The COVID-19 in athletes (COVA) study: a national study on cardio-pulmonary involvement of SARS-CoV-2 infection among elite athletes

Background

COVID-19 can cause cardiopulmonary involvement. Physical activity and cardiac complications can worsen prognosis, while pulmonary complications can reduce performance.

Aims

To determine the prevalence and clinical implications of SARS-CoV-2 cardiopulmonary involvement in elite athletes.

Methods

An observational study between 1 July 2020 and 30 June 2021 with the assessment of coronary biomarkers, electrocardiogram, echocardiography, Holter-monitoring, spirometry, and chest X-ray in Danish elite athletes showed that PCR-tested positive for SARS-CoV-2. The cohort consisted of male football players screened weekly (cohort I) and elite athletes on an international level only tested if they had symptoms, were near-contact, or participated in international competitions (cohort II). All athletes were categorized into two groups based on symptoms and duration of COVID-19: Group 1 had no cardiopulmonary symptoms and duration ≤7 days, and; Group 2 had cardiopulmonary symptoms or disease duration >7 days.

Results

In total 121 athletes who tested positive for SARS-CoV-2 were investigated. Cardiac involvement was identified in 2/121 (2%) and pulmonary involvement in 15/121 (12%) participants. In group 1, 87 (72%), no athletes presented with signs of cardiac involvement, and 8 (7%) were diagnosed with radiological COVID-19-related findings or obstructive lung function. In group 2, 34 (28%), two had myocarditis (6%), and 8 (24%) were diagnosed with radiological COVID-19-related findings or obstructive lung function.

Conclusions

These clinically-driven data show no signs of cardiac involvement among athletes who tested positive for SARS-CoV-2 infection without cardiopulmonary symptoms and duration <7 days. Athletes with cardiopulmonary symptoms or prolonged duration of COVID-19 display, exercise-limiting cardiopulmonary involvement.

Direct Oral Anticoagulants After Percutaneous Patent Foramen Ovale (PFO) Closure: A Call for Caution

BACKGROUND Transient atrial fibrillation (AF) following percutaneous patent foramen ovale (PFO) closure is common. Anticoagulation therapy should be considered in selected cases of prolonged AF after PFO closure, but guidelines do not provide clear recommendations on indication or choice of anticoagulant therapy for patients with post-procedural AF. CASE REPORT A 45-year-old woman presented with cryptogenic stroke verified by magnetic resonance imaging (MRI). Echocardiography revealed a PFO, which was closed percutaneously using a Gore septal occluder (25 mm). She was discharged on aspirin monotherapy (75 mg oral daily) according to institutional standard. Three weeks later, she presented with atrial fibrillation (AF). A direct oral anticoagulant (DOAC) (rivaroxaban 20 mg once daily) was initiated and aspirin was discontinued. After 4 months of follow-up, a routine echocardiography revealed large thrombi attached to both sides of the PFO occluder. CONCLUSIONS DOACs may be ineffective in preventing thrombus formation on device surfaces. Until more evidence has been provided, we suggest that DOACs are not routinely used for stroke prevention in patients following PFO closure or similar procedures within the first 3 months after device implantation.

Design and rationale of the Danish trial of beta-blocker treatment after myocardial infarction without reduced ejection fraction: study protocol for a randomized controlled trial

Background

Treatment with beta-blockers is currently recommended after myocardial infarction (MI). The evidence relies on trials conducted decades ago before implementation of revascularization and contemporary medical therapy or in trials enrolling patients with heart failure or reduced left ventricular ejection fraction (LVEF ≤ 40%). Accordingly, the impact of beta-blockers on mortality and morbidity following acute MI in patients without reduced LVEF or heart failure is unclear.

Methods/design

The Danish trial of beta-blocker treatment after myocardial infarction without reduced ejection fraction (DANBLOCK) is a prospective, randomized, controlled, open-label, non-blinded endpoint clinical trial designed to evaluate the efficacy of beta-blocker treatment in post-MI patients in the absence of reduced LVEF or heart failure. We will randomize 3570 patients will be randomized within 14 days of index MI to beta-blocker or control for a minimum of 2 years. The primary endpoint is a composite of all-cause mortality, recurrent MI, acute decompensated heart failure, unstable angina pectoris, or stroke. The primary composite endpoint will be assessed through locally reported and adjudicated endpoints supplemented by linkage to the Danish national registers. A number of secondary endpoints will be investigated including patient reported outcomes and cardiovascular mortality. Data from similar ongoing trials in Norway and Sweden will be pooled to perform an individual patient data meta-analysis.

Discussion

DANBLOCK is a randomized clinical trial investigating the effect of long-term beta-blocker therapy after myocardial infarction in patients without heart failure and reduced LVEF. Results from the trial will add important scientific evidence to inform future clinical guidelines.

Trial registration

Clinicaltrials.gov, NCT03778554. Registered on 19 December 2018.

European Clinical Trials Database, 2018-002699-42, registered on 28 September 2018.

[Adverse events with oral anticoagulants]

Anticoagulant therapy is widely used for prevention and treatment of cardiovascular disease and is frequently prescribed both in primary and secondary care. In comparison to other drugs, the frequency of medication errors is high for anticoagulant therapy. In Denmark, 4,383 adverse events with vitamin K antagonists and 3,234 adverse events with non-vitamin K antagonist oral anticoagulants were reported to the Danish Patient Safety Authority in 2014-2017. In this review, we provide an overview of medication errors and discuss frequent adverse events and pitfalls.

[False positive troponin I due to heterophile antibodies]

The troponin I (TnI) level is essential in the diagnosis of acute myocardial infarction, but may be elevated by other cardial and non-cardial causes. We report a 32-year-old pregnant woman admitted to hospital because of chest pain and dyspnoea. TnI levels were significantly elevated, although there was no suspicion of acute coronary syndrome or myocarditis, and supplementary diagnostics excluded pulmonary embolism. The TnI level was found to be falsely elevated due to immunoassay interference. We stress the need to be aware of the possibility of false positive TnI, especially during pregnancy.

[Antithrombotic treatment of patients with valvular atrial fibrillation]

Atrial fibrillation (AF) is associated with a markedly increased risk of thromboembolic events, particularly in patients with valvular AF. Recent trials comparing vitamin K antagonists with non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in AF excluded most patients with valvular AF. Although the definition of valvular AF is disputed, the lack of evidence regarding the use of NOACs for these patients is not. We discuss the definition of valvular AF, the risk of thromboembolism, and the antithrombotic treatment for stroke prevention in these patients.

Effect of tighter glycemic control on cardiac function, exercise capacity, and muscle strength in heart failure patients with type 2 diabetes: a randomized study

OBJECTIVES

In patients with type 2 diabetes (T2D) and heart failure (HF), the optimal glycemic target is uncertain, and evidence-based data are lacking. Therefore, we performed a randomized study on the effect of optimized glycemic control on left ventricular function, exercise capacity, muscle strength, and body composition.

DESIGN AND METHODS

40 patients with T2D and HF (left ventricular ejection fraction (LVEF) 35±12% and hemoglobin A1c (HbA1c) 8.4±0.7% (68±0.8 mmol/mol)) were randomized to either 4-month optimization (OPT group) or non-optimization (non-OPT group) of glycemic control. Patients underwent dobutamine stress echocardiography, cardiopulmonary exercise test, 6 min hall-walk test (6-MWT), muscle strength examination, and dual X-ray absorptiometry scanning at baseline and at follow-up.

RESULTS

39 patients completed the study. HbA1c decreased in the OPT versus the non-OPT group (8.4±0.8% (68±9 mmol/mol) to 7.6±0.7% (60±7 mmol/mol) vs 8.3±0.7% (67±10 mmol/mol) to 8.4±1.0% (68±11 mmol/mol); p<0.001). There was no difference between the groups with respect to changes in myocardial contractile reserve (LVEF (p=0.18)), oxygen consumption (p=0.55), exercise capacity (p=0.12), and 6-MWT (p=0.84). Muscle strength decreased in the non-OPT compared with the OPT group (37.2±8.1 to 34.8±8.3 kg vs 34.9±10.2 to 35.4±10.7 kg; p=0.01), in line with a non-significant decrease in lean (p=0.07) and fat (p=0.07) tissue mass in the non-OPT group. Hypoglycemia and fluid retention did not differ between groups.

CONCLUSIONS

4 months of optimization of glycemic control was associated with preserved muscle strength and lean body mass in patients with T2D and HF compared with lenient control, and had no deleterious effect on left ventricular contractile function and seemed to be safe.

TRIAL REGISTRATION NUMBER

NCT01213784; pre-results.

Myocardial perfusion imaging in patients with a recent, normal exercise test

AIM: To investigate the added value of myocardial perfusion scintigraphy imaging (MPI) in consecutive patients with suspected coronary artery disease (CAD) and a recent, normal exercise electrocardiography (ECG).

METHODS: This study was a retrospective analysis of consecutive patients referred for MPI during a 2-year period from 2006-2007 at one clinic. All eligible patients were suspected of suffering from CAD, and had performed a satisfactory bicycle exercise test (i.e., peak heart rate > 85% of the expected, age-predicted maximum) within 6 mo of referral, their exercise ECG was had no signs of ischemia, there was no exercise-limiting angina, and no cardiac events occurred between the exercise test and referral. The patients subsequently underwent a standard 2-d, stress-rest exercise MPI. Ischemia was defined based on visual scoring supported by quantitative segmental analysis (i.e., sum of stress score > 3). The results of cardiac catheterization were analyzed, and clinical follow up was performed by review of electronic medical files.

RESULTS: A total of 56 patients fulfilled the eligibility criteria. Most patients had a low or intermediate ATPIII pre-test risk of CAD (6 patients had a high pre-test risk). The referral exercise test showed a mean Duke score of 5 (range: 2 to 11), which translated to a low post-exercise risk in 66% and intermediate risk in 34%. A total of seven patients were reported with ischemia by MPI. Three of these patients had high ATPIII pre-test risk scores. Six of these seven patients underwent cardiac catheterization, which showed significant stenosis in one patient with a high pre-test risk of CAD, and indeterminate lesions in three patients (two of whom had high pre-test risk scores). With MPI as a gate keeper for catheterization, no significant, epicardial stenosis was observed in any of the 50 patients (0%, 95% confidence interval 0.0 to 7.1) with low to intermediate pre-test risk of CAD and a negative exercise test. No cardiac events occurred in any patients within a median follow up period of > 1200 d.

CONCLUSION: The added diagnostic value of MPI in patients with low or intermediate risk of CAD and a recent, normal exercise test is marginal.

Implantable loop recorder is an effective diagnostic tool for unexplained syncope

INTRODUCTION

Patients with cardiac syncope have a significantly higher mortality than patients with syncope of non-cardiac causes, while patients with syncope of unknown aetiology constitute an intermediate risk group, presumably because this group is mixed, which suggests that further diagnostic testing is warranted.

MATERIAL AND METHODS

This was a retrospective single-centre study evaluating the diagnostic yield of an implantable loop recorder (ILR) in establishing the cause of recurrent, unexplained syncope.

RESULTS

A total of 44 patients received ILR between 2007 and 2011. Follow-up data were available for 39 patients, the mean age was 63 years (range 23-94 years), 59% were female and the mean follow-up period was 349 days. The average time to first recurrence of syncope with ECG documentation was 244 days (range 11-699 days). The mean follow-up for the total population was 349 days (range 11-1,083 days) and for the group without recurrence 460 days (range 176-1,083 days). Diagnoses were obtained in 22 patients (56%) of which the cause of syncope was cardiac in 64%.

CONCLUSION

ILR was an effective tool to establish an arrhythmic cause of the recurrent, unexplained syncope, and useful in ruling out arrhythmia as a cause of syncope. New studies are needed to demonstrate whether very prolonged monitoring in case of absent recurrence may further improve the diagnostic yield. Additionally, there is much need for randomized controlled trials to investigate whether ILR-guided therapy reduces recurrence rate and mortality.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

[Arteriovenous shunt after splenectomy. A rare cause of cardiac incompensation and portal hypertension]

A 50-year-old man, who underwent splenectomy after trauma 23 years previously, presented with upper gastrointestinal bleeding caused by varices and cardiac insufficiency with lung oedema, ascites and peripheral oedema. An arteriovenous splenic shunt from artery to vein with an aneurysm measuring 10 cm across was closed using transarterial coiling technique. One year later the shunt was still closed, but a cardiac insufficiency requiring medical anticongestive therapy persisted.

[Refeeding syndrome in severely malnourished patient]

Refeeding syndrome is a potentially lethal condition observed in severely malnourished patients due to severe shifts in electrolytes during refeeding. We report the refeeding of a severely malnourished 53-year old male with a body mass index (BMI) of 10. Initially refeeding was enteral 25 kCal/kg which had to be replaced by combined enteral and parenteral nutrition. The patient suffered several complications, e.g. severe electrolyte disturbances, oedema of the lung, and infections. The patient was successfully discharged to a recreational facility after three months.