Adverse Effects Associated With the Use of Antimalarials During The COVID-19 Pandemic in a Tertiary Care Center in Mexico City

Background: Antimalarial drugs were widely used as experimental therapies against COVID-19 in the initial stages of the pandemic. Despite multiple randomized controlled trials demonstrating unfavorable outcomes in both efficacy and adverse effects, antimalarial drugs are still prescribed in developing countries, especially in those experiencing recurrent COVID-19 crises (India and Brazil). Therefore, real-life experience and pharmacovigilance studies describing the use and side effects of antimalarials for COVID-19 in developing countries are still relevant.

Objective: To describe the adverse effects associated with the use of antimalarial drugs in hospitalized patients with COVID-19 pneumonia at a reference center in Mexico City.

Methods: We integrated a retrospective cohort with all adult patients hospitalized for COVID-19 pneumonia from March 13th, 2020, to May 17th, 2020. We compared the baseline characteristics (demographic and clinical) and the adverse effects between the groups of patients treated with and without antimalarial drugs. The mortality analysis was performed in 491 patients who received optimal care and were not transferred to other institutions (210 from the antimalarial group and 281 from the other group).

Results: We included 626 patients from whom 38% (n = 235) received an antimalarial drug. The mean age was 51.2 ± 13.6 years, and 64% were males. At baseline, compared with the group treated with antimalarials, the group that did not receive antimalarials had more dyspnea (82 vs. 73%, p = 0.017) and cyanosis (5.3 vs. 0.9%, p = 0.009), higher respiratory rate (median of 28 vs. 24 bpm, p < 0.001), and lower oxygen saturation (median of 83 vs. 87%, p < 0.001). In the group treated with antimalarials, 120 patients had two EKG evaluations, from whom 12% (n = 16) prolonged their QTc from baseline in more than 50 ms, and six developed a ventricular arrhythmia. Regarding the trajectories of the liver function tests over time, no significant differences were found for the change in the mean value per day between the two groups. Among patients who received optimal care, the mortality was 16% (33/210) in those treated with antimalarials and 15% (41/281) in those not receiving antimalarials (RR 1.08, 95% 0.75–1.64, and adjusted RR 1.12, 95% CI 0.69–1.82).

Conclusion: The adverse events in patients with COVID-19 treated with antimalarials were similar to those who did not receive antimalarials at institutions with rigorous pharmacological surveillance. However, they do not improve survival in patients who receive optimal medical care.

Prognostic value of cardiac troponin T elevation is independent of renal function and clinical findings in heart failure patients

BACKGROUND

The aim of this study is to determine the prevalence and prognostic value of elevated cardiac troponin (cTnT) and its association with clinical characteristics according to renal function status in patients with stable heart failure.

METHODS

In a prospective observational study, 152 consecutive patients from the Heart Failure Clinic of the INCMNSZ were followed for a period of 42 months. All underwent clinical evaluation, echocardiography, and determination of body composition by electric bioimpedance to identify hypervolemia. Concentrations of cTnT were quantified by immunoassay with electrochemoluminescence and > or = 0.02 ng/mL levels were considered elevated. Also glomerular filtration rate (eGFR) was estimated using the Cockcroft-Gault equation.

RESULTS

Elevated cTnT was significantly associated with increased all-cause mortality in the observational period even after adjusting for eGFR < 60 mL/min/1.73 m2 and clinical findings such as hypertension, functional class, loop diuretics, angiotensin converting enzyme inhibitors, pulmonary pressure and hypervolemia in Cox regression analysis with a hazard ratio of 4.58 (95% confidence interval: 1.84-11.45).

CONCLUSIONS

Heart failure patients with elevated cardiac-specific troponin T are at increased risk of death independently of the presence of chronic kidney disease.

Changes in the arrhythmic profile of patients treated for heart failure are associated with modifications in their myocardial perfusion conditions

BACKGROUND

Heart failure (HF) patients can benefit from a proper RS. We had observed that they show an increase in the number of arrhythmias during the first year of pharmacological treatment.

METHODS

We carried out a prospective observational study in which patients in an HF Clinic were included when they had follow-up Holter monitoring. Patients also had a baseline myocardial perfusion scan (Tc99 sestaMIBI/dypiridamole) and a control scan.

RESULTS

We included 90 patients with follow-up Holter and 35 with scintigraphy, for analysis. Fifty-six (62.2%) were men and the average age was 60.8 +/- 14.6 years. Follow-up periods were divided by six-month intervals up to 18 months or more, an increase in premature ventricular contractions (PVCs) occurred in the six-month to one-year period (1915.4 +/- +/- 4686.9 vs. 2959 +/- 6248.1, p = 0.09). In the one-year to 18-month control, PVCs went from 781.6 +/- 1082.4 to 146.9 +/- 184.1, p = 0.05. The increase in PVCs correlated with a reduction in scintigraphy-detected ischemic territories, 5.64 +/- 5.9 vs. 3.18 +/- 3 (p = 0.1) and a gain in those showing a reverse redistribution pattern (0.18 +/- 0.6 vs. 2.09 +/- 4.01, p = 0.1). Necrotic territories and time domain heart rate variability did not show significant changes.

CONCLUSIONS

PVCs increase during the first year of HF treatment, and then they tend to diminish and stabilize. These changes seem to correlate with changes in the perfusion state of the patient. While ischemic territories decrease, reverse redistribution increases, showing that endothelial dysfunction could have a relevant role in arrhythmia generation, possibly because of membrane instability of recovered hibernating myocardium.

Microalbuminuria in systolic and diastolic chronic heart failure patients

BACKGROUND

Microalbuminuria is considered a major risk factor predisposing to cardiovascular morbidity and mortality. Microalbuminuria levels in patients with or without diabetes have been associated with a higher risk of chronic heart failure (HF). However, there are limited data regarding prevalence of microalbuminuria in chronic heart failure and its prognostic value. The aim of this study was to assess the occurrence of microalbuminuria in chronic heart failure patients as well as its association with clinical, echocardiographic, and body composition markers.

METHODS

In a cross-sectional study, we included 72 chronic heart failure patients (NYHA I-III) on standard HF therapy. All patients had an echocardiogram and body composition by vector bioelectric impedance analysis (measured by Body Stat Quad Scan).

RESULTS

The studied population consisted of 64% men at mean age of 62.6 +/- 15.1 years. Patients were divided into systolic and diastolic HF groups. Microalbuminuria was observed in 40% of diastolic and 24% systolic HF patients (p = 0.04). Microalbuminuria was present in more patients with volume overload (80 vs. 21.9%, p = 0.002), with a worse phase angle and lower serum albumin (4.7 vs. 5.9 degrees and 3.5 vs. 4.0 mg/dl, p = 0.02) and higher pulmonary arterial pressure compared with patients without microalbuminuria in systolic HF patients. There was no significant association between frequency of microalbuminuria and ejection fraction. In the diastolic HF group, the presence of microalbuminuria was not associated with any known risk factor.

CONCLUSIONS

Microalbuminuria was more frequent in diastolic than systolic HF patients. In systolic HF patients microalbuminuria was associated with factors known to be markers of worse prognosis.

Aldosterone receptor antagonists induce favorable cardiac remodeling in diastolic heart failure patients

BACKGROUND

Serum levels of aldosterone in heart failure are increased up to 20 times compared to normal subjects. After an acute myocardial infarction, aldosterone increases progressively as well as interstitial fibrosis and collagen synthesis from cardiac fibroblasts, forming a patchy heterogeneous interstitial collagen matrix that affects ventricular function. Even if angiotensin converting enzyme inhibitors (ACEI) or angiotensin II receptor antagonists (ARA) can reduce aldosterone levels early during treatment, they increase again after a 12 week treatment. The aim of this study was to evaluate the changes in structure and function of the left ventricle in symptomatic (NYHA I-III) diastolic heart failure patients receiving an aldosterone receptor antagonist.

METHODS

Twenty-eight subjects with diastolic heart failure, on BB, ACEI and/ or ARA were randomized to receive spironolactone (group A) on a mean dose of 37.5 mg once a day (n = 14, age 63.7 +/- 21.6 years and body mass index, BMI 27.5 +/- 9.4), or not (group B, n = 14, Age 64.8 +/- 11.9, BMI 26.9 +/- 4.7). All patients were followed-up for a mean of 13.79 +/- 0.99 months.

RESULTS

Group A showed a 42.8% ischemic origin of heart failure, while in group B was 55% (p = 0.2). No other co-morbidities were significativelly different among both groups. Mean percentage of changes by echocardiogram was as follows: Interventricular septum (IVS) -12.2 +/- 11% vs. 1.3 +/- 15.2 (p = 0.03), pulmonary systolic artery pressure (PSAP was 0.99 +/- 3.8% vs. 10.5 +/- 9.1, p = 0.05). Other parameters did not show statistically significant differences.

CONCLUSION

Aldosterone receptor antagonists reduce or avoid increasing of PSAP and inducing a favorable remodeling of the left ventricle, especially in the IVS in diastolic heart failure patients.

Effects of Thalidomide Treatment in Heart Failure Patients

BACKGROUND

Several studies have reported a direct association between elevated plasma levels of inflammatory cytokines and worse functional class (New York Heart Association [NYHA]) and cardiac function, measured as left ventricular ejection fraction (LVEF). Thalidomide has recently shown to improve LVEF in chronic heart failure patients, accompanied by a marked decrease in plasma levels of tumor necrosis factor alpha (TNF-alpha).

METHODS

In a randomized prospective open label study of men and women with heart failure (HF) due to ischemic and non-ischemic cardiomyopathy who had systolic dysfunction (LVEF <40%) and NHYA classification, functional classes II and III were assigned to control (without thalidomide, 60 patients) or thalidomide group (20 patients). The initial dose of thalidomide was 100 mg once a day, and it was increased to 100 mg twice a day after a period of 10 days, if the prior dosage was well-tolerated. Demographic characteristics, etiology of HF, prior myocardial infarction, co-morbidities associated were registered and laboratory routine test, TNF-alpha serum levels, and echocardiogram were obtained at the beginning and after 6 months of follow-up.

RESULTS

Clinical status (NYHA) at the end of the follow-up period, improved moderately in both groups. TNF-alpha levels were initially of 5.88 +/- 0.9 and 6.49 +/- 1.82 vs. 6.32 +/- 1.6 and 7.94 +/- 3.8 pg/ml during follow-up, for thalidomide and control groups, respectively. There were non-significant differences in echocardiography variables.

CONCLUSION

In conclusion, although there is a large amount of information supporting a direct relationship between TNF-alpha and worsening of symptoms and prognosis in patients with HF and recently, the beneficial effect on thalidomide treatment has been suggested, these preliminary observations should be confirmed in a larger prospective study, specially trying to clarify the action mechanisms.

[Atrial fibrillation. New views on an old disease]

Atrial fibrillation (Afib) is clinically the most common arrhythmia. Its main complications are recurrent embolic events and a variable deterioration of functional class. Atrial fibrillation induces changes in cellular ionic channels that self-perpetuate the arrhythmia. The pharmacologic treatment of Afib is directed toward correction of those changes and return to sinus rhythm. It is also intended to maintain adequate heart rates and prevent embolic events through anticoagulation or platelet antiagregation. There are presently several class IC or class III antiarrhythmics available for attempting a return to sinus rhythm. The success rates are irregular, the best achieved with flecainide or propafenone among patients without structural heart disease. Amiodarone is the best choice when there is such a problem. The combination possibilities are huge, so that each case must be individualized. The new class III antiarrhythmics are very effective, but have a relatively high rate of side effects including torsade de pointes. Anticoagulation should be the preferred treatment among the majority of patients, but each case should be individually evaluated. New therapies such as focal or linear catheter ablation techniques, atrial or biatrial programmed stimulation, and atrial cardioverter-defibrillator need longer follow-up and experience to be objectively evaluated, although there are reasons to be optimistic in the future, even if patients need antiarrhythmic support at present. Surgery has high morbi-mortality rates, so it is not the preferred approach.

Cardiac conduction disturbances in mixed connective tissue disease

BACKGROUND

Myocardial involvement occurs in about 20% of patients with mixed connective tissue disease. The purpose of this study was to determine the prevalence of conduction disturbances, their association with other manifestations of the disease.

OBJECTIVE

Determine the prevalence of cardiac conduction disturbances in patients with mixed connective tissue disease attended in an institute in Mexico City and their relation with other manifestations of the disease.

METHODS

One hundred thirteen patients admitted to the Institute with a diagnosis of mixed connective tissue disease were divided into those with conduction disturbances (n = 23) and those without (n = 90). Over a mean follow-up of 10.2 +/- 7.8 years, clinical course, treatment, duration of the disease, types of conduction disturbances and systemic alterations were examined.

RESULTS

There was an overwhelming predominance of women in both groups. Conduction disturbances occurred in about 20% of the patients with mixed connective tissue disease and that was not possible to find significant differences in the outcome of them. As could be expected a significant difference between the two groups was QRS axis, related to anterior hemiblock, the most common conduction alteration observed. During the follow-up one patient death in-group A, but none in group B.

CONCLUSION

Conduction disturbances were present in 20%; in agree with other authors in the literature. However, did not participate in the outcome of the disease.