Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Acute pulmonary embolism in COVID-19 pandemic: prevalence and intrahospital outcome: a single center experience

Funding Acknowledgements

Type of funding sources: None.

Purpose

We want to evaluate clinical, laboratory profiles and intra-hospital outcome in patients with acute PE treated in intensive care unit in the period of COVID-19 pandemic.

Methods

This is a single center, retrospective cohort study of patients with confirmed acute PE admitted in Intensive Cardiac Care Unit of a tertiary level university hospital between January and December 2020. Detailed history, risk factors, laboratory parameters and treatment strategy based on patient risk were assessed. All patients underwent 2-dimensional echocardiography, lower limb venous Doppler and CT pulmonary angiography (CTPA). sPESI score and intra-hospital outcomes were evaluated in all patients. Nasopharyngeal smear and real-time reverse transcriptase–polymerase chain reaction (RT-PCR) assay was performed in order to confirm COVID-19 infection.

Results

We studied 47 patients with acute PE treated in our ICU, with mean age 58.6 ± 19.4 years. Eight patients (17%) had massive PE (central thrombus) and 39 (83%) had sub massive PE (subsegmental thrombus) confirmed by CTPA. Six patients (12,7%) had history of deep vein thrombosis (DVT), 3 patients (6,3%) had history of prior PE, 4 patients (8,5%) were operated within 3 months, 7 patients (14,8%) had history of malignancy, 24 patient’s had increased body weight and obesity (51%). Twelve patients (25,5%) were tested for COVID 19 with real-time reverse transcriptase–polymerase chain reaction (RT-PCR) assay, and 3 come positive (12.5%). Eight patients were high risk with shock (17%), intermediate high risk were 29 patients (61.7%) and intermediate low risk were 10 patients (21.3%).  sPESI score was >1 in all 47 patients. Abnormal RV function with PAH was found in 32 patients (68%). Five high risk, unstable patients died within 72 hours of admission, resulting in an overall ICU mortality rate of 10,6% and 62.5% mortality rate in patients with cardiogenic shock. Patients with PE and COVID-19 had significantly higher D-dimer and hs-Troponin I levels comparing to the patients with patients negative for COVID-19. Multivariate logistic regression analysis showed thrombolytic therapy OR 2.145 (95% CI: 1.105−4,512), D-Dimers >4.500 ng/ml OR 1.893 (95% CI: 0.932–3.241), high risk PE OR 3.98 (95% CI: 1.396−5.641) and acute renal failure OR 2.421 (95% CI: 1.105−4.762) as independent mortality predictors. Eight patients have been treated with fibrinolysis (t-PA), and 39 patients with Heparin therapy. 40 survived patients were discharged with NOAC treatment (95,2%).

Conclusions

Pulmonary embolism cardiology clinic ICU admission in the period of COVID-19 pandemic decreased, with increase of PE severity, patients risk and mortality rate. Thrombolytic therapy, D-Dimers >4.500 ng/ml, high risk PE and acute renal failure were independent mortality predictors. Thrombolysis was successful treatment for high risk patients with low bleeding risk.

Women leaders in Cardiology. Contemporary profile of the WHO European region

Aims

Women’s participation is steadily growing in medical schools, but they are still not sufficiently represented in cardiology, particularly in cardiology leadership positions. We present the contemporary distribution of women leaders in cardiology departments in the World Health Organization European region.

Methods and results

Between August and December 2020, we applied purposive sampling to collect data and analyse gender distribution of heads of cardiology department in university/third level hospitals in 23 countries: Austria, Azerbaijan, Belgium, Bosnia-Herzegovina, Croatia, France, Germany, Greece, Italy, North Macedonia, Morocco, Poland, Portugal, Russia, Serbia, Slovakia, Slovenia, Spain, Switzerland, Tunisia, Turkey, Ukraine, and the UK. Age, cardiology subspecialty, and number of scientific publications were recorded for a subgroup of cardiology leaders for whom data were available. A total of 849 cardiology departments were analysed. Women leaders were only 30% (254/849) and were younger than their men counterpart (♀ 52.2 ± 7.7 years old vs. ♂ 58.1 ± 7.6 years old, P = 0.00001). Most women leaders were non-interventional experts (♀ 82% vs. ♂ 46%, P < 0.00001) and had significantly fewer scientific publications than men {♀ 16 [interquartile range (IQR) 2–41] publications vs. ♂ 44 (IQR 9–175) publications, P < 0.00001}.

Conclusion

Across the World Health Organization European region, there is a significant gender disparity in cardiology leadership positions. Fostering a diverse and inclusive workplace is a priority to achieve the full potential and leverage the full talents of both women and men.

A rare presentation of an elderly patient with acute lymphocytic leukemia and platelet count of zero associated with ST-elevation myocardial infarction, pulmonary thromboembolism in the setting of SARS-CoV 2: a case report

Background

Novel coronavirus disease 2019 (COVID-19) is known to lead not only to severe acute respiratory syndrome, but also can result in thromboembolic events in both the venous and the arterial circulation by inducing coagulation disorders. The potential causes of coagulopathy are inflammation, platelet activation, endothelial dysfunction, and stasis. The thrombotic events including pulmonary embolism, deep venous thrombosis as well as intracatheter thrombosis are more likely to develop in patients infected with severe form of SARS-CoV-2 who are admitted to ICU. Furthermore, these events contribute to multi-organ failure.

Case presentation

Herein, we report a case of an immunocompromised COVID-19 elderly patient with acute lymphocytic leukemia who developed myocardial infarction with ST elevation in the setting of acute pulmonary thromboembolism in the presence of zero platelet count. Despite successful urgent coronary revascularization and platelet transfusion, the patient eventually died after failed resuscitation efforts.

Conclusion

Patients with COVID-19 infection are at a greater risk of developing cardiovascular complications, but their appropriate management can decrease the risk of fatal events. Coronary thrombosis associated with pulmonary thromboembolism in the setting of thrombocytopenia is a rare and a complex to manage condition. Significance of single antiplatelet agent in STEMI with thrombocytopenia merits further studies. According to expert opinions and literature reviews, we must avoid dual antiplatelet therapy in these patients and keep platelet transfusion as a standard therapy to avoid drastic bleeding complications.

Women's perspective on the COVID-19 pandemic: Walking into a post-peak phase

The pandemic of Novel Coronavirus Disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has provoked hundreds of thousands of deaths, resulting in catastrophe for humans. Although some insights have been garnered in studies on women, children and young adults infected with COVID-19, these often remain fragmented in literature. Therefore, we discussed the impact of COVID-19 pandemic on women, children and young patients, particularly those with underlying cardiovascular comorbidities or congenital heart disease. Furthermore, we gathered and distilled the existing body of literature that describes their cardiovascular complications and the recommended actions in favour of those patients toward the post-peak pandemic period. Although many questions still require answers, this article is sought to help the practicing clinician in the understanding and management of the threatening disease in special populations.

Fulminant Myocarditis in Covid 19 - Case report

Fulminant myocarditis (FM) is a syndrome characterized by sudden and severe diffuse cardiac inflammation often leading to death resulting from cardiogenic shock, ventricular arrhythmias, or multi-organ system failure. Clinical presentations vary widely, but the main characteristic is a rapidly progressive clinical course with the need of hemodynamic support. We present a clinical case of a patient with COVID-19 admitted to our cardiac intensive care unit with severely reduced left ventricular ejection fraction and worsening clinical course ending in cardiogenic shock in a very short time. The only available imaging technique in these fast-deteriorating patients is the bedside echocardiography, helping to provide accurate assessment and adequate treatment as soon as possible. Even though the current recommendations imply the use of cardiac magnetic resonance (CMR) and endomyocardial biopsy (EMB) as a diagnostic tool for myocarditis, their application in the COVID-19 pandemic is limited. The use of inotropes and mechanical support is the recommended and the final challenge as a bridge to recovery or bridge to transplant. In the settings where CMR and EMB are not feasible from an infection control standpoint, the diagnose should rely on the integration of clinical, laboratory (cardiac biomarkers), electrocardiographic (ST-segment changes), and echocardiographic -wall motion abnormalities, ejection fraction, and pericardial effusion- data. Keywords: myocarditis; COVID-19; cardiogenic shock; echocardiography; endomyocardial biopsy

Coronavirus Disease 2019 and Catheterisation Laboratory Considerations: "Looking for Essentials"

The current coronavirus disease 2019 (COVID-19) outbreak is a significant health crisis that impacts every healthcare system worldwide, and has led to a dramatic change in dealing with different diseases during the pandemic. Interventional cardiologists are frontline workers who deal with many cardiovascular emergencies, either in patients with proven COVID-19 or in suspected cases. Many heart associations worldwide are currently setting appropriate recommendations for the management of emergency cardiac interventions. In this expert opinion, the authors highlight the essential requirements in the cardiac catheterisation laboratory during the COVID-19 pandemic.

Antiphospholipid Syndrome - A Case Report of Pulmonary Thromboembolism, Followed with Acute Myocardial Infarction in Patient with Systemic Sclerosis

AIM

We are presenting an uncommon case of pulmonary embolism, followed with an acute myocardial infarction, in a patient with progressive systemic sclerosis.

CASE PRESENTATION

A female 40 years of age was admitted with signs of pulmonary embolism, confirmed with CT scan, which also reviled a thrombus in the right ventricle. The patient had medical history of systemic sclerosis since the age of 16 years. She suffered an ischemic stroke 6 years ago, but she was not taking any anticoagulant or antithrombotic medications ever since. She received a treatment with thrombolytic therapy, and subsequent UFH, but, on the second day after receiving fibrinolysis, she felt chest pain accompanied with ECG changes consistent for ST-segment elevation myocardial infarction (STEMI). Urgent coronary angiography was undertaken, which reviled cloths causing total occlusion in 4 blood vessels, followed with thromboaspiration, but without successful reperfusion. Several hours later the patient developed rapid deterioration with letal ending. During the very short hospital course, blood sampling reviled presence of antiphospholipid antibodies.

CONCLUSION

The acquired antiphospholipid syndrome is common condition in patients with systemic autoimmune diseases, but relatively rare in patients with systemic sclerosis. Never the less, we have to be aware of it when treating the patients with systemic sclerosis.