observed with higher GlycA, but not hsCRP. GlycA mediated a substantial proportion of the relationship between infection and metabolome/lipidome, with hsCRP generally mediating a lower proportion. Analogous relationships were observed between infection and 6-month inflammation, HDL cholesterol, and apolipoprotein A1.

Conclusions:

Infants with a greater infection burden in the first year of life had proinflammatory and proatherogenic plasma metabolomic/lipidomic profiles at 12 months of age that in adults are indicative of heightened risk of cardiovascular disease, obesity, and type 2 diabetes. These findings suggest potentially modifiable pathways linking early life infection and inflammation with subsequent cardiometabolic risk.

Funding:

The establishment work and infrastructure for the BIS was provided by the Murdoch Children’s Research Institute (MCRI), Deakin University, and Barwon Health. Subsequent funding was secured from National Health and Medical Research Council of Australia (NHMRC), The Shepherd Foundation, The Jack Brockhoff Foundation, the Scobie & Claire McKinnon Trust, the Shane O’Brien Memorial Asthma Foundation, the Our Women’s Our Children’s Fund Raising Committee Barwon Health, the Rotary Club of Geelong, the Minderoo Foundation, the Ilhan Food Allergy Foundation, GMHBA, Vanguard Investments Australia Ltd, and the Percy Baxter Charitable Trust, Perpetual Trustees. In-kind support was provided by the Cotton On Foundation and CreativeForce. The study sponsors were not involved in the collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication. Research at MCRI is supported by the Victorian Government’s Operational Infrastructure Support Program. This work was also supported by NHMRC Senior Research Fellowships to ALP (1008396); DB (1064629); and RS (1045161) , NHMRC Investigator Grants to ALP (1110200) and DB (1175744), NHMRC-A*STAR project grant (1149047). TM is supported by an MCRI ECR Fellowship. SB is supported by the Dutch Research Council (452173113).

New Paradigms for Familiar Diseases: Lessons Learned on Circulatory Bacterial Signatures in Cardiometabolic Diseases

Despite the strongly accumulating evidence for microbial signatures in metabolic tissues, including the blood, suggesting a novel paradigm for metabolic disease development, the notion of a core blood bacterial signature in health and disease remains a contentious concept. Recent studies clearly demonstrate that under a strict contamination-free environment, methods such as 16 S rRNA gene sequencing, fluorescence in-situ hybridization, transmission electron microscopy, and several more, allied with advanced bioinformatics tools, allow unambiguous detection and quantification of bacteria and bacterial DNA in human tissues. Bacterial load and compositional changes in the blood have been reported for numerous disease states, suggesting that bacteria and their components may partially induce systemic inflammation in cardiometabolic disease. This concept has been so far primarily based on measurements of surrogate parameters. It is now highly desirable to translate the current knowledge into diagnostic, prognostic, and therapeutic approaches.This review addresses the potential clinical relevance of a blood bacterial signature pertinent to cardiometabolic diseases and outcomes and new avenues for translational approaches. It discusses pitfalls related to research in low bacterial biomass while proposing mitigation strategies for future research and application approaches.

Endothelial Dysfunction in SARS-CoV-2 Infection

One of the hallmarks of the SARS-CoV-2 infection has been the inflammatory process that played a role in its pathogenesis, resulting in mortality within susceptible individuals. This uncontrolled inflammatory process leads to severe systemic symptoms via multiple pathways; however, the role of endothelial dysfunction and thrombosis have not been truly explored. This review aims to highlight the pathogenic mechanisms of these inflammatory triggers leading to thrombogenic complications. There are direct and indirect pathogenic pathways of the infection that are examined in detail. We also describe the case of carotid artery thrombosis in a patient following SARS-CoV-2 infection while reviewing the literature on the role of ACE2, the endothelium, and the different mechanisms by which SARS-CoV-2 may manifest both acutely and chronically. We also highlight differences from the other coronaviruses that have made this infection a pandemic with similarities to the influenza virus.

Risk of Acute Myocardial Infarction in Patients with Gastroenteritis: A Nationwide Case-Control Study

Gastroenteritis promotes the development of systemic inflammation and a hypercoagulable state. There are limited data regarding the association between gastroenteritis and acute myocardial infarction (AMI). We aimed to evaluate the risk of AMI after an episode of gastroenteritis. In this nested case-control study, we selected patients who were hospitalized for AMI (N = 103,584) as a case group during 2010-2017 and performed propensity score matching (case-control ratio 1:1) to select eligible controls from insurance research data in Taiwan. We applied multivariable logistic regressions to calculate adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for the risk of AMI associated with recent gastroenteritis within 14 days before AMI. We also compared the outcomes after AMI in patients with or without gastroenteritis. A total of 1381 patients (1.3%) with AMI had a prior episode of gastroenteritis compared to 829 (0.8%) among the controls. Gastroenteritis was significantly associated with a subsequent risk of AMI (adjusted OR: 1.68, 95% CI: 1.54-1.83), which was augmented in hospitalizations for gastroenteritis (adjusted OR: 2.50, 95% CI: 1.20-5.21). The outcomes after AMI were worse in patients with gastroenteritis than in those without gastroenteritis, including increased 30-day in-hospital mortality (adjusted OR: 1.28, 95% CI: 1.08-1.52), medical expenditure, and length of hospital stay. Gastroenteritis may act as a trigger for AMI and correlates with worse post-AMI outcomes. Strategies of aggressive hydration and/or increased antithrombotic therapies for this susceptible population should be further developed.

Cardiovascular System during SARS-CoV-2 Infection

SARS-CoV-2 virus can not only damage the respiratory system but may also pose a threat to other organs, such as the heart or vessels. This review focuses on cardiovascular complications of COVID-19, including acute cardiac injury, arrhythmias, biomarkers, accompanying comorbidities and outcomes in patients diagnosed with SARS-CoV-2 infection. The research was conducted on the databases: PubMed, Springer, ScienceDirect, UpToDate, Oxford Academic, Wiley Online Library, ClinicalKey. Fifty-six publications from 1 November 2020 till 15 August 2021 were included in this study. The results show that cardiac injury is present in about 1 in 4 patients with COVID-19 disease, and it is an independent risk factor, which multiplies the death rate several times in comparison to infected patients without myocardial injury. New-onset cardiac injury occurs in nearly every 10th patient of the COVID-19-suffering population. Comorbidities (such as hypertension, cardiovascular disease and diabetes) severely deteriorate the outcome. Therefore, patients with SARS-CoV-2 infection should be carefully assessed in terms of cardiac medical history and possible cardiological complications.

Acute and Subclinical Myocardial Injury in COVID-19

Coronavirus disease 2019 (COVID-19) is a global pandemic that, at the time of this writing, has led to 178,000,000 cases worldwide and more than 3,875,000 deaths. Cardiovascular complications of COVID-19 have become the focus of investigation after many hospitalized COVID-19 patients-with or without established cardiovascular disease-incurred clinical or subclinical myocardial injury, including isolated biomarker elevations, myocardial infarction, arrhythmia, heart failure, myocarditis, and cardiogenic shock. In this review, we highlight the most recent evidence of the prevalence and potential etiologies of acute and subclinical myocardial injury in COVID-19 patients.

A case-control analysis of stroke in COVID-19 patients: Results of unusual manifestations of COVID-19-study 11

OBJECTIVE

We investigated the incidence, predictor variables, clinical characteristics, and stroke outcomes in patients with COVID-19 seen in emergency departments (EDs) before hospitalization.

METHODS

We retrospectively reviewed all COVID-19 patients diagnosed with stroke during the COVID-19 outbreak in 62 Spanish EDs. We formed two control groups: COVID-19 patients without stroke (control A) and non-COVID-19 patients with stroke (control B). We compared disease characteristics and four outcomes between cases and controls.

RESULTS

We identified 147 strokes in 74,814 patients with COVID-19 seen in EDs (1.96‰, 95% confidence interval [CI] = 1.66‰ to 2.31‰), being lower than in non-COVID-19 patients (6,541/1,388,879, 4.71‰, 95% CI = 4.60‰ to 4.83‰; odds ratio [OR] = 0.42, 95% CI = 0.35 to 0.49). The estimated that standardized incidences of stroke per 100,000 individuals per year were 124 and 133 for COVID-19 and non-COVID-19 individuals, respectively (OR = 0.93 for COVID patients, 95% CI = 0.87 to 0.99). Baseline characteristics associated with a higher risk of stroke in COVID-19 patients were hypertension, diabetes mellitus, and previous cerebrovascular and coronary diseases. Clinically, these patients more frequently presented with confusion, decreased consciousness, and syncope and higher D-dimer concentrations and leukocyte count at ED arrival. After adjustment for age and sex, the case group had higher hospitalization and intensive care unit (ICU) admission rates (but not mortality) than COVID-19 controls without stroke (OR = 3.41, 95% CI = 1.27 to 9.16; and OR = 3.79, 95% CI = 1.69 to 8.50, respectively) and longer hospitalization and greater in-hospital mortality than stroke controls without COVID-19 (OR = 1.55, 95% CI = 1.24 to 1.94; and OR = 1.77, 95% CI = 1.37 to 2.30, respectively).

CONCLUSIONS

The incidence of stroke in COVID-19 patients presenting to EDs was lower than that in the non-COVID-19 reference sample. COVID-19 patients with stroke had greater need for hospitalization and ICU admission than those without stroke and longer hospitalization and greater in-hospital mortality than non-COVID-19 patients with stroke.

Risk of infections in psoriasis: assessment and challenges in daily management

INTRODUCTION

In daily practice management of psoriasis, evaluation of risk factors for infections is having a growing influence. Indeed, in psoriatic patients, risk of infections may be due to psoriasis itself, immunomodulatory therapy, and comorbidities that may increase this risk and patient hospitalization.

AREAS COVERED

Given the greater understanding of psoriasis pathogenesis and the increasing number of treatment options, it is particularly important to customize therapy according to each, single patient; psoriasis features and comorbidities are also essential to tailor treatment goals.

EXPERT OPINION

In this perspective, the current knowledge on the infectious risk in psoriatic patient, related to comorbidities, such as diabetes mellitus, cardiovascular disease, and chronic obstructive pulmonary, to 'special populations,' to chronic infections, such as latent tuberculosis, chronic hepatitis B and C, and HIV, and to the most recent Covid-19 pandemic scenario, is reviewed and discussed in order to suggest the most appropriate approach and achieve the best available therapeutic option.

COVID-19 and Cardiac Arrhythmias: A Review of the Literature

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of the ongoing coronavirus disease 2019 (COVID-19) pandemic. There are many documented COVID-19-related cardiac complications, one of the most feared is arrhythmia. Many ongoing studies are evaluating the pathophysiology of COVID-19-induced arrhythmia. However, our knowledge about the exact mechanism of the latter is still limited. The underlying possible mechanisms could be related to direct or indirect endomyocardial tissue damage. It is also noted in several studies that cardiac arrhythmias are the consequence of systemic illness, proarrhythmic medications, and electrolytes imbalances in hospitalized patients and not solely the direct effects of COVID-19 infection. In this review article, we present the different aspects of arrhythmias in COVID patients, possible associated conditions, and triggers.

Utilizing Heart Rate Variability for Coaching Athletes During and After Viral Infection: A Case Report in an Elite Endurance Athlete

Background: Viral diseases have different individual progressions and can lead to considerable risks/long-term consequences. Therefore, it is not suitable to give general recommendations on a time off from training for athletes. This case report aims to investigate the relevance of detecting heart rate (HR) and HR variability (HRV) during an orthostatic test (OT) to monitor the progression and recovery process during and after a viral disease in an elite endurance athlete.

Methods: A 30-year-old elite marathon runner contracted a viral infection (upper respiratory tract infection) 4 weeks after a marathon race. RR intervals in HR time series in supine and standing positions were monitored daily in the morning. Analyzed parameters included HR, the time-domain HRV parameter root mean square of successive difference (RMSSD), peak HR (HRpeak) in a standing position, and the time to HR peak (tHRpeak).

Results: During the 6-day viral infection period, HR increased significantly by an average of 11 bpm in the supine position and by 22 bpm in the standing position. In addition, the RMSSD decreased from 20.8 to 4.2 ms, the HRpeak decreased by 13 bpm, and the tHRpeak increased by 18 s in the standing position significantly. There were no significant changes in the pre-viral infection RMSSD values in the supine position. The viral infection led to a significant change in HR and HRV parameters. The cardiac autonomic system reacted more sensitively in the standing position compared to the supine position after a viral infection in the present case study.

Conclusion: These data have provided supportive rationale as to why the OT with a change from supine to standing body position and the detection of different indicators based on HR and a vagal driven time-domain HRV parameter (RMSSD) is likely to be useful to detect viral diseases early on when implemented in daily routine. Given the case study nature of the findings, future research has to be conducted to investigate whether the use of the OT might be able to offer an innovative, non-invasive, and time-efficient possibility to detect and evaluate the health status of (elite endurance) athletes.

Dying "from" or "with" COVID-19 during the Pandemic: Medico-Legal Issues According to a Population Perspective

There is still a lack of knowledge concerning the pathophysiology of death among COVID-19-deceased patients, and the question of whether a patient has died with or due to COVID-19 is still very much debated. In Italy, all deaths of patients who tested positive for SARS-CoV-2 are defined as COVID-19-related, without considering pre-existing diseases that may either contribute to or even cause death. Our study included nine subjects from two different nursing homes (Cases 1–4, Group A; Cases 5–9, Group B). The latter included patients who presumably died from CO poisoning due to a heating system malfunction. All subjects tested positive for COVID-19 both ante- and post-mortem and were examined using post-mortem computed tomography prior to autopsy. COVID-19 was determined to be a contributing cause in the deaths of four out of nine subjects (death due to COVID-19; i.e., pneumonia and sudden cardiac death). In the other five cases, for which CO poisoning was identified as the cause of death, the infection presumably had no role in exitus (death with COVID-19). In our attempt to classify our patients as dying with or due to COVID-19, we found the use of complete assessments (both histological analyses and computed tomography examination) fundamental.

MATHEMATICAL MODEL FOR THE INVESTIGATION OF HYPOXIC STATES IN THE HEART MUSCLE AT VIRAL DAMAGE

The main complications of organism damaged by SARS-CoV-2 virus are various cardiovascular system lesions. As a result, the secondary tissue hypoxia is developed and it is relevant to search the means for hypoxic state alleviation. Mathematical modeling of this process, followed by the imitation of hypoxic states development, and subsequent correction of hypoxia at this model may be one of the directions for investigations. Aim. The purpose of this study was to construct mathematical models of functional respiratory and blood circulatory systems to simulate the partial occlusion of blood vessels during viral infection lesions and pharmacological correction of resulting hypoxic state. Methods. Methods of mathematical modeling and dynamic programming were used. Transport and mass exchange of respiratory gases in organism, partial occlusion of blood vessels and influence of antihypoxant were described by the systems of ordinary nonlinear differential equations. Results. Mathematical model of functional respiratory system was developed to simulate pharmacological correction of hypoxic states caused by the complications in courses of viral infection lesions. The model was based on the theory of functional systems by P. K. Anokhin and the assumption about the main function of respiratory system. The interactions and interrelations of individual functional systems in organism were assumed. Constituent parts of our model were the models of transport and mass exchange of respiratory gases in organism, selforganization of respiratory and blood circulatory systems, partial occlusion of blood vessels and the transport of pharmacological substance. Conclusions. The series of computational experiments for averaged person organism demonstrated the possibility of tissue hypoxia compensation using pharmacological substance with vasodilating effect, and in the case of individual data array, it may be useful for the development of strategy and tactics for individual patient medical treatment.

(Absence of) Association Between Non-Vitamin K Antagonist Oral Anticoagulant Therapy and Urinary Tract Infection in Patients With Atrial Fibrillation

ABSTRACT

The aim of the present study is to identify a potential association of urinary tract infections (UTI) in a large population of patients receiving oral anticoagulation therapy treated in general practices in Germany. This study contains patients diagnosed with atrial fibrillation who received at least one prescription of either non-vitamin K antagonist oral anticoagulation (NOAC) or vitamin K antagonists (VKA) within January 2015 and December 2018. The incidence of UTI was examined cumulatively on the basis of Kaplan-Meier methods and was complemented by incidence rates measured in cases per 1000 patient years. Sex-stratified Cox regressions were conducted to examine possible associations in specific sex groups. The study comprised 26,934 patients receiving NOAC therapy and 8121 patients treated with VKA agents. Within a period of 5 years, slightly more NOAC than VKA users were diagnosed with UTI (20.3% vs. 19.3%), whereas the incidence rate was slightly higher in patients receiving NOAC therapy than in those under VKA treatment (50.8 cases vs. 50.5 cases in 1000 patient years). There was no significant association between direct oral anticoagulants versus vitamin K antagonists and infections of the urinary tract. Our study did not identify any significant association between therapy with direct oral anticoagulants versus vitamin K anticoagulants and UTI in patients diagnosed with atrial fibrillation in general practices in Germany. Because current findings regarding the risk of UTI in patients receiving oral anticoagulation therapy remain limited and contradictory, further investigations including a broad patient population are necessary to determine patients at risk for UTI and reconcile conflicting evidence.

Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method

OBJECTIVES

Diagnostic error is a serious public health problem. Measuring diagnostic performance remains elusive. We sought to measure misdiagnosis-related harms following missed acute myocardial infarctions (AMI) in the emergency department (ED) using the symptom-disease pair analysis of diagnostic error (SPADE) method.

METHODS

Retrospective administrative data analysis (2009-2017) from a single, integrated health system using International Classification of Diseases (ICD) coded discharge diagnoses. We looked back 30 days from AMI hospitalizations for antecedent ED treat-and-release visits to identify symptoms linked to probable missed AMI (observed > expected). We then looked forward from these ED discharge diagnoses to identify symptom-disease pair misdiagnosis-related harms (AMI hospitalizations within 30-days, representing diagnostic adverse events).

RESULTS

A total of 44,473 AMI hospitalizations were associated with 2,874 treat-and-release ED visits in the prior 30 days. The top plausibly-related ED discharge diagnoses were "chest pain" and "dyspnea" with excess treat-and-release visit rates of 9.8% (95% CI 8.5-11.2%) and 3.4% (95% CI 2.7-4.2%), respectively. These represented 574 probable missed AMIs resulting in hospitalization (adverse event rate per AMI 1.3%, 95% CI 1.2-1.4%). Looking forward, 325,088 chest pain or dyspnea ED discharges were followed by 508 AMI hospitalizations (adverse event rate per symptom discharge 0.2%, 95% CI 0.1-0.2%).

CONCLUSIONS

The SPADE method precisely quantifies misdiagnosis-related harms from missed AMIs using administrative data. This approach could facilitate future assessment of diagnostic performance across health systems. These results correspond to ∼10,000 potentially-preventable harms annually in the US. However, relatively low error and adverse event rates may pose challenges to reducing harms for this ED symptom-disease pair.

Harmful Effects of COVID-19 on Major Human Body Organs: A Review

The world experienced the outbreak of a new pandemic disease in 2019, known as coronavirus (CoV) disease 2019 (COVID-19), which is caused by the novel severe acute respiratory syndrome-CoV-2 (SARS-CoV-2). The respiratory system is the organ system most commonly affected by COVID-19; however, several other organ systems have been reported to be affected. The SARS-CoV-2 RNA found in infected stub samples can cause lung contagion by binding to the angiotensin-converting enzyme-2 (ACE-2) receptor of the alveolar epithelial cells. The gut microbiota (GM) promote immunity, indicating that the alignment of the microbiota and corresponding metabolic processes in COVID-19 can help to identify novel biomarkers and new therapeutic targets for this disease. The cause of kidney damage in COVID-19 patients is possibly multifactorial, involving a complex mechanism that involves complement dysregulation and thrombotic microangiopathy, as well as the occurrence of a “cytokine storm” syndrome, which are immune responses that are abandoned and dysfunctional with unfavorable prognosis in severe COVID-19 cases. Furthermore, COVID-19 involves a continuous proliferation and activation of macrophages and lymphocytes. SARS-CoV-2 can also bind to the ACE-2 receptor expressed in the cerebral capillary endothelial cells that can invade the blood-brain wall, to penetrate the brain parenchyma. However, in the ongoing pandemic, there has been a surge in studies on a wide range of topics, including causes of respiratory failure, asymptomatic patients, intensive care patients, and survivors. This review briefly describes the damaging effects of COVID-19 on vital human organs and the inhibitory function of the ACE-2 receptor on the GM, which causes gut dysbiosis, and thus, this review discusses topics that have an opportunity for further investigation.

Characteristics and Outcomes Among US Patients Hospitalized for Ischemic Stroke Before vs During the COVID-19 Pandemic

IMPORTANCE

After the emergence of COVID-19, studies reported a decrease in hospitalizations of patients with ischemic stroke (IS), but there are little to no data regarding hospitalizations for the remainder of 2020, including outcome data from a large cohort of patients with IS and comorbid COVID-19.

OBJECTIVE

To assess hospital discharge rates, demographic factors, and outcomes of hospitalization associated with the COVID-19 pandemic among US patients with IS before vs during the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from the Vizient Clinical Data Base on 324 013 patients with IS at 478 nonfederal hospitals in 43 US states between January 1, 2019, and December 31, 2020. Patients were eligible if they were admitted to the hospital on a nonelective basis and were not receiving hospice care at the time of admission. A total of 41 166 discharged between January and March 2020 were excluded from the analysis because they had unreliable data on COVID-19 status, leaving 282 847 patients for the study.

EXPOSURE

Ischemic stroke and laboratory-confirmed COVID-19.

MAIN OUTCOMES AND MEASURES

Monthly counts of discharges among patients with IS in 2020. Demographic characteristics and outcomes, including in-hospital death, among patients with IS who were discharged in 2019 (control group) were compared with those of patients with IS with or without comorbid COVID-19 (COVID-19 and non-COVID-19 groups, respectively) who were discharged between April and December 2020.

RESULTS

Of the 282 847 patients included in the study, 165 912 (50.7% male; 63.4% White; 26.3% aged ≥80 years) were allocated to the control group; 111 418 of 116 935 patients (95.3%; 51.9% male; 62.8% White; 24.6% aged ≥80 years) were allocated to the non-COVID-19 group and 5517 of 116 935 patients (4.7%; 58.0% male; 42.5% White; 21.3% aged ≥80 years) to the COVID-19 group. A mean (SD) of 13 846 (553) discharges per month among patients with IS was reported in 2019. Discharges began decreasing in February 2020, reaching a low of 10 846 patients in April 2020 before returning to a prepandemic level of 13 639 patients by July 2020. A mean (SD) of 13 492 (554) discharges per month was recorded for the remainder of 2020. Black and Hispanic patients accounted for 21.4% and 7.0% of IS discharges in 2019, respectively, but accounted for 27.5% and 16.0% of those discharged with IS and comorbid COVID-19 in 2020. Compared with patients in the control and non-COVID-19 groups, those in the COVID-19 group were less likely to smoke (16.0% vs 17.2% vs 6.4%, respectively) and to have hypertension (73.0% vs 73.1% vs 68.2%) or dyslipidemia (61.2% vs 63.2% vs 56.6%) but were more likely to have diabetes (39.8% vs 40.5% vs 53.0%), obesity (16.2% vs 18.4% vs 24.5%), acute coronary syndrome (8.0% vs 9.2% vs 15.8%), or pulmonary embolus (1.9% vs 2.4% vs 6.8%) and to require intubation (11.3% vs 12.3% vs 37.6%). After adjusting for baseline factors, patients with IS and COVID-19 were more likely to die in the hospital than were patients with IS in 2019 (adjusted odds ratio, 5.17; 95% CI, 4.83-5.53; National Institutes of Health Stroke Scale adjusted odds ratio, 3.57; 95% CI, 3.15-4.05).

CONCLUSIONS AND RELEVANCE

In this cohort study, after the emergence of COVID-19, hospital discharges of patients with IS decreased in the US but returned to prepandemic levels by July 2020. Among patients with IS between April and December 2020, comorbid COVID-19 was relatively common, particularly among Black and Hispanic populations, and morbidity was high.

Impact of cardiovascular disease and risk factors on fatal outcomes in patients with COVID-19 according to age: a systematic review and meta-analysis

OBJECTIVE

Previous studies that evaluated cardiovascular risk factors considered age as a potential confounder. We aimed to investigate the impact of cardiovascular disease (CVD) and its risk factors on fatal outcomes according to age in patients with COVID-19.

METHODS

A systematic literature review and meta-analysis was performed on data collected from PubMed and Embase databases up to 11 June 2020. All observational studies (case series or cohort studies) that assessed in-hospital patients were included, except those involving the paediatric population. Prevalence rates of comorbid diseases and clinical outcomes were stratified by mean patient age in each study (ranges: <50 years, 50-60 years and ≥60 years). The primary outcome measure was a composite fatal outcome of severe COVID-19 or death.

RESULTS

We included 51 studies with a total of 48 317 patients with confirmed COVID-19 infection. Overall, the relative risk of developing severe COVID-19 or death was significantly higher in patients with risk factors for CVD (hypertension: OR 2.50, 95% CI 2.15 to 2.90; diabetes: 2.25, 95% CI 1.89 to 2.69) and CVD (3.11, 95% 2.55 to 3.79). Younger patients had a lower prevalence of hypertension, diabetes and CVD compared with older patients; however, the relative risk of fatal outcomes was higher among the former.

CONCLUSIONS

The results of the meta-analysis suggest that CVD and its risk factors (hypertension and diabetes) were closely related to fatal outcomes in COVID-19 for patients across all ages. Although young patients had lower prevalence rates of cardiovascular comorbidities than elderly patients, relative risk of fatal outcome in young patients with hypertension, diabetes and CVD was higher than in elderly patients.

PROSPERO REGISTRATION NUMBER

CRD42020198152.

Impact of COVID-19 on Outcomes in Ischemic Stroke Patients in the United States

BACKGROUND

Studies have shown worse outcomes in patients with comorbid ischemic stroke (IS) and coronavirus disease 2019 (COVID-19), but have had small sample sizes.

METHODS

We retrospectively identified patients in the Vizient Clinical Data Base® with IS as a discharge diagnosis. The study outcomes were in-hospital death and favorable discharge (home or acute rehabilitation). In the primary analysis, we compared IS patients with laboratory-confirmed COVID-19 (IS-COVID) discharged April 1-July 31, 2020 to pre-COVID IS patients discharged in 2019 (IS controls). In a secondary analysis, we compared a matched cohort of IS-COVID patients to patients within the IS controls who had pneumonia (IS-PNA), created with inverse-probability-weighting (IPW).

RESULTS

In the primary analysis, we included 166,586 IS controls and 2086 IS-COVID from 312 hospitals in 46 states. Compared to IS controls, IS-COVID were less likely to have hypertension, dyslipidemia, or be smokers, but more likely to be male, younger, have diabetes, obesity, acute renal failure, acute coronary syndrome, venous thromboembolism, intubation, and comorbid intracerebral or subarachnoid hemorrhage (all p<0.05). Black and Hispanic patients accounted for 21.7% and 7.4% of IS controls, respectively, but 33.7% and 18.5% of IS-COVID (p<0.001). IS-COVID, versus IS controls, were less likely to receive alteplase (1.8% vs 5.6%, p<0.001), mechanical thrombectomy (4.4% vs. 6.7%, p<0.001), to have favorable discharge (33.9% vs. 66.4%, p<0.001), but more likely to die (30.4% vs. 6.5%, p<0.001). In the matched cohort of patients with IS-COVID and IS-PNA, IS-COVID had a higher risk of death (IPW-weighted OR 1.56, 95% CI 1.33-1.82) and lower odds of favorable discharge (IPW-weighted OR 0.63, 95% CI 0.54-0.73).

CONCLUSIONS

Ischemic stroke patients with COVID-19 are more likely to be male, younger, and Black or Hispanic, with significant increases in morbidity and mortality compared to both ischemic stroke controls from 2019 and to patients with ischemic stroke and pneumonia.

Cardiovascular Pathophysiology, Epidemiology, and Treatment Considerations of Coronavirus Disease 2019 (COVID-19): A Review

The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is rapidly evolving, with important cardiovascular considerations. The presence of underlying cardiovascular risk factors and established cardiovascular disease (CVD) may affect the severity and clinical management of patients with COVID-19. We conducted a review of the literature to summarize the cardiovascular pathophysiology, risk factors, clinical presentations, and treatment considerations of COVID-19 patients with underlying CVD. Angiotensin-converting enzyme 2 (ACE2) has been identified as a functional receptor for the SARS-CoV-2 virus, and it is associated with the cardiovascular system. Hypertension, diabetes, and CVD are the most common comorbidities in COVID-19 patients, and these factors have been associated with the progression and severity of COVID-19. However, elderly populations, who develop more-severe COVID-19 complications, are naturally exposed to these comorbidities, underscoring the possible confounding of age. Observational data support international cardiovascular societies' recommendations to not discontinue ACE inhibitor/angiotensin-receptor blocker therapy in patients with guideline indications for fear of the increased risk of SARS-CoV-2 infection, severe disease, or death. In addition to the cardiotoxicity of experimental antivirals and potential interactions of experimental therapies with cardiovascular drugs, several strategies for cardiovascular protection have been recommended in COVID-19 patients with underlying CVD. Troponin elevation is associated with increased risk of in-hospital mortality and adverse outcomes in patients with COVID-19. Cardiovascular care teams should have a high index of suspicion for fulminant myocarditis-like presentations being SARS-CoV-2 positive, and remain vigilant for cardiovascular complications in COVID-19 patients.

Double trouble: combined cardiovascular effects of particulate matter exposure and coronavirus disease 2019

The coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly grown into a pandemic. According to initial reports, the lungs were thought to be the primary target, but recent case studies have shown its reach can extend to other organs including the heart and blood vessels. The severity of cardiac complications of COVID-19 depends on multiple underlying factors, with air pollutant exposure being one of them, as reported by several recent studies. Airborne particulate matter (PM) attracts heightened attention due to its implication in various diseases, especially respiratory and cardiovascular diseases. Inhaled PM not only carries microorganisms inside the body but also elicits local and systemic inflammatory responses resulting in altering the host's immunity and increasing susceptibility to infection. Previous and recent studies have documented that PM acts as a 'carrier' for the virus and aids in spreading viral infections. This review presents the mechanisms and effects of viral entry and how pollution can potentially modulate pathophysiological processes in the heart. We aimed to concisely summarize studies examining cardiovascular outcomes in COVID-19 patients and postulate on how PM can influence these outcomes. We have also reviewed evidence on the use of renin-angiotensin system inhibitors, namely angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, in patients with COVID-19. The interplay of pollution and SARS-CoV-2 is essential to understanding the effects of accentuated cardiovascular effects of COVID-19 and deserves in-depth experimental investigations.

A 61-Year-Old Man with SARS-CoV-2 Infection and Venous Thrombosis Presenting with Painful Swelling and Gangrene of the Lower Limb Consistent with Phlegmasia Cerulea Dolens

Patient: Male, 61-year-old

Final Diagnosis: Phlegmasia cerulea dolens

Symptoms: Bilateral leg swelling • breathlessness • cough • fever

Medication: —

Clinical Procedure: —

Specialty: Cardiology • Infectious Diseases • Medicine, General and Internal

COVID-19 and cardiovascular consequences: Is the endothelial dysfunction the hardest challenge?

A Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) has become a pandemic disease named Coronavirus Disease-19 (COVID-19) of epochal dimension. The clinical spectrum of COVID-19 is wide, ranging from asymptomatic forms to severe pneumonia, sepsis and multiple organ dysfunction syndromes resulting in poor outcomes. Among the various consequences of severe COVID-19, cardiovascular (CV) collapse appears the most serious and potentially lethal. On the other hand, pre-existent CV comorbidities are also associated with higher mortality. The most reliable hypothetical pathogenetic mechanism for CV complications and cardiac injury in severe COVID-19 patients appears to be a sustained endothelial dysfunction, caused by the interplay of inflammation and coagulation. In this review, we survey papers addressing issues related to severe COVID-19, characterized by enhanced lung microvascular loss, hypercytokinemia, hypoxemia and thrombosis. We discuss about how the virus-induced downregulation of the angiotensin converting enzyme-2 (ACE2) receptor, used to enter the host cell, could affect the renin-angiotensin system, attempting to clarify the doubts about the use of ACE inhibitors and Angiotensin-II receptor blockers in COVID-19 patients. Finally, we point out how the delicate and physiological homeostatic function of the endothelium, which turns into a disastrous battlefield of the complex interaction between "cytokine and coagulative storms", can be irreparably compromised and result in systemic inflammatory complications.

Immunoinflammatory, Thrombohaemostatic, and Cardiovascular Mechanisms in COVID-19

The global coronavirus disease 2019 (COVID-19) pandemic has deranged the recent history of humankind, afflicting more than 27 million individuals to date. While the majority of COVID-19 patients recuperate, a considerable number of patients develop severe complications. Bilateral pneumonia constitutes the hallmark of severe COVID-19 disease but an involvement of other organ systems, namely the cardiovascular system, kidneys, liver, and central nervous system, occurs in at least half of the fatal COVID-19 cases. Besides respiratory failure requiring ventilation, patients with severe COVID-19 often display manifestations of systemic inflammation and thrombosis as well as diffuse microvascular injury observed postmortem. In this review, we survey the mechanisms that may explain how viral entry and activation of endothelial cells by severe acute respiratory syndrome coronavirus 2 can give rise to a series of events including systemic inflammation, thrombosis, and microvascular dysfunction. This pathophysiological scenario may be particularly harmful in patients with overt cardiovascular disease and may drive the fatal aspects of COVID-19. We further shed light on the role of the renin-angiotensin aldosterone system and its inhibitors in the context of COVID-19 and discuss the potential impact of antiviral and anti-inflammatory treatment options. Acknowledging the comorbidities and potential organ injuries throughout the course of severe COVID-19 is crucial in the clinical management of patients affecting treatment approaches and recovery rate.

Myocardial involvement in coronavirus disease 19

Background

In late 2019, a cohort of patients presenting with pneumonia of unclear etiology in Wuhan, China, heralded the outbreak of coronavirus disease 19 (COVID-19). Previous severe acute respiratory syndrome (SARS) beta-coronavirus infections have been associated with tachyarrhythmias and signs and symptoms of heart failure. The emergence of SARS coronavirus 2 (SARS-CoV-2), which causes COVID-19, has rapidly developed into a pandemic, and a large number of infected patients have been reported to have underlying cardiovascular disease.

Objective

Since there are only scant published data regarding cardiovascular burden in the wake of viral epidemics, this study aimed to evaluate cardiac involvement in COVID-19.

Material and methods

This prospective cohort study included 40 adult inpatients at two centers in Germany. Adult patients diagnosed with COVID-19 in accordance with World Health Organization (WHO) interim guidance were included in the study, which focused on the potential cardiac involvement of SARS-CoV‑2. It was based on laboratory parameters as well as electro- and echocardiographic values to determine the impact of SARS-CoV‑2 virus on heart tissues.

Results

The conducted investigations confirmed the relationship between the presence of acute cardiac injury and COVID-19.

Conclusion

Myocardial injury and impaired myocardial function due to COVID-19 are common; however, no correlation was established between cardiac laboratory or echocardiographic values and mortality. Cardiovascular monitoring upon COVID-19 infection is crucial to determine the burden of cardiac involvement.

Blood Microbiota and Circulating Microbial Metabolites in Diabetes and Cardiovascular Disease

Diabetes and cardiovascular disease (CVD) have evolved as the leading cause of mortality and morbidity worldwide. In addition to traditional risk factors, recent studies have established that the human microbiota, particularly gut bacteria, plays a role in the development of diabetes and CVD. Although the presence of microbes in blood has been known for centuries, mounting evidence in this metagenomic era provides new insights into the role of the blood microbiota in the pathogenesis of non-infectious diseases such as diabetes and CVD. We highlight the origin and physiology of the blood microbiota and circulating microbial metabolites in relation to the etiology and progression of diabetes and CVD. We also discuss translational perspectives targeting the blood microbiota in the diagnosis and treatment of diabetes and CVD.

Potential Effects of Coronaviruses on the Cardiovascular System: A Review

Importance

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19) has reached a pandemic level. Coronaviruses are known to affect the cardiovascular system. We review the basics of coronaviruses, with a focus on COVID-19, along with their effects on the cardiovascular system.

Observations

Coronavirus disease 2019 can cause a viral pneumonia with additional extrapulmonary manifestations and complications. A large proportion of patients have underlying cardiovascular disease and/or cardiac risk factors. Factors associated with mortality include male sex, advanced age, and presence of comorbidities including hypertension, diabetes mellitus, cardiovascular diseases, and cerebrovascular diseases. Acute cardiac injury determined by elevated high-sensitivity troponin levels is commonly observed in severe cases and is strongly associated with mortality. Acute respiratory distress syndrome is also strongly associated with mortality.

Conclusions and Relevance

Coronavirus disease 2019 is associated with a high inflammatory burden that can induce vascular inflammation, myocarditis, and cardiac arrhythmias. Extensive efforts are underway to find specific vaccines and antivirals against SARS-CoV-2. Meanwhile, cardiovascular risk factors and conditions should be judiciously controlled per evidence-based guidelines.

Association between Cardiovascular Burden and Requirement of Intensive Care among Patients with Mild COVID-19

Background

Information regarding the impact of cardiovascular (CV) conditions on disease progression among patients with mild coronavirus disease 2019 (COVID-19) is limited.

Methods

This study evaluated the association of underlying CV conditions with disease progression in patients with mild COVID-19. The primary outcome was the need to be transferred to the designated hospital for intensive care due to COVID-19 disease progression. The patients were divided into with and without CV conditions as well as stable and intensive care groups.

Results

Of the 332 patients with mild COVID-19, the median age was 51 years (IQR, 40-59 years), and 200 (61.2%) were female. Of the 48 (14.5%) patients with CV conditions, 23 (47.9%) progressed to severe disease status and required intensive care. Compared with patients without CV conditions, patients with CV conditions were older and more likely to have fatigue, chest tightness, and myalgia. The rate of requiring intensive care was significantly higher among patients with CV conditions than in patients without CV conditions (47.92% vs. 12.4%; P < 0.001). In subgroup analysis, the rate of requiring intensive care was also higher among patients with either hypertension or coronary heart disease (CHD) than in patients without hypertension or CHD. The multivariable regression model showed that CV condition served as an independent risk factor for intensive care (odds ratio (OR), 2.652 (95% CI, 1.019-6.899)) after adjustment for various cofounders.

Conclusions

Patients with mild COVID-19 complicating CV conditions are susceptible to develop severe disease status and requirement for intensive care.

Impact of cerebrovascular and cardiovascular diseases on mortality and severity of COVID-19-systematic review, meta-analysis, and meta-regression

BACKGROUND

We conducted a systematic review and meta-analysis to evaluate the latest evidence on the association between cerebrovascular, and cardiovascular diseases and poor outcome in patients with Coronavirus Disease 2019 (COVID-19) pneumonia.

METHODS

A comprehensive systematic literature search was performed using PubMed, SCOPUS, EuropePMC, and Cochrane Central Database. The outcome of interest was composite poor outcome that comprised of mortality and severe COVID-19.

RESULTS

A total of 4448 patients were obtained from 16 studies. Cerebrovascular disease was associated with an increased composite poor outcome (RR 2.04 [1.43,2.91], p<0.001; I2: 77%). Subgroup analysis revealed that cerebrovascular disease was associated with mortality (RR 2.38 [1.92,2.96], p<0.001; I2: 0%) and showed borderline significance for severe COVID-19 (RR 1.88 [1.00,3.51], p = 0.05; I2: 87%). Cardiovascular disease was associated with increased composite poor outcome (RR 2.23 [1.71,2.91], p<0.001; I2: 60%), mortality (RR 2.25 [1.53,3.29], p<0.001; I2: 33%) and severe COVID-19 (RR 2.25 [1.51,3.36], p<0.001; I2: 76%). Meta-regression demonstrate that the association was not influenced by gender, age, hypertension, diabetes, and respiratory comorbidities. Furthermore, the association between cerebrovascular disease and poor outcome was not affected by cardiovascular diseases and vice versa.

CONCLUSION

Cerebrovascular and cardiovascular diseases were associated with an increased risk for poor outcome in patients with COVID-19.

Cardiovascular manifestation and treatment in COVID-19

The novel coronavirus disease 2019 (COVID-19), with first presentation of atypical pneumonia, has spread rapidly from Wuhan, China, on December 12, 2019 to over 200 countries, caused 2 310 572 infected individuals and 158 691 mortalities, updated on April 19, 2020. Many studies have published timely to help global healthcare workers to understand and control the disease. Vulnerable patients with risk factors such as elderly, cardiovascular diseases (eg, hypertension, coronary disease, or cardiomyopathy), diabetes, and chronic kidney disease have worse outcomes after COVID-19 infection. COVID-19 could directly cause cardiovascular injuries such as pericarditis, myocarditis, myocardial infarction, heart failure, arrhythmias, or thromboembolic events, which urge cardiologists to be involved in the frontline to practice. Here, we provide a review of COVID-19 on cardiovascular system to assist clinical cardiologists to better understand the disease and being capable of providing comprehensive medical support.

Acute exacerbations of COPD are associated with a prothrombotic state through platelet-monocyte complexes, endothelial activation and increased thrombin generation

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) are at increased risk for cardiovascular events, particularly following an acute exacerbation (AE-COPD). Exacerbations are associated with increased systemic inflammation, which may drive coagulation. This prospective cohort study aimed to determine how an AE-COPD affects platelet activation, the endothelium, plasmatic coagulation and fibrinolysis, and its association with systemic inflammation.

MATERIALS AND METHODS

Fifty-two patients with an AE-COPD were included. Blood samples at admission, at day 3 of treatment and at convalescence were available for 32 patients. Platelet-monocyte complex (PMC) formation, monocyte Mac-1 expression and platelet (re)activity (P-selectin expression, αIIbβ3 activation) were measured by flow cytometry. Von Willebrand Factor (VWF), thrombin generation (TG) and clot lysis time (CLT) were determined as measures of endothelial activation, plasmatic coagulation and fibrinolysis, respectively.

RESULTS

Exacerbations were associated with increased PMCs (MFI 31.3 vs 23.8, p = 0.004) and Mac-1 (MFI 38.2 vs 34.8, p = 0.006) compared to convalescence, but not with changes in platelet (re)activity. VWF (antigen, activity, active fraction) and TG (peak, ETP and velocity index) were all significantly higher during AE-COPD compared to convalescence. PMCs, Mac-1, VWF and TG were positively associated with systemic inflammation (CRP). CLT was prolonged in AE-COPD patients with systemic inflammation. Moreover, platelet hyperreactivity on admission was associated with an increased risk for exacerbation relapse.

CONCLUSIONS

Acute exacerbations are associated with an inflammation-associated prothrombotic state, characterized by increased PMCs, endothelial activation and plasmatic coagulation. Our findings provide direction for future studies on biomarkers predicting the risk of exacerbation relapse and cardiovascular events.

Covid-19 and cardiovascular risk: Susceptibility to infection to SARS-CoV-2, severity and prognosis of Covid-19 and blockade of the renin-angiotensin-aldosterone system. An evidence-based viewpoint

The presence of cardiovascular co-morbidities and the known effects of coronaviruses on the cardiovascular system have called attention to the potential implications for patients with cardiovascular risk factors. This evidence-based viewpoint will address two questions: (a) are individuals with underlying cardiovascular risk factors (e.g. high blood pressure or diabetes) or overt disease (e.g. coronary heart disease, heart failure, kidney disease) more likely to develop severe Covid-19 and to die than those without underlying conditions? (b) does the regular use of angiotensin-converting enzyme inhibitors (ACE-i) or angiotensin-receptor blockers (ARB) make patients more likely to get infected and to die of Covid-19? With a necessary cautionary note that the evidence around the links between Covid-19 and cardiovascular disease is accruing at a fast pace, to date we can conclude that: (a) the greater susceptibility of individuals with underlying cardiovascular conditions to develop more severe Covid-19 with higher mortality rate is likely to be confounded, in part, by age and the type of co-morbidities. Patients with heart failure or chronic kidney disease might show an excess risk; (b) neither ACE-i nor ARB are associated with greater risk of SARS-Cov2 infection, or severity or risk of death in patients with Covid-19. Patients on these drugs should not stop them, unless under strict medical supervision and with the addition of a suitable replacement medicine.

Incidental COVID-19 related lung apical findings on stroke CTA during the COVID-19 pandemic

BACKGROUND

Authors have noticed an increase in lung apex abnormalities on CT angiography (CTA) of the head and neck performed for stroke workup during the coronavirus disease 2019 (COVID-19) pandemic.

OBJECTIVE

To evaluate the incidence of these CTA findings and their relation to COVID-19 infection.

METHODS

In this retrospective multicenter institutional review board-approved study, assessment was made of CTA findings of code patients who had a stroke between March 16 and April 5, 2020 at six hospitals across New York City. Demographic data, comorbidities, COVID-19 status, and neurological findings were collected. Assessment of COVID-19 related lung findings on CTA was made blinded to COVID-19 status. Incidence rates of COVID-19 related apical findings were assessed in all code patients who had a stroke and in patients with a stroke confirmed by imaging.

RESULTS

The cohort consisted of a total of 118 patients with mean±SD age of 64.9±15.7 years and 57.6% (68/118) were male. Among all code patients who had a stroke, 28% (33/118) had COVID-19 related lung findings. RT-PCR was positive for COVID-19 in 93.9% (31/33) of these patients with apical CTA findings.Among patients who had a stroke confirmed by imaging, 37.5% (18/48) had COVID-19 related apical findings. RT-PCR was positive for COVID-19 in all (18/18) of these patients with apical findings.

CONCLUSION

The incidence of COVID-19 related lung findings in stroke CTA scans was 28% in all code patients who had a stroke and 37.5% in patients with a stroke confirmed by imaging. Stroke teams should closely assess the lung apices during this COVID-19 pandemic as CTA findings may be the first indicator of COVID-19 infection.

COVID-19 Is an Independent Risk Factor for Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Coronavirus disease 2019 (COVID-19) is an active worldwide pandemic with diverse complications. Stroke as a presentation has not been strongly associated with COVID-19. The authors aimed to retrospectively review a link between COVID-19 and acute stroke.

MATERIALS AND METHODS

We conducted a retrospective case-control study of 41 cases and 82 control subjects matched by age, sex, and risk factors. Cases were patients who underwent stroke alert imaging with confirmed acute stroke on imaging between March 16 and April 5, 2020, at 6 hospitals across New York City. Control subjects were those who underwent stroke alertimaging during the same timeframe without imaging evidence of acute infarction. Data pertaining to diagnosis of COVID-19 infection, patient demographics, and risk factors were collected. A univariate analysis was performed to assess the covariate effect of risk factors and COVID-19 status on stroke imaging with positive findings.

RESULTS

The mean age for cases and controls was 65.5 ± 15.3 years and 68.8 ± 13.2 years, respectively. Of patients with acute ischemic stroke, 46.3% had COVID-19 infection compared with 18.3% of controls (P = .001). After adjusting for age, sex, and risk factors, COVID-19 infection had a significant independent association with acute ischemic stroke compared with control subjects (OR, 3.9; 95% CI, 1.7-8.9; P = .001).

CONCLUSIONS

We demonstrated that COVID-19 infection is significantly associated with imaging confirmation of acute ischemic stroke, and patients with COVID-19 should undergo more aggressive monitoring for stroke.

Risk of subsequent ischemic stroke in patients with nontyphoidal salmonellosis: A nationwide population-based cohort study

OBJECTIVES

To explore the association between nontyphoidal salmonellosis (NTS) and the risk of acute ischemic stroke (IS) by using a nationwide, population-based study.

METHODS

A retrospective cohort study using claim data from Taiwan's National Health Insurance Research Database (NHIRD), patients aged 18 years and older with histories of NTS (N = 1618) were included from January 1, 2000-December 31, 2012, and the non-NTS group (N = 6472) without NTS were matched by propensity score. The follow-up period was defined as the time from the initial diagnosis of NTS to the date of development of IS, death or 31 December, 2013. Patients previously diagnosed with stroke were excluded. The Cox proportional hazard model with robust sandwich estimator was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) of IS after adjusting for demographic and clinical covariates.

RESULTS

The adjusted hazard ratio (aHR) for the NTS group compared with the non-NTS group was 1.34 (95% confidence interval [CI], 1.10-1.65) for overall stroke. Furthermore, the NTS cohort had an increased risk of IS compared to the non-NTS groups (aHR, 1.42; 95% CI, 1.14-1.78). Stratified analysis showed that compared with propensity score matched non-NTS group, subjects aged ≥65 years, female, those with hypertension, hyperlipidemia, COPD, cancer and heart failure had higher risk of developing stroke. A 1.93-fold significant increase risk for stroke was observed during the first 3-12 months of follow-up (95% CI, 1.07-3.48).

CONCLUSIONS

Patients with NTS is associated with increased risk of developing ischemic stroke compared with non-NTS patients. Timely and mindful treatment plan about NTS may be a milestone to stroke prevention especially in some subpopulation.

A Rapid Decrease in Stroke, Acute Coronary Syndrome, and Corresponding Interventions at 65 United States Hospitals Following Emergence of COVID-19

Background Following the emergence of coronavirus disease 2019 (COVID-19), early reports suggested a decrease in stroke and acute coronary syndrome (ACS). We sought to provide descriptive statistics for stroke and ACS from a sample of hospitals throughout the United States, comparing data from March 2020 to similar months pre-COVID. Methods We performed a retrospective analysis of 65 academic and community hospitals in the Vizient Clinical Data Base. The primary outcome is monthly count of stroke and ACS, and acute procedures for both, from February and March in 2020 compared to the same months in 2018 and 2019. Results are aggregated for all hospitals and reported by Census Region. Results We identified 51,246 strokes (42,780 ischemic, 8,466 hemorrhagic), 1,043 mechanical thrombectomies (MT), 836 tissue plasminogen activator (tPA) administrations, 36,551 ACS, and 3,925 percutaneous coronary interventions (PCI) for ACS. In February 2020, relative to February 2018 and 2019, hospitalizations with any discharge diagnosis of stroke and ACS increased by 9.8% and 12.1%, respectively, while in March 2020 they decreased 18.5% and 7.5%, relative to March 2018 and 2019. When only including hospitalizations with the primary discharge diagnosis of stroke or ACS, in March 2020 they decreased 17.6% and 25.7%, respectively. In March 2020, tPA decreased 3.3%, MT increased 18.8%, although in February 2020 it had increased 36.8%, and PCI decreased 14.7%. These decreases were observed in all Census regions. Conclusions Following greater recognition of the risks of COVID-19, hospitalizations with stroke and ACS were markedly diminished in a geographically diverse sample of United States hospitals. Because the most likely explanation is that some patients with stroke and ACS did not seek medical care, the underlying reasons for this decrease warrant additional study to inform public health efforts and clinical care during this and future pandemics.

Possible effects of coronavurus infection (COVID-19) on the cardiovascular system

Acute viral respiratory infections can increase the risk of progression of a pre-existing condition, including a cardiovascular pathology. Life-threatening complications of Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) necessitate research into the cardiovascular effects of COVID-19 crucial for developing adequate treatment strategy for infected patients, especially those of advanced age. This article reviews the literature on the clinical and functional characteristics of patients with COVID-19, including those with poor outcomes. The article looks at the pathophysiological processes occurring in the cardiovascular system in the setting of SARS-CoV-2 infection, risk factors and death predictors. It also discusses continuation of therapy with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in patients with COVID-19.

Intravenous Iron Dosing and Infection Risk in Patients on Hemodialysis: A Prespecified Secondary Analysis of the PIVOTAL Trial

BACKGROUND

Experimental and observational studies have raised concerns that giving intravenous (IV) iron to patients, such as individuals receiving maintenance hemodialysis, might increase the risk of infections. The Proactive IV Iron Therapy in Haemodialysis Patients (PIVOTAL) trial randomized 2141 patients undergoing maintenance hemodialysis for ESKD to a high-dose or a low-dose IV iron regimen, with a primary composite outcome of all-cause death, heart attack, stroke, or hospitalization for heart failure. Comparison of infection rates between the two groups was a prespecified secondary analysis.

METHODS

Secondary end points included any infection, hospitalization for infection, and death from infection; we calculated cumulative event rates for these end points. We also interrogated the interaction between iron dose and vascular access (fistula versus catheter).

RESULTS

We found no significant difference between the high-dose IV iron group compared with the lose-dose group in event rates for all infections (46.5% versus 45.5%, respectively, which represented incidences of 63.3 versus 69.4 per 100 patient years, respectively); rates of hospitalization for infection (29.6% versus 29.3%, respectively) also did not differ. We did find a significant association between risk of a first cardiovascular event and any infection in the previous 30 days. Compared with patients undergoing dialysis with an arteriovenous fistula, those doing so via a catheter had a higher incidence of having any infection, hospitalization for infection, or fatal infection, but IV iron dosing had no effect on these outcomes.

CONCLUSIONS

The high-dose and low-dose IV iron groups exhibited identical infection rates. Risk of a first cardiovascular event strongly associated with a recent infection.