Impact of dexamethasone on cardiac injury in critically ill COVID-19 patients

Aims/Background

Severe COVID-19 pneumonia requiring intensive care treatment remains a clinical challenge to date. Dexamethasone was reported as a promising treatment option, leading to a reduction of mortality rates in severe COVID-19 disease as well as ventilator-dependent days. However, the effect of dexamethasone treatment on cardiovascular outcomes including cardiac injury monitored by cardiac enzymes remains largely elusive.

Methods

For this study, we retrospectively screened 224 consecutive COVID-19 patients between 4/2020 and 1/2021 in three Europeen Hospitals. To avoid bias effects of further applied COVID-19 specific medications including tacilizumab, remdesevir and sarilumab, 46 patients treated with at least one of these substances were excluded from further analyses. In total 178 critically ill COVID-19 patients requiring intensive care treatment and mechanical ventilation were recruited. 113 patients (63.5%) were treated with dexamethasone for a median duration of 10 days (IQR 9–10). 65 patients (36.5%) constituted the non-dexamethasone group. The assessment of cardiac injury was based on cardiac enzymes.

Results

Baseline charactaristics shown in Tab. 1. While peak inflammatory markers seemed to be reduced by dexamethasone treatment (CRP and a trend towards decrease of interleukin 6 levels (CRP maximum level: median: 20 ng/mL (IQR 12–28) vs. 22 ng/mL (IQR 14–37), p=0.043; IL-6 maximum level: median: 192 pg/mL (IQR 78–533) vs. 708 pg/mL (550–885), p=0.085), in the dexamethasone Group also shown a significant reduction in peak troponine levels as shown in Figure 1. CK and CK-MB do not differ significantly by Dexamethasone application. Of note, no significant changes in baseline characteristics were observed between the dexamethasone and non-dexamethasone group (Table 1).

Conclusion

In severe COVID-19, antiinflammatory effects of dexamethasone treatment could be associated with a significant reduction in myocardial injury. Further studies should further evaluate whether Dexamethasone effects directly myocardial involvement in COVID 19.

Funding Acknowledgement

Type of funding sources: None.

Effects of angiotensin receptor-neprilysin inhibitors (ARNIs) on the glucose and fat metabolism biomarkers leptin and fructosamin

Background

Heart Failure with reduced ejection fraction (HFrEF) has a life time risk about 20% among adults aged 40 years or older and a 5-year mortality rate about 60% [1,2]. However novel therapies have shown to improve this outcome. One novel agent are angiotensin receptor-neprilysin inhibitors (ARNIs) that increase the BNP levels via inhibiting neprilsyin [3]. This has beneficial effects on heart failure by reducing preload, inflammation and fibrosis. Neprilysin also interacts with leptin and is known to correlate with the incidence and progression of heart failure if chronically elevated [4]. Furthermore beneficial affects of ARNI therapy on glucose metabolism were reported in a post-hoc analysis of the PARADIGM-HF trial [5]. In this study we aim to investigate the effect of ARNI therapy on the fat metabolism markers leptin and on the glucose metabolism marker fructosamin.

Methods

In total, we included 74 patients with HFrEF with ischemic (N=37) and non-ischemic (n=37) origin in the present study. The mean NYHA class was II–III, the mean BMI 28 (SD 6.3). Patients had well established heart failure therapy before starting ARNI therapy with sacubitril/valsartan. 88% of patients were on ACE-inhibitors, 86% on beta blockers and 68% on mineralocorticoid receptor antagonists. Serum samples were obtained and analyzed for leptin, fructosamin and pBNP before and 3–6 month after ARNI therapy. The clinical parameters LVEF and NYHA class were assessed before and 3–6 month after ARNI therapy.

Results

Baseline leptin level was 15.0 (SD 17.2), baseline fructosamin level was 370.1 (SD 167.7) and baseline pBNP level was 1494.9 (SD 1281.4). Under therapy a significant improvement of ejection fraction from 29,8% to 37,5% (7,7 SD 8,5 P≤0.001), an improvement of NYHA stadium from 2.46 (SD 0.62) to 1.96 (SD 0.63, p=0.005) and a significant decrease of pBNP (562.1 SD 1256.4, p=0.018) was found. Along with that, a significant increase in leptin levels (3.6 SD 8.85, p=0.012) and a significant increase in fructosamine levels (93.5 SD 160.6, p=0.013) was shown.

Conclusion

Under therapy with ARNI we showed a sufficient therapy response with improvement of ejection fraction and decrease of pBNP in line with literature. Surprisingly metabolism biomarkers did significantly worsen under the first three to six month after new ARNI therapy. To distinguish between a side effect of ARNI therapy or consequence of heart failure itself further investigations are needed.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of cavotricuspid isthmus ablation for typical atrial flutter in patients with heart failure and reduced ejection fraction

Background

The CASTLE-AF trial in 2018, showed that pulmonary vein isolation provides a survival benefit and a reduced hospitalization rate in patients with heart failure and concomitant atrial fibrillation. Typical atrial flutter (AFL) can also induce heart failure (tachymyopathy) or, if cardiomyopathy of other origin is prevalent, can further worsen it. Cavotricuspid isthmus ablation (CTI) is a simple, invasive electrophysiological procedure that can effectively treat AFL. Prognostic data on the impact of CTI in patients with heart failure and reduced ejection fraction (HFrEF) is lacking.

Purpose

This study focused on the analysis of the clinical impact of CTI vs. medical therapy in patients with HFrEF.

Methods

The present retrospective, international, multi-center study included 104 patients <85 years with AFL and heart failure (LVEF <50%). 64 patients underwent an electrophysiological study with successful CTI (ablation group), whereas 40 patients received medical therapy alone with frequency or rhythm control and guideline-compliant heart failure therapy (medical therapy group). Patients were followed up for a total of 2 years, with particular emphasis on recording the change in LVEF over time. The primary endpoints were cardiovascular mortality and hospitalization for cardiac causes.

Results

Patients after CTI showed a significant increase in LVEF after 1 year (with the exception of valvular cardiomyopathy). The optimization of LVEF was also reflected in the Kaplan-Meier curves, as the ablation group had a significantly lower 2-year, cardiovascular mortality (p<0.001). The hospitalization rate for cardiac causes in the overall cohort showed a tendency towards reduced hospitalizations (p=0.072). Elderly patients also benefited from CTI in this study. Specifically, Patients ≥70 years of age showed a significantly lower re-hospialization rate after CTI (p=0.043) as well as a significantly reduced mortality after 2 years (p=0.012).

Conclusions

CTI in patients with AFL and HFrEF was associated with significant optimization of LVEF and lower rates of hospitalization and mortality after 2 years. Patient age should not be a primary exclusion criterion for CTI because in this study, patients ≥70 years also benefited significantly from intervention in terms of mortality and hospitalization.

Funding Acknowledgement

Type of funding sources: None.

Dexamethasone improves cardiovascular outcomes in critically ill COVID-19, a real world scenario multicenter analysis

Background

Severe COVID-19 pneumonia requiring intensive care treatment remains a clinical challenge to date. Dexamethasone was reported as a promising treatment option, leading to a reduction of mortality rates in severe COVID-19 disease. However, the effect of dexamethasone treatment on cardiac injury and pulmonary embolism remains largely elusive.

Methods

In total 178 critically ill COVID-19 patients requiring intensive care treatment and mechanical ventilation were recruited in three European medical centres and included in the present retrospective study. 113 patients (63.5%) were treated with dexamethasone for a median duration of 10 days (IQR 9–10). 65 patients (36.5%) constituted the non-dexamethasone control group.

Results

While peak inflammatory markers were reduced by dexamethasone treatment, the therapy also led to a significant reduction in peak troponin levels (231% vs. 700% indicated as relative to cut off value, p=0.001). Similar, dexamethasone resulted in significantly decreased peak D-Dimer levels (2.16 mg/l vs. 6.14mg/l, p=0.002) reflected by a significant reduction in pulmonary embolism rate (4.4% vs. 20.0%, p=0.001). The antithrombotic effect of dexamethasone treatment was also evident in the presence of therapeutic anticoagulation (pulmonary embolism rate: 6% vs. 34.4%, p<0.001). Of note, no significant changes in baseline characteristics were observed between the dexamethasone and non-dexamethasone group.

Conclusion

In severe COVID-19, antiinflammatory effects of dexamethasone treatment seem to be associated with a significant reduction in myocardial injury. Similar, a significant decrease in pulmonary embolism, independent of anticoagulation, was evident, emphasizing the beneficial effect of dexamethasone treatment in severe COVID-19.

Funding Acknowledgement

Type of funding sources: None.

Higher incidence of stroke in severe COVID-19 is not associated with a higher burden of arrhythmias: comparison to other types of severe pneumonia

Background

Thromboembolic events, including stroke, are typical complications of COVID-19. Whether arrhythmias, frequently described in severe COVID-19, are disease-specific and thus promote strokes is unclear. We investigated the occurrence of arrhythmias, and stroke during rhythm monitoring in critically ill COVID-19, compared to severe pneumonias of other origin.

Methods

Recruited were 120 critically ill patients requiring mechanical ventilation in three European tertiary hospitals, including n=60 COVID-19, matched according to risk factors for occurrence of arrhythmias to n=60 patients from a retrospective consecutive cohort of severe pneumonias of other origin.

Results

Arrhythmias, mainly atrial fibrillation (AF), were frequent in COVID-19. However, when compared to nonCOVID-19, no difference was observed with respect to ventricular tachycardias (VT) and relevant bradyarrhythmias (VT 10.0 vs. 8.4%, p=ns and asystole 5.0 vs. 3.3%, p=ns) with consequent similar rates of cardiopulmonary resuscitation (6.7 vs. 10.0% p=ns). AF was even more common in nonCOVID-19 (AF 18.3 vs. 43.3%, p=0.003; newly onset AF 10.0 vs. 30.0%, p=0.006) which resulted in higher need for electrical cardioversion (6.7 vs. 20.0%, p=0.029). Despite these findings and comparable rates of therapeutic anticoagulation (TAC), the incidence of stroke was higher in COVID-19 (6.7.% vs. 0.0, p=0.042). These events happened also in absence of AF (50%) and with TAC (50%).

Conclusion

Arrhythmias were common in severe COVID-19, consisting mainly of AF, yet less frequent than in matched pneumonias of other origin. A contrasting higher incidence of stroke independent of arrhythmias observed also with TAC, seems to be an arrhythmia-unrelated disease-specific feature of COVID-19.

Funding Acknowledgement

Type of funding sources: None.

Association of leptin serum concentration with heart adipose tissue and parameters of systolic and diastolic function in heart failure patients

Aims

Leptin has recently been related to myocardial remodeling in animal experimentation studies on heart failure (HF). Furthermore, leptin has been reported to be related to diastolic dysfunction, however only in healthy population. With the emergence of new medical therapies targeting cardiac remodeling, there needs to be a better understanding of the metabolic pathways involving leptin. Our study aims to investigate leptin's correlation to parameters of systolic and diastolic heart function, as well as epicardial and pericardial adipose tissue (EAT and PAT) in heart failure (HF) patients.

Methods

The study included 51 patients with chronic heart failure with reduced ejection fraction (HFrEF) of ischemic (n=22) and non-ischemic (n=29) origin (NYHA II-III, mean EF 29.56%, SD 8.1; mean BMI 28.08, SD 5.8). Serum concentrations of leptin, NT-proBNP, HbA1c, LDL, and total cholesterol were also measured. Global longitudinal strain (GLS) and other LV function parameters were assessed in transthoracic echocardiography, as well as EAT and PAT in parasternal long and short-axis views.

Results

We found a significant correlation between leptin serum concentration and epicardial, as well as pericardial adipose tissue (EAT r=0.336, p=0.030; PAT r=0.565, p&lt;0.001). There was a significant negative correlation between leptin and GLS (r=−0.332; p=0.045), as well a positive correlation between Leptin and E/E' ration (r=0.373; p=0.039). There was no significant difference between ischemic and non-ischemic HF patients.

Conclusion

We provide evidence of serum leptin correlation to remodeling parameters, as well as epicardial and pericardial fat tissue in HF patients. Whether leptin has positive effects on reversing or preventing remodeling in heart failure, needs further investigation.

Correlation of leptin vs. GLS

Funding Acknowledgement

Type of funding source: None

P6287Analysis of novel cardiac markers sST2 and IL-33 in chronic heart failure with reduced ejection fraction

Background

Soluble (s) ST-2 has been recently evaluated as a monitoring parameter in heart failure (HF). Besides being a marker for cardiac strain and hemodynamic stress, studies also found an influence of ST2 on the immune system, above all mediated through its Janus-Face ligand IL-33, an alarmin released under stress conditions or by cellular death. In contrast to sST2, the role of IL-33 in HF is yet unknown.

Objective

In this project, we aimed for an analysis of the ST2/IL33 pathway in patients with heart failure with reduced ejection fraction (HFrEF).

Methods

In total, 200 patients were included in the study: 59 with ischemic (ICM), 65 with dilated (DCM) cardiomyopathy (mean LVEF 38%), as well as 76 control patients without coronary artery disease or signs of heart failure. Serum samples were analyzed by use of ELISA after informed consent.

Results

sST2 showed a significant elevation in all HF patients (p<0.0001) compared to the control group. No significant differences in levels of sST2 were observed between ICM and DCM patients. In contrast to sST2, no differences between HF patients and control group were observed for IL-33. Furthermore, sST2 showed a significant correlation with CRP (p<0.001, r=0.28), NT-pro-BNP (p<0.0001, r=0.40) and an inverse correlation with ejection fraction (p<0.0001, r=−0.40). Additionally, sST2 showed a significant elevation in patients in NYHA stages I-II (p=0.030) and NYHA stages III-IV (p<0.01). Again, no significant correlations were observed between IL-33 and parameters mentioned above.

Analysis of sST2 in heart failure

Conclusions

We observed a significant increase and correlation with disease severity of sST2 in chronic HFrEF patients of both ischemic and non-ischemic origin, but contrary to our expectations, no significant changes in serum levels of IL-33. Thus, a mechanism independent of ST2/IL33 axis could be responsible of sST2 secretion in HF. Further studies including acute decompensated patients could provide a better understanding of the IL-33 role in HF.

The ESC ACCA EAPCI EORP acute coronary syndrome ST-elevation myocardial infarction registry

Aims 

The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI.

Methods and results 

Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission.

Conclusion 

The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Origin of parietal podocytes in atubular glomeruli mapped by lineage tracing

Parietal podocytes are fully differentiated podocytes lining Bowman's capsule where normally only parietal epithelial cells (PECs) are found. Parietal podocytes form throughout life and are regularly observed in human biopsies, particularly in atubular glomeruli of diseased kidneys; however, the origin of parietal podocytes is unresolved. To assess the capacity of PECs to transdifferentiate into parietal podocytes, we developed and characterized a novel method for creating atubular glomeruli by electrocoagulation of the renal cortex in mice. Electrocoagulation produced multiple atubular glomeruli containing PECs as well as parietal podocytes that projected from the vascular pole and lined Bowman's capsule. Notably, induction of cell death was evident in some PECs. In contrast, Bowman's capsules of control animals and normal glomeruli of electrocoagulated kidneys rarely contained podocytes. PECs and podocytes were traced by inducible and irreversible genetic tagging using triple transgenic mice (PEC- or Pod-rtTA/LC1/R26R). Examination of serial cryosections indicated that visceral podocytes migrated onto Bowman's capsule via the vascular stalk; direct transdifferentiation from PECs to podocytes was not observed. Similar results were obtained in a unilateral ureter obstruction model and in human diseased kidney biopsies, in which overlap of PEC- or podocyte-specific antibody staining indicative of gradual differentiation did not occur. These results suggest that induction of atubular glomeruli leads to ablation of PECs and subsequent migration of visceral podocytes onto Bowman's capsule, rather than transdifferentiation from PECs to parietal podocytes.

Proximal tubular cells contain a phenotypically distinct, scattered cell population involved in tubular regeneration

Regeneration of injured tubular cells occurs after acute tubular necrosis primarily from intrinsic renal cells. This may occur from a pre-existing intratubular stem/progenitor cell population or from any surviving proximal tubular cell. In this study, we characterize a CD24-, CD133-, and vimentin-positive subpopulation of cells scattered throughout the proximal tubule in normal human kidney. Compared to adjacent 'normal' proximal tubular cells, these CD24-positive cells contained less cytoplasm, fewer mitochondria, and no brush border. In addition, 49 marker proteins are described that are expressed within the proximal tubules in a similar scattered pattern. For eight of these markers, we confirmed co-localization with CD24. In human biopsies of patients with acute tubular necrosis (ATN), the number of CD24-positive tubular cells was increased. In both normal human kidneys and the ATN biopsies, around 85% of proliferating cells were CD24-positive - indicating that this cell population participates in tubular regeneration. In healthy rat kidneys, the novel cell subpopulation was absent. However, upon unilateral ureteral obstruction (UUO), the novel cell population was detected in significant amounts in the injured kidney. In summary, in human renal biopsies, the CD24-positive cells represent tubular cells with a deviant phenotype, characterized by a distinct morphology and marker expression. After acute tubular injury, these cells become more numerous. In healthy rat kidneys, these cells are not detectable, whereas after UUO, they appeared de novo - arguing against the notion that these cells represent a pre-existing progenitor cell population. Our data indicate rather that these cells represent transiently dedifferentiated tubular cells involved in regeneration.

Subtotal ablation of parietal epithelial cells induces crescent formation

Parietal epithelial cells (PECs) of the renal glomerulus contribute to the formation of both cellular crescents in rapidly progressive GN and sclerotic lesions in FSGS. Subtotal transgenic ablation of podocytes induces FSGS but the effect of specific ablation of PECs is unknown. Here, we established an inducible transgenic mouse to allow subtotal ablation of PECs. Proteinuria developed during doxycycline-induced cellular ablation but fully reversed 26 days after termination of doxycycline administration. The ablation of PECs was focal, with only 30% of glomeruli exhibiting histologic changes; however, the number of PECs was reduced up to 90% within affected glomeruli. Ultrastructural analysis revealed disruption of PEC plasma membranes with cytoplasm shedding into Bowman's space. Podocytes showed focal foot process effacement, which was the most likely cause for transient proteinuria. After >9 days of cellular ablation, the remaining PECs formed cellular extensions to cover the denuded Bowman's capsule and expressed the activation marker CD44 de novo. The induced proliferation of PECs persisted throughout the observation period, resulting in the formation of typical cellular crescents with periglomerular infiltrate, albeit without accompanying proteinuria. In summary, subtotal ablation of PECs leads the remaining PECs to react with cellular activation and proliferation, which ultimately forms cellular crescents.

Parietal epithelial cells participate in the formation of sclerotic lesions in focal segmental glomerulosclerosis

The pathogenesis of the development of sclerotic lesions in focal segmental glomerulosclerosis (FSGS) remains unknown. Here, we selectively tagged podocytes or parietal epithelial cells (PECs) to determine whether PECs contribute to sclerosis. In three distinct models of FSGS (5/6-nephrectomy + DOCA-salt; the murine transgenic chronic Thy1.1 model; or the MWF rat) and in human biopsies, the primary injury to induce FSGS associated with focal activation of PECs and the formation of cellular adhesions to the capillary tuft. From this entry site, activated PECs invaded the affected segment of the glomerular tuft and deposited extracellular matrix. Within the affected segment, podocytes were lost and mesangial sclerosis developed within the endocapillary compartment. In conclusion, these results demonstrate that PECs contribute to the development and progression of the sclerotic lesions that define FSGS, but this pathogenesis may be relevant to all etiologies of glomerulosclerosis.

Forearm oxygen consumption and forearm blood flow in healthy children and adolescents measured by near infrared spectroscopy

The assessment of forearm oxygen consumption (VO(2)) and forearm blood flow (FBF) by means of near infrared spectroscopy has become widespread in adults, whereas in children and adolescents no data are available. The aim of the present study was to analyze VO(2) and FBF in healthy children and adolescents.

METHODS

In a prospective cohort study, 20 male and 20 female healthy children and adolescents were investigated. The measurements of VO(2) and FBF were performed by means of near infrared spectroscopy in combination with the venous occlusion method.

RESULTS

Mean VO(2) was 0.08 +/- 0.04 ml 100 g(-1) min(-1) in male and 0.09 +/- 0.05 ml 100 g(-1) min(-1) in female subjects. Mean FBF was 1.95 +/- 1.25 ml 100 g(-1) min(-1) in male and 1.82 +/- 0.98 ml 100 g(-1) min(-1) in female subjects. No significant difference was found between male and female subjects. A significant negative correlation of VO(2) and FBF to age was observed in both groups.

CONCLUSION

In the present study we were able to show that VO(2) and FBF decreased with increasing age in children and adolescents without significant differences between male and female subjects.

[Accuracy of sonography in the diagnosis of diffuse liver parenchymal diseases--comparison of sonography and liver histology]

A prospective study has been carried out on 127 patients to test the accuracy of sonography in the diagnosis of diffuse liver diseases compared with histology based on percutaneous liver biopsy. Using sonographic criteria - size, margin, surface, elasticity, echo structure and sonic conductivity of the liver, hepatic veins and portal vein - and measuring the size of the gallbladder and the spleen, the following sonographic diagnoses were made: normal liver, fatty liver, fatty liver fibrosis, alcoholic hepatitis, chronic active hepatitis, cirrhosis. Sonographic diagnosis predicted histological diagnosis in case of normal liver in 56%, fatty liver 70%, alcoholic hepatitis 92%, chronic active hepatitis 63%, cirrhosis 79%. The specificity of sonography was 95%, the overall sensitivity was 82%: e.g. fatty liver 84%, chronic active hepatitis 93% and cirrhosis 79%. We conclude that sonography is an ideal screening method for detecting diffuse liver diseases. In cases of fatty liver and of cirrhosis it can spare the patient further invasive investigation. Furthermore, this method is suitable for evaluating the course of diffuse diseases of the liver, especially of toxic-nutritive liver damage and also of chronic active hepatitis.