Combined cardiac risk factors predict COVID-19 related mortality and the need for mechanical ventilation in Coptic Clergy

Background and aims

The clinical adverse events of COVID-19 among clergy worldwide have been found higher than among ordinary communities, probably because of the nature of their work. The aim of this study, was to assess the impact of cardiac risk factors on COVID-19-related mortality and the need for mechanical ventilation in Coptic clergy.

Methods

Of 1576 Coptic clergy participating in the COVID-19-Clergy study, serving in Egypt, USA and Europe, 213 had the infection and were included in this analysis. Based on the presence of systemic arterial hypertension (AH), participants were divided into two groups: Group-I, Clergy with AH (n=77) and Group-II, without AH (n=136).Participants' demographic indices, cardiovascular risk factors, COVID-19 management details and related mortality were assessed.

Results

Clergy with AH were older (p<0.001), more obese (p=0.04), had frequent type 2 diabetes (DM) (p=0.001), dyslipidemia (p=0.001) and coronary heart disease (CHD) (p=0.04) compared to those without AH. COVID-19 treatment at home, hospital or in intensive care did not differ between the patient groups (p>0.05 for all). Clergy serving in Northern and Southern Egypt had a higher mortality rate compared to those from Europe and the USA combined (5.22%, 6.38%, 0%; p=0.001). The impact of AH on mortality was significant only in Southern Egypt (10% vs. 3.7%; p=0.01) but not in Northern Egypt (4.88% vs. 5.81%; p=0.43).

In multivariate analysis, CHD OR 1.607 [(0.982 to 3.051); p=0.02] and obesity, OR 3.403 [(1.902 to 4.694); p=0.04]predicted COVID-19 related mortality. A model combining cardiac risk factors (systolic blood pressure (SBP) ≥160 mmHg, DM, obesity, dyslipidemia and history of CHD), was the most powerful independent predictor of COVID-19-related mortality, OR 4.813 [(2.011 to 7.017); p=0.008]. The same model also proved the best independent multivariate predictor of mechanical ventilation OR 1.444 [(0.949 to 11.88); p=0.001].

Conclusion

In Coptic clergy, the cumulative impact of risk factors is the most powerful predictor of mortality and the need for mechanical ventilation in Coptic clergy.

Funding Acknowledgement

Type of funding sources: None.

P895 Relationship between left ventricular function components and cardiovascular risk factors in asymptomatic individuals

Funding Acknowledgements

none

Background and Aim

Coronary artery disease is commonly related to conventional cardiovascular (CV) risk factors. The exact role of those risk factors in early development of CV disease or left ventricular (LV) dysfunction before the development of sign and symptoms remains debated. We studied the relationship between conventional risk factors and LV systolic, diastolic and synchronous function in a population sample of asymptomatic individuals.

Methods

All participants underwent a detailed echocardiographic examination as part of a cross-sectional survey for the prevalence of coronary risk factors in randomly selected individuals from general population. LV end-systolic and end-diastolic dimensions, and LV volumes and ejection fraction (EF) were all calculated. From the spectral Doppler flow, LV early diastolic (E wave) and atrial systolic (A wave) velocities were measured and E/A ratio calculated. LV filling time (FT) was also measured from the onset of E wave to the end of A wave, and LV ejection time (ET) from the onset to the end of aortic Doppler velocity. Global LV dyssynchrony was assessed using total isovolumic time (T-IVT) as 60 – (total filling time + total ejection time), and Tei index was also calculated.

Results

The study population comprised 184 individuals (96 male and 88 female, mean age 55.9 (11.3), range 25-78 years). There was no relationship between systolic LV function expressed by EF and CV risk factors. Markers of diastolic function: LV filling velocities and E/A ratio, were correlated with age (r= -0.36, p < 0.000, r= -0.57, p < 0.000, respectively), with glycemia (r= -0.21, p < 0.000, r= -0.14, p = 0.004,) and with systolic blood pressure (r= -0.31, p < 0.000, r= -0.34, p < 0.000). Markers of LV dyssynchrony, in the form of prolonged T-IVT, and raised Tei index, directly correlated with age, glycemia and systolic blood pressure (r = 0.58, p < 0.000, r = 0.18, p < 0.000, r = 0.33, p < 0.000, respectively). However, when these correlations were adjusted for age in a multivariate analysis, the statistical significance was strongly reduced (LV filling) or completely lost (IVT and E/A).

Conclusions

In normal asymptomatic population, age, rather than CV risk factors, is the main determinant of changes in diastolic and synchronous function.

Hepatic artery aneurysm rupture in a woman with primary antiphospholipid syndrome

Primary antiphospholipid syndrome (APS) is associated with arterial and venous thrombosis. However, a small number of patients present with visceral aneurysms. Although such aneurysms are rare, their presence in patients who are usually treated with lifelong anticoagulation raises important therapeutic problems, in view of the risk of aneurysm rupture and acute abdominal hemorrhage. We report the case of a young woman with APS who presented with abdominal bleeding due to ruptured common hepatic artery aneurysm. She was successfully treated by proximal ligation. The features of such aneurysms are discussed. Lupus (2007) 16, 355—357.

Metformin-induced lactic acidosis in a type 2 diabetic patient with acute renal failure

Metformin is a biguanide commonly used in type 2 diabetes mellitus (DM). Lactic acidosis, a potentially life-threatening metabolic disorder, may be due to a number of different causes, including metformin therapy. We present a case of a severe metformin-induced lactic acidosis in a patient with type 2 DM, admitted to the emergency department with a history of dehydration due to diarrhoea and complicated by acute renal failure. Patient complained malaise and severe weakness and was tachypneic (Kussmaul's respiration), agitated and confused, with a Glasgow Coma Scale score of 13/15. Heart rate was 75 b/min and blood pressure 110/80 mmHg. The pH was 6.87, HCO3- 3 mmol/l, lactate 15 mmol/l, potassium 6.9 mEq/l. The renal function was markedly impaired with a creatinine of 9.75 mg/dl, and pancreatic enzymes, amylase and lipase, were also increased in absence of abdominal pain. Patient was treated with intravenous fluids, bicarbonate infusion and haemodialysis with bicarbonate buffered replacement fluid. Clinical conditions improved rapidly, with a progressive normalization of the acid-base balance and the other laboratory data. Authors discuss the pathophysiologic mechanisms of these alterations with particular regard to the role played by metformin as potential cause of lactic acidosis.

The Italian register of cardiovascular diseases: attack rates and case fatality for cerebrovascular events

BACKGROUND

The Italian register of cardiovascular diseases is a surveillance system of fatal and nonfatal cardiovascular events in the general population aged 35-74 years. It was launched in Italy at the end of the 1990 s with the aim of estimating periodically the occurrence and case fatality rate of coronary and cerebrovascular events in the different geographical areas of the country. This paper presents data for cerebrovascular events.

METHODS

Current events were assessed through record linkage between two sources of information: death certificates and hospital discharge diagnosis records. Events were identified through the ICD codes and duration. To calculate the number of estimated events, current events were multiplied by the positive predictive value of each specific mortality or discharge code derived from the validation of a sample of suspected events. Attack rates were calculated by dividing estimated events by resident population, and case fatality rate at 28 days was determined from the ratio of estimated fatal to total events.

RESULTS

Attack rates were found to be higher in men than in women: mean age-standardized attack rate was 21.9/10,000 in men and 12.5/10,000 in women; age-standardized 28-day case fatality rate was higher in women (17.1%) than in men (14.5%). Significant geographical differences were found in attack rates of both men and women. Case fatality was significantly heterogeneous in both men and women.

CONCLUSIONS

Differences still exist in the geographical distribution of attack and case fatality rates of cerebrovascular events, regardless of the north-south gradient. These data show the feasibility of implementing a population-based register using a validated routine database, necessary for monitoring cardiovascular diseases.

Impaired glucose metabolism in patients with acute stroke and no previous diagnosis of diabetes mellitus

BACKGROUND

About a third of patients with acute stroke and no prior diagnosis of diabetes have hyperglycaemia during the acute phase of stroke. Whether this is an acute stress response or a reflection of underlying diabetes is controversial.

AIM

To assess whether impaired glucose metabolism in patients with acute ischaemic stroke and no previous diagnosis of diabetes persists after 3 months, and whether such persistence can be predicted.

DESIGN

Prospective observational study.

METHODS

We enrolled 106 patients with acute ischaemic stroke and no history of diabetes. Fasting blood glucose, serum insulin and the insulin resistance index HOMA were recorded during hospital stay. A standard oral glucose tolerance test was performed at discharge and 3 months later.

RESULTS

Ten patients did not complete the study. Eighty-one patients (84.4%) had abnormal glucose metabolism at discharge and 62 (64.6%) after 3 months. Thirty-seven (38.5%) had impaired glucose tolerance at discharge and 26 (27.1%) after 3 months. Forty-four (45.8%) had diabetes at discharge, and 36 (37.5%) at 3 months. Post-load hyperglycaemia at discharge was a predictor of diabetes after 3 months. A plasma glucose cut-off of 11.7 mmol/l (210 mg/dl) had a specificity of 90.0% and a positive predictive value of 81.3%. HOMA increased progressively from patients with normal glucose metabolism to those with newly diagnosed diabetes.

DISCUSSION

Impaired glucose tolerance and previously unrecognized diabetes could be detected early in the stroke course, and persisted after 3 months in more than two-thirds of our patients. Post-load hyperglycaemia during the acute phase of stroke may be useful in identifying patients with abnormal glucose metabolism, which places them at risk for adverse outcomes, including cardiovascular disease.

[Hemoptysis from dorsal tongue base varices secondary to portal hypertension]

Portal hypertension secondary to cirrhosis of the liver is the main factor leading to the formation of portosystemic collaterals. The sites of such collateral circulation are well known. We describe a case of haemoptysis from dorsal tongue base varices, which are not recognised as portosystemic anastomosis, in a cirrhotic patient with portal hypertension.

Hyperlipidaemia: differences in management practices and attitudes in two regions in Europe--Sicily and the Stockholm area

In order to compare attitudes and management concerning hyperlipidaemia and risk factors for coronary heart disease among doctors in northern and in southern Europe, a questionnaire study was undertaken among doctors in primary health care and departments of internal medicine in Sicily and Stockholm. The regions differed in culture and health-care structure. Guidelines were similar, but screening of healthy individuals was recommended in Sicily, and not in Sweden. One hundred and fifty-three general practitioners in Sicily and 120 in Stockholm, 211 internists in Sicily and 83 in Stockholm participated. Main outcome measures were management policies for investigation and treatment and also attitudes. Routine lipid checks at first visits were done by few doctors in Stockholm but by a majority in Sicily (p < 0.001); in the presence of general cardiovascular risk factors (other than heredity, diabetes, cardiovascular disease and hypertension), routine checks were carried out more often by both general practitioners (p < 0.001) and internists (p < 0.005) in Stockholm. Drug treatment was initiated at lower cholesterol levels for secondary and primary intervention, cardiovascular disease, cardiovascular risk factors and hereditary hyperlipidaemia by both groups in Sicily (p < 0.001), as was dietary treatment. Secondary prevention was considered important by all groups, but primary prevention only by Sicilian doctors. We concluded that there were differences in views and management practice between doctors in Sicily and in Stockholm on the investigation and treatment of patients with hyperlipidaemia. Doctors tested lipids at first visits in Sicily but not in Stockholm. Treatment was initiated at lower levels of cholesterol in Sicily.

[Inverse relationship between fetal growth and arterial pressure in children and adults]

BACKGROUND

Increased prevalence of hypertension, ischaemic heart disease and stroke has been reported in subjects with impaired growth during fetal life and infancy. Blood pressure could mediate this relation. Indeed, reduced growth in fetal life and infancy has been associated with a raised blood pressure in children and adults. However, there is controversy about the relative importance of intrauterine environment and extrauterine adverse environment which can act throughout the life course. We therefore studied the relation between birth weight, which is known to be an indicator of fetal growth, and blood pressure in children and their parents. This association could thus be assessed in childhood before the external environmental influences became important, and in adulthood.

METHODS

Seven hundred and fifteen healthy schoolchildren (379 boys) aged 3-12 years from primary schools, and 448 parents (252 women) aged 20-44 years, born at term, without hypertension or diabetes, were studied. Blood pressure and birth weight were measured. Birth weight was taken from the hospital records. Data were analysed by tabulation of means and linear regression and correlation techniques. Mean systolic and diastolic blood pressure were calculated according to birth weight and current weight as fourths of their distributions.

RESULTS

There was a significant inverse relation between birth weight and systolic blood pressure both in children and adults. Current weight standardised regression coefficient showed a change of -2.68 mm Hg (95% Cl - 2.0 to 3.26, p = 0.027) for each Kg increase in birth weight in children, and -3.82 mmHg (95% Cl -3.21 to -4.39, p = 0.011) in adults. Within each current body weight group the reduction in mean systolic blood pressure from the lowest to the highest birth weight group was larger in adults (10.4 mmHg) than in children (4.1 mmHg). Adults but not children showed also an inverse relation between birth weight and diastolic blood pressure. Weight standardised regression coefficient was -3.0 mm Hg (95% Cl -2.45 to -3.62, p = 0.036).

CONCLUSIONS

Blood pressure in inversely related to birth weight in childhood. This relation becomes stronger in adulthood. Therefore, reduced growth during fetal life may be linked with an increased risk of developing hypertension and cardiovascular disease.

[Sublingual captopril in hypertensive crises]

Captopril is widely used in severe hypertension. Oral administration takes one-two hours to achieve a maximum effect and is not useful in hypertensive crisis. Few reports describe a more rapid effect on blood pressure following sublingual administration. We evaluated the effect of sublingual captopril 50 mg, in 26 patients with hypertensive crisis. Blood pressure levels started to decrease within 10 minutes and the maximum effect was observed 30 minutes after administration of the tablet. In all patients mean (CI 95%) systolic blood pressure dropped from 202.5 (199-206) mmHg to 160.6 (156-165) mmHg and diastolic blood pressure from 105.6 (102-109) mmHg to 86.9 (83-7-90.1) mmHg. This effect was maintained over two hours. There were no side effects. Sublingual captopril is highly effective in hypertensive crisis and its gradual hypotensive action avoid dangerous abrupt fall in blood pressure.

Discrepancies in the measurement of isovolumic relaxation time: a study comparing M mode and Doppler echocardiography

Mitral valve cusp separation on M mode echogram, the mitral valve opening artefact, and the onset of forward transmitral flow recorded by Doppler echocardiography have all been taken to mark the end of isovolumic relaxation, while its onset has been taken either as the aortic closure sound (A2) recorded phonocardiographically or the aortic closure artefact determined by Doppler technique. Possible differences in the measurement of the isovolumic relaxation time were studied when these landmarks were used in 44 healthy people, 14 patients with mitral stenosis, 21 patients with left ventricular hypertrophy, and 24 patients with dilated cardiomyopathy by recording M mode echograms of the mitral valve, and pulsed and continuous wave Doppler spectra of transmitral flow, with simultaneous electrocardiograms and phonocardiograms. A2 was effectively synchronous with the aortic artefact. However, when the onset of Doppler flow was regarded as the end of isovolumic relaxation, the interval was significantly longer than when mitral cusp separation on M mode echograms was used: by 25 (10) ms in healthy individuals, by 25 (15) ms in patients with left ventricular hypertrophy, and by 50 (35) ms in patients with dilated cardiomyopathy. In patients with mitral stenosis the interval was only 5 (5) ms longer. The mitral valve opening artefact consistently followed the onset of flow and corresponded much more closely to the E point on the M mode echogram. This shows that it occurred during the rapid filling period and well beyond isovolumic relaxation by any definition. Thus isovolumic relaxation time measured from A2 to the onset of transmitral flow or the mitral valve opening artefact differs from that derived from A2 to mitral valve cusp separation. These intervals cannot be used interchangeably to measure "isovolumic relaxation time".

Relationship of QRS amplitude to left ventricular dimensions after acute blood volume reduction in normal subjects

The relationship between the acute reduction in left ventricular dimensions induced by intravenous frusemide and scalar electrocardiographic QRS amplitude was studied in 14 normal subjects. The major electrocardiographic change was a significant increase in QRS voltages inversely proportional to the changes in left ventricular dimensions. This effect was opposite to the change predicted by the Brody effect. Surface electrocardiographic voltages are greatly influenced by myocardial cell orientation and the effective dipoles of the wave of activation are parallel to the long axes of cardiac fibres. As in the normal ventricle the arrangement of fibres is mainly circumferential, the body surface potentials are strongly affected by longitudinal wave front voltages. We suggest that during acute reduction of blood volume the inverse relationship of left ventricular volume and QRS amplitude can be explained by a reduced short-circuiting effect of blood mass on a longitudinally directed wave of activation.

Relation of third and fourth heart sounds to blood velocity during left ventricular filling

To investigate the relation between changes in left ventricular inflow velocity and the timing of third and fourth heart sounds, simultaneous phonocardiograms and continuous wave Doppler traces were recorded in 48 patients (aged 17-78) with heart disease and in 21 normal children. The onset of the first vibration of the third heart sound coincided with peak left ventricular inflow blood velocity to within 5 ms in all but two of the patients. The mean (SD) difference between the two events was 5 (5) ms, which did not differ significantly from zero. The relation was similar in patients with primary myocardial disease (11), and in those with valve disease (26), hypertension (five), and coronary artery disease (four). In the normal children, the mean interval was 2.5 (5) ms--not significantly different from zero. By contrast, the first deflection of the fourth heart sound consistently preceded the timing of peak atrial inflow velocity by 55 (10) ms. Agreement was much closer between the onset of atrial flow and the onset of the atrial sound (mean difference 1 (5) ms, not significantly different from zero). Gallop sounds seem to be closely related to changes in ventricular inflow velocity, and thus to the effects of forces acting on blood flow. The forces underlying the third sound seem to arise within the ventricle and are responsible for sudden deceleration of flow during rapid ventricular filling. The fourth sound, occurring at the onset of the "a" wave, is more likely to arise from dissipation of forces causing acceleration of blood flow--that is, atrial systole itself.

Isolated congenital left ventricular diverticulum

We describe a patient with congenital left ventricular diverticulum as an isolated lesion. The patient was asymptomatic until adult life and the diagnosis was apparent on cross-sectional echocardiography. The finding was confirmed by cardiac catheterisation.

[Echopolycardiographic evaluation of left ventricular function after hemodialysis]

The acute effects of haemodialysis on left ventricular (LV) function were studied by echocardiography and systolic time intervals in 19 patients maintained on long-term haemodialysis. Dialysis resulted in a significant reduction in body weight, an increase in heart rate and a small reduction in systolic blood pressure. A significant decrease was observed in LV diastolic and systolic dimensions, with an increase in the mean rate of circumferential shortening (mean VCF). The LV ejection time (LVET) decreased significantly, while changes in the pre-ejection period (PEP) were insignificant. The PEP/LVET ratio increased in all patients. Haemodialysis reduced the serum potassium levels; an increase was noted in the serum calcium concentrations, with a significant, although small, correction of blood pH. The major haemodynamic change induced by dialysis was a decrease in blood volume with a reduction in LV pre-load. These changes are suggested by the reduction in body weight and by the shortening in LV end-diastolic dimension and LVET. There was also a reduction in after-load, as expressed by the shortening in LV systolic diameter and by the decrease in systolic blood pressure. It should be emphasized that the study of LV function in patients on chronic dialysis is greatly influenced by the loading conditions. In such patients the assessment of LV function by echocardiography and systolic time intervals provides information regarding the haemodynamic changes induced by dialysis; however, no direct evidence can be derived about the functional state of the left ventricle.