1-year mortality after myocardial injury in COVID-19 patients

Background

Myocardial injury is a known complication of COVID-19 and is related to a worse prognosis on admission. However, its impact on 1-year mortality is unknown.

Methods

Retrospective cohort study with patients admitted to intensive care and confirmed diagnosis of COVID-19 by RT-PCR and with at least one measurement of troponin during hospitalization. The study period was from March/2020 to June/2021. Clinical characteristics and the occurrence of myocardial were assessed between deaths and survivors using the chi-square test and Student's t-test. Variables with p<0.01 in the univariate analysis were included in the Cox regression model to identify predictor variables of 1-year mortality.

Results

1037 patients were included, with a mean follow-up of 1.06±0.58 years, mean age = 59.9±16.2 years, and 62.7% men. The prevalence of myocardial injury was 42.8% and occurred 204 deaths (19.7%). In the univariate analysis, the variables associated with 1-year mortality were: myocardial injury (OR 7.5; CI95% 5.2–10.9), age >60 years (OR 5.65; CI95% 3.9–8.2), arterial hypertension (OR 2.8; CI95% 2.0–3.9), diabetes (OR 2.3; CI95% 1.6–3.1), chronic kidney failure (OR 3.9; CI95% 2.2–6.8), dementia (OR 1.8; CI95% 1.2–2.6) and mechanical ventilation (OR 50.5; CI95% 33.9–77.3). In Cox regression, the predictor variables were: myocardial injury (HR 2.4; CI95% 1.7–3.5), age >60 years (HR 2.5; CI95% 1.8–3.6), chronic kidney disease (HR 1.9; CI95% 1.2–2.9), dementia (HR 3.2; CI95% 2.1–5.0) and mechanical ventilation (HR 17.5; CI95% 12.2–25.2).

Conclusion

In patients admitted to intensive care by COVID-19, the detection of myocardial injury more than doubled the risk of death in 1 year.

Funding Acknowledgement

Type of funding sources: None.

Perioperative myocardial injury after non-cardiac surgery: long-term mortality according to cardiovascular risk

Background

Perioperative Myocardial injury that occurs after non-cardiac surgery (MINS) is prevalent and increases mortality in 30 days. However, few studies have assessed the impact of cardiovascular risk and MINS in long-term mortality.

Methods

Retrospective study including all non-cardiac surgery patients admitted to a postoperative care unit who stayed at least one night in this unit and had at least one measurement of high-sensitive cardiac troponin. The study period was from January/2011 to December/2019, ensuring a minimum follow-up of 2 years. The criteria for defining a high cardiovascular risk patient (HCR) were: history of established cardiovascular disease (myocardial infarction, stroke, or peripheral arterial disease), diabetes, chronic kidney disease with clearance <60 ml/min, or presence of, at least, 3 risk factors (hypertension, smoking, dyslipidemia, or age >65 years). The population was divided into 4 subgroups according to the presence of HCR and elevated troponin. Clinical characteristics and the occurrence of MINS were assessed between deaths and survivors using the chi-squared test and Student's t-test. Variables with p<0.01 in the univariate model and the subgroups were included in the Cox regression model to identify predictor variables.

Results

2230 patients were included, with a mean follow-up of 6.21±2.74 years, mean age = 63.7±16.2 years, and 55.6% women. The prevalence of MINS was 9.4%. There were 556 deaths (24.9%). Group 1 (no MINS and no HCR) had 1521 patients (68.2%); Group 2, 126 patients (5.7%); Group 3, 500 patients (22.4%) and Group 4, 83 patients (3.7%). In the univariate analysis, the following variables were associated with death: age, arterial hypertension, BMI, previous myocardial infarction, urgent surgery, dementia, peripheral artery disease (PAD), and atrial fibrillation. These variables were included in Cox's regression model with the predefined subgroups and the predictive variables of all-cause death were: Group 2 (HR 2.12; 95% CI: 1.56–2.87), Group 4 (HR 2.50; 95% CI: 1.79–3.50), previous myocardial infarction (HR 1.44; 95% CI: 1.08–1.93); dementia (HR 2.90; 95% CI: 2.15–3.92), PAD (HR 1.91; 95% CI: 1.27–2.90) and age (HR 1.05; 95% CI: 1.04–1.06).

Conclusion

Cardiovascular risk did not influence long-term mortality in patients undergoing non-cardiac surgery, demonstrating that myocardial injury is one of the main predictors of death independently of cardiovascular risk.

Funding Acknowledgement

Type of funding sources: None.

Impact of high cardiovascular risk on hospital mortality in patients admitted to intensive care by COVID-19

Background

Some studies have shown a higher prevalence of deaths in patients with cardiovascular risk factors (CRF) during hospitalization for COVID-19. The impact of high cardiovascular risk on hospital mortality has not been evaluated.

Methods

Retrospective study with patients admitted to intensive care and confirmed diagnosis of COVID-19 by RT-PCR and with at least one measurement of troponin during hospitalization. The criteria for defining a high cardiovascular risk patient (HCR) were: history of established cardiovascular disease (myocardial infarction, stroke, or peripheral arterial disease), diabetes, chronic kidney disease with clearance <60ml/min, or presence of, at least, 3 risk factors (hypertension, smoking, dyslipidemia or age>65 years). The population was divided into 4 groups according to the presence of HCR and elevated troponin. Mortality was assessed using the chi-square method, according to the number of CRF, and was assessed in the 4 predetermined groups through logistic regression adjusted for severity (using the SAPS3 score).

Results

After evaluating 271 admissions during the study period, 236 patients were included for analysis. The mean age was 61.14±16.2 years, with 63.1% men. The prevalence of hypertension was 55.5% and diabetes, 33.1%. 47.4% of the patients had HCR. There was a significant increase in mortality as the number of risk factors increased (no CRF: 5.9%; 1 CRF: 17.5%; 2 CRF: 32.2% and ≥3 CRF: 41.2%; p=0.001). In logistic regression, patients with high cardiovascular risk and high troponin had a higher incidence of hospital mortality (OR 40.38; 95% CI 11.78–138.39). Patients without high cardiovascular risk, but with high troponin also showed a significant association with the primary outcome (OR 16.7; 95% CI 4.45–62.74). In contrast, patients with high cardiovascular risk and normal troponin were not at higher risk of death (OR 2.06; 95% CI 0.56–7.56).

Conclusion

In patients admitted to intensive care by COVID-19, the high cardiovascular risk impacts on hospital mortality only in patients who presented an increase in troponin levels.

FUNDunding Acknowledgement

Type of funding sources: None.

Echocardiogram in critically ill patients with COVID-19

Background

Describe echocardiographic characteristics in patients admitted to an intensive care unit by COVID-19 and identify clinical and laboratory findings associated with an abnormal echocardiogram and its association with in-hospital mortality.

Methods

Included all patients with RT-PCR-confirmed COVID-19 who underwent echocardiography during hospitalization. Echocardiographic characteristics were assessed in the entire population and subgroups. We also analyzed clinical characteristics associated with an abnormal echocardiogram. An echocardiogram was defined as abnormal when it demonstrates systolic ventricular dysfunction of any degree (left and/or right ventricle) and/or high filling pressures (E/E' ratio>16; SPAP>40mmHg, RAP>15mmHg or diastolic dysfunction ≥ grade 2) and/or moderate to severe pericardial effusion. Clinical variables were also assessed using a classification tree and binary logistic regression was performed with characteristics that showed a statistical significance in univariate analysis. Finally, echocardiographic variables were assessed for in-hospital mortality outcome using the chi-square test.

Results

272 admissions to ICU by COVID-19 were identified. Of these, 159 underwent echocardiography (58.5%). 39 were excluded by incomplete demographic data. 72 echocardiograms (60%) were abnormal according to pre-established criteria. Low occurrence of left and right ventricular systolic dysfunction was observed, as well as 30.8% of the population had a normal diastolic function. In univariate analysis, characteristics associated with abnormal echocardiogram were age, elevated troponin, previous heart failure, and SAPS3 score. In the regression model, troponin was the independent marker of abnormal echocardiography in patients admitted to the intensive care unit by COVID19. This finding was corroborated by the classification tree. The abnormal echocardiogram was not associated with in-hospital mortality (OR 1.60; CI95% 0.75–3.41), but the presence of systolic ventricular dysfunction of any degree was associated with a higher occurrence of this outcome (OR 3.52; CI95% 1.12–11.1).

Conclusions

In intensive care COVID-19 patients, many manifested elevated ventricular filling pressures, but the occurrence of ventricular dysfunction was low. Elevated serum troponin level was the independent marker associated with an abnormal echocardiogram. Systolic ventricular dysfunction was the only echocardiographic variable associated with in-hospital mortality.

FUNDunding Acknowledgement

Type of funding sources: None.

Long-term mortality in patients with myocardial injury after non-cardiac surgery

Background

Myocardial injury that occurs after non-cardiac surgery (MINS) increases mortality in 30 days. However, few studies have assessed the impact of MINS occurrence on long-term mortality.

Methods

Retrospective study including all non-cardiac surgery patients admitted to an postoperative care unit who stayed at least one night in this unit, and had at least one measurement of high-sensitive cardiac troponin. Patients undergoing coronary angiography and patients with an underlying disease with a poor prognosis were excluded. The study period was from January/2011 to December/2019, ensuring a minimum follow-up of 2 years. Clinical characteristics and the occurrence of MINS were assessed between deaths and survivors using the chi-square test and Student's t-test. Variables with p&lt;0.01 in the univariate model were included in the Cox regression model to identify predictor variables.

Results

2532 patients were included, with a mean follow-up of 8.62±2.72 years, mean age = 63.23±16.5 years and 53.6% women. The prevalence of MINS was 12.5% (317 patients). There were 620 deaths (24.5%). In the univariate analysis, the following variables were associated with death: MINS (OR 2.65; p&lt;0.001); previous heart failure (OR 3.87; p&lt;0.001); chronic renal failure (OR 5.0; p&lt;0.001), arterial hypertension (OR 1.83; p&lt;0.001), previous myocardial infarction (OR 2.57; p&lt;0.001), atrial fibrillation (OR 2.59; p&lt;0.001), dementia (OR 8.15; p&lt;0.001) and age (60±16 x 73±13, p&lt;0.001). These variables were included in Cox's regression model and the predictive variables of all-cause death were: MINS (HR 1.76; CI95% 1.44–2.15), previous heart failure (HR 1.85; CI95% 1.18–2.90), previous myocardial infarction (HR 1.46; CI95% 1.17–1.83); dementia (HR 2.85; CI95% 2.18–3.75) and age (HR 1.05; CI95% 1.04–1.06).

Conclusion

In patients undergoing non-cardiac surgery, the increase in high-sensitive troponin increased the risk of death from all causes in the long term.

Funding Acknowledgement

Type of funding sources: None. Survival curve

P5671Risk factors associated with recurrence of syncopal episodes in patients admitted to a syncope care unit

Introduction

Recurrent syncope takes a serious toll on quality of life, being compared to chronic diseases, particularly on the elderly.

Objectives

Identify recurrence predictors in patients treated attended at syncope units (SU).

Method

Study involving patients attended at SUs in the emergency care units of 11 hospitals over the period from May 2015 to July 2017. The SUs were provided around-the-clock dedicated phone support by specialists and a set of standardized protocols (SP) for diagnostic guidance and risk stratification based on current guidelines. In our statistical analysis, we implemented the parametric model for logistic regression (LR) and the non-parametric classification tree (CART) model. All 45 SP variables were included and subsequently selected through the use of elastic net regularization. In the LR, we considered significances of 5 and 10% for the recurrence outcome. These final variables were used to develop the classification trees (CART).

Results

We observed 1189, the majority of them (57.4%) were woman and the average age was 59 years old, with a wide range of variation (14–103). Cardiovascular and neurological diseases, as well as diabetes were more prevalent in men. The cause of syncopal episodes were diagnosticated in 81.1% of the patients, being reflex syncope the most common finding (59.4%). Episodes of recurrence were reported by 45.8%, with women representing 62.9% of this group, and 54.7% of them were younger than 59. In describing symptoms, 18.0% reported trauma associated with syncope, 38.2% showed no trigger incidents and 27.0% showed no prodromal symptoms. Women showed more prodromal symptoms, particularly dizziness, blurry vision, nausea and excessive sweating. In the variable analysis process, the LR highlighted: gender, diastolic blood pressure (DBP) and the incidence of: excessive sweating, blurry vision, palpitations, neurological diseases, changes in the conduction system detected by electrocardiogram and pacemakers (PM) as risk factors for recurrence. The CART classified the most relevant among these factors: age, DBP, sweating, blurry vision, neurological diseases and PM. Following the CART, it was detected that in female patients with signs of excessive sweating and normal DBP, the chance of recurrence was 59.6%, and when DBP ≤60 mmHg, that probability rose to 94.4%. In male patients with neurological diseases, the probability was 59%, but the chance of recurrence rose to 80% in patients with PM, even without concurrent neurological diseases.

Conclusion

The SUs and use of the SP allowed for the identification of high-risk patients and factors associated with higher probability of recurrence, improving overall approach towards syncope treatment.

Acknowledgement/Funding

OWN FINANCIAL SUPPORT

In vitro effects of Crotalus atrox snake venom on chick and mouse neuromuscular preparations

The neuromuscular effect of venoms is not a major clinical manifestation shared between rattlesnakes native to the Americas, which showed two different venom phenotypes. Taking into account this dichotomy, nerve muscle preparations from mice and chicks were used to investigate the ability of Crotalus atrox venom to induce in vitro neurotoxicity and myotoxicity. Unlike crotalic venoms of South America, low concentrations of C. atrox venom did not result in significant effects on mouse neuromuscular preparations. The venom was more active on avian nerve-muscle, showing reduction of twitch heights after 120 min of incubation with 10, 30 and 100 μg/mL of venom with diminished responses to agonists and KCl. Histological analysis highlighted that C. atrox was myotoxic in both species of experimental animals; as evidenced by degenerative events, including edematous cells, delta lesions, hypercontracted fibers and muscle necrosis, which can lead to neurotoxic action. These results provide key insights into the myotoxicity and low neurotoxicity of C. atrox in two animal models, corroborating with previous genomic and proteomic findings and would be useful for a deeper understanding of venom evolution in snakes belonging to the genus Crotalus.

Cobalt chloride induces metaphase when topically applied to larvae and pupae of the stingless bee Melipona scutellaris (Hymenoptera, Apidae, Meliponini)

In order to optimize preparations of bee metaphases, we tested cobalt chloride, which has been used as a metaphase inducer in other organisms, such as hamsters and fish. Four microliters of 65 mM cobalt chloride aqueous solution was topically applied to larval and pupal stages of the stingless bee Melipona scutellaris. The cerebral ganglion was removed after treatment and prepared for cytogenetic analysis. Identically manipulated untreated individuals were used as controls. The number of metaphases was increased 3-fold in treated individuals compared to controls. The micronucleus test showed no mutagenic effects of cobalt chloride on M. scutellaris cells. We concluded that cobalt chloride is a metaphase-inducing agent in M. scutellaris, thus being useful for cytogenetic analyses.

The association of ACE gene D/I polymorphism with cardiovascular risk factors in a population from Rio de Janeiro

Our aim was to determine the frequencies of the angiotensin-converting enzyme (ACE) gene alleles D and I and any associations to cardiovascular risk factors in a population sample from Rio de Janeiro, Brazil. Eighty-four adults were selected consecutively during a 6-month period from a cohort subgroup of a previous large cross-sectional survey in Rio de Janeiro. Anthropometric data and blood pressure measurements, echocardiogram, albuminuria, glycemia, lipid profile, and ACE genotype and serum enzyme activity were determined. The frequency of the ACE*D and I alleles in the population under study, determined by PCR, was 0.59 and 0.41, respectively, and the frequencies of the DD, DI, and II genotypes were 0.33, 0.51, and 0.16, respectively. No association between hypertension and genotype was detected using the Kruskal-Wallis method. Mean plasma ACE activity (U/mL) in the DD (N = 28), DI (N = 45) and II (N = 13) groups was 43 (in males) and 52 (in females), 37 and 39, and 22 and 27, respectively; mean microalbuminuria (mg/dL) was 1.41 and 1.6, 0.85 and 0.9, and 0.6 and 0.63, respectively; mean HDL cholesterol (mg/dL) was 40 and 43, 37 and 45, and 41 and 49, respectively, and mean glucose (mg/dL) was 93 and 108, 107 and 98, and 85 and 124, respectively. A high level of ACE activity and albuminuria, and a low level of HDL cholesterol and glucose, were found to be associated with the DD genotype. Finally, the II genotype was found to be associated with variables related to glucose intolerance.