Impact of COVID-19 Pandemic on Cardiovascular Testing in Asia

Background

The coronavirus disease-2019 (COVID-19) pandemic significantly affected management of cardiovascular disease around the world. The effect of the pandemic on volume of cardiovascular diagnostic procedures is not known.

Objectives

This study sought to evaluate the effects of the early phase of the COVID-19 pandemic on cardiovascular diagnostic procedures and safety practices in Asia.

Methods

The International Atomic Energy Agency conducted a worldwide survey to assess changes in cardiovascular procedure volume and safety practices caused by COVID-19. Testing volumes were reported for March 2020 and April 2020 and were compared to those from March 2019. Data from 180 centers across 33 Asian countries were grouped into 4 subregions for comparison.

Results

Procedure volumes decreased by 47% from March 2019 to March 2020, showing recovery from March 2020 to April 2020 in Eastern Asia, particularly in China. The majority of centers cancelled outpatient activities and increased time per study. Practice changes included implementing physical distancing and restricting visitors. Although COVID testing was not commonly performed, it was conducted in one-third of facilities in Eastern Asia. The most severe reductions in procedure volumes were observed in lower-income countries, where volumes decreased 81% from March 2019 to April 2020.

Conclusions

The COVID-19 pandemic in Asia caused significant reductions in cardiovascular diagnostic procedures, particularly in low-income countries. Further studies on effects of COVID-19 on cardiovascular outcomes and changes in care delivery are warranted.

Heart Failure Integrated Care Project: overcoming barriers encountered by primary health care providers in heart failure management

ObjectiveHeart failure (HF) is associated with increased morbidity and mortality. A significant proportion of HF patients will have repeated hospital presentations. Effective integration between general practice and existing HF management programs may address some of the challenges in optimising care for this complex patient population. The Heart Failure Integrated Care Project (HFICP) investigated the barriers encountered by primary healthcare providers in providing care to patients with HF in the community. MethodsFive general practices in the St George and Sutherland regions (NSW, Australia) that employed practice nurses (PNs) were enrolled in the project. Participants responded to a printed survey that asked about their perceived role in the management of HF patients and their current knowledge and confidence in managing this condition. Participants also took part in a focus group meeting and were asked to identify barriers to improving HF patient management in general practice, and to offer suggestions about how the project could assist them to overcome those barriers. ResultsBarriers to effective delivery of HF management in general practice included clinical factors (consultation time limitations, underutilisation of patient management systems, identifying patients with HF, lack of patient self-care materials), professional factors (suboptimal hospital discharge summary letters, underutilisation of PNs), organisation factors (difficulties in communication with hospital staff, lack of education regarding HF management) and system issues (no Medicare rebate for B-type natriuretic peptide testing, insufficient Medicare rebate for using PN in chronic disease management). ConclusionsThe HFICP identified several barriers to improving integrated management for HF patients in the Australian setting. These findings provide important insights into how an HF integrated care model can be implemented to strengthen the working relationship between hospitals and primary care providers in delivering better care to HF patients. What is known about the topic?Multidisciplinary HF programs are heterogeneous in their structures, they have low patient participation rates and a significant proportion of HF patients have further presentations to hospital with HF. Integrating the care of HF patients into the primary care system following hospital admission remains challenging. What does this paper add?This paper identified several factors that hinder the effective delivery of care by primary care providers to patients with HF. What are the implications for practitioners?The findings provide important insights into how an HF integrated care model can be implemented to strengthen the working relationship between tertiary health facilities and primary care providers in delivering better care to HF patients.

The incidence of airway haemorrhage in manual versus mechanical cardiopulmonary resuscitation

OBJECTIVE

The aim of this study was to compare the incidence of airway haemorrhage between participants who received manual cardiopulmonary resuscitation (CPR) and those who had received mechanical CPR using the LUCAS device.

METHODS

A retrospective cohort study was conducted by means of a medical chart review. All non-traumatic cardiac arrest patients that presented to the ED, from May 2014 to February 2018, were recruited. The groups were stratified according to those who had the majority of CPR performed using the LUCAS and those who had the majority of CPR performed manually. The primary outcome was the proportion of participants with airway haemorrhage, defined as blood observed in the endotracheal tube, pharynx, trachea or mouth, and documented in the doctor or nursing notes. Logistic regression analysis was performed to adjust for confounders.

RESULTS

12 of 54 (22%) participants in the majority LUCAS CPR group had airway haemorrhage, compared with 20 of 215 (9%) participants in the majority manual CPR group, a difference of 13% (95% CI 3% to 26%, p=0.02). The unadjusted odds for developing airway haemorrhage in the majority LUCAS CPR group was 2.8 (95% CI 1.3 to 6.1). After adjusting for confounders, the odds for developing airway haemorrhage in the majority LUCAS CPR group was 2.5 (95% CI 1.1 to 5.7).

CONCLUSIONS

The LUCAS mechanical CPR device is associated with a higher incidence of airway haemorrhage compared with manual CPR. Limitations in the study design mean this conclusion is not robust.

Cellular cholesterol regulates ubiquitination and degradation of the cholesterol export proteins ABCA1 and ABCG1

The objective of this study was to examine the influence of cholesterol in post-translational control of ABCA1 and ABCG1 protein expression. Using CHO cell lines stably expressing human ABCA1 or ABCG1, we observed that the abundance of these proteins is increased by cell cholesterol loading. The response to increased cholesterol is rapid, is independent of transcription, and appears to be specific for these membrane proteins. The effect is mediated through cholesterol-dependent inhibition of transporter protein degradation. Cell cholesterol loading similarly regulates degradation of endogenously expressed ABCA1 and ABCG1 in human THP-1 macrophages. Turnover of ABCA1 and ABCG1 is strongly inhibited by proteasomal inhibitors and is unresponsive to inhibitors of lysosomal proteolysis. Furthermore, cell cholesterol loading inhibits ubiquitination of ABCA1 and ABCG1. Our findings provide evidence for a rapid, cholesterol-dependent, post-translational control of ABCA1 and ABCG1 protein levels, mediated through a specific and sterol-sensitive mechanism for suppression of transporter protein ubiquitination, which in turn decreases proteasomal degradation. This provides a mechanism for acute fine-tuning of cholesterol transporter activity in response to fluctuations in cell cholesterol levels, in addition to the longer term cholesterol-dependent transcriptional regulation of these genes.

Comparing radial and femoral access for coronary angiography and interventions

Cardiac catheterization and coronary intervention via the radial approach is increasingly adopted as the preferred vascular access to avoid transfemoral vascular complications. Recent clinical trials have confirmed that radial access reduces vascular complications and local bleeding with similar procedural efficacy. Transradial access has inherent technical challenges, including smaller vessel size of the radial artery, arterial spasm and tortuosity involving the radial and subclavian arteries, which may undermine the procedural success of this approach. A number of strategies have been reported to minimize complications of radial access, including the use of hydrophilic introducer sheaths and smaller sheath sizes, administration of nitroglycerin and unfractionated heparin during the procedure, patent hemostasis of the radial artery and careful patient selection. Operators experienced in transradial percutaneous coronary intervention can achieve comparable clinical outcomes to the transfemoral approach and minimize vascular complications. Radial artery access is likely to become widely accepted as the preferred percutaneous coronary intervention approach.

How Should We Treat Multi-Vessel Disease in STEMI Patients?

OPINION STATEMENT

Primary angioplasty of the culprit coronary artery lesion is the preferred reperfusion strategy for ST-elevation myocardial infarction (STEMI) when timely access to a catheterization laboratory is available. The presence of multi-vessel disease (MVD) in patients undergoing primary PCI is common, occurring in about 40 %-50 % of patients. The presence of MVD in patients who have undergone successful primary PCI substantially increases the risks of mortality and major adverse cardiac events, such as reinfarction or need for urgent revascularization. The current evidence supporting revascularization of non-culprit lesions is sparse, with no large, adequately powered randomized trials to guide clinical practice. An analysis combining observational data and small randomized trials suggests that complete revascularization with PCI to significant non-culprit lesions may afford a benefit compared with medical management alone. However, this benefit appears to be confined to when revascularization is performed as a separate, staged procedure. By contrast, when non-culprit lesion PCI is performed during the initial primary PCI procedure, the risk of death or cardiovascular events is higher than medical management alone or to staged revascularization. A large, adequately powered randomized trial is urgently needed to determine whether routine staged PCI plus optimal medical therapy is superior to optimal medical therapy alone for significant non-culprit coronary artery lesions in patients who have undergone successful primary PCI for STEMI.

Safety and efficacy of rescue angioplasty for ST-elevation myocardial infarction with high utilization rates of glycoprotein IIb/IIIa inhibitors

BACKGROUND

Fibrinolytic therapies remain widely used for ST-elevation myocardial infarction, and for "failed reperfusion," rescue percutaneous coronary intervention (PCI) is guideline recommended to improve outcomes. However, these recommendations are based on data from an earlier era of pharmacotherapy and procedural techniques.

METHODS AND RESULTS

To determine factors affecting prognosis after rescue PCI, we studied 241 consecutive patients (median age 55 years, interquartile range [IQR] 48-65) undergoing procedures between 2001 and 2009 (53% anterior ST-elevation myocardial infarction and 78% transferred). The median treatment-related times were 1.2 hours (IQR 0.8-2.2) from symptom onset to door, 2 hours (IQR 1.3-3.2) from symptom onset to fibrinolysis (93% tenecteplase), and 3.9 hours (IQR 3.1-5.2) from fibrinolysis to balloon. Procedural characteristics were stent deployment in 95% (11.6% drug eluting) and 78% glycoprotein IIb/IIIa inhibitor use, and Thrombolysis In Myocardial Infarction (TIMI) 3 flow rates pre-PCI and post-PCI were 41% and 91%, respectively (P < .001). At 30 days, TIMI major bleeding occurred in 16 (6.6%) patients, and 23 (9.5%) patients received transfusions; nonfatal stroke occurred in 4 (1.7%) patients (2 hemorrhagic). Predictors of TIMI major bleeding were female gender (odds ratio 3.194, 95% CI 1.063-9.597; P = .039) and pre-PCI shock (odds ratio 3.619, 95% CI,1.073-12.207; P = .038). Mortality at 30 days was 6.2%, and 3.2% in patients without pre-PCI shock. One-year mortality was 8.2% (5.3% in patients without pre-PCI cardiogenic shock), 5.2% had reinfarction, and the target vessel revascularization rate was 6.4% (2.6% in arteries ≥ 3.5 mm in diameter). Pre-PCI shock, female gender, and post-PCI TIMI flow grades ≤ 2 were significant predictors of 1-year mortality on multivariable regression modeling, but TIMI major bleeding was not.

CONCLUSIONS

Rescue PCI with contemporary treatments can achieve mortality rates similar to rates for contemporary primary PCI in patients without pre-PCI shock. Whether rates of bleeding can be reduced by different pharmacotherapies and interventional techniques needs clarification in future studies.

Expression and stability of two isoforms of ABCG1 in human vascular cells

OBJECTIVE

To evaluate the expression of two ABCG1 isoforms that differ in the presence or absence of a 12 amino acid (AA) peptide between the ABC cassette and the transmembrane region, termed ABCG1(+12) and ABCG1(-12), respectively, in human vascular cells and tissues.

METHODS AND RESULTS

mRNA for both isoforms was expressed in human macrophages, vascular endothelial and smooth muscle cells as well as whole human spleen, lung, liver and brain tissue. However, ABCG1(+12) was not expressed in mouse tissues. 2D gel electrophoresis of ABCG1 protein indicated that both protein isoforms were expressed in human macrophages. Furthermore the half-lives of the two ABCG1 protein isoforms, stably expressed in CHOK1 cells, measured under basal conditions were different, suggesting the presence of a degradation or stabilising signal in or near the 12AA region of ABCG1(+12).

CONCLUSION

ABCG1(+12) is an isoform of ABCG1 exclusively expressed in human cells at the RNA and protein level. As ABCG1(+12) is not expressed in mice, although mouse models are widely used to elucidate the function of ABCG1, further investigations into the importance of this human ABCG1 isoform are warranted.

Oxygen metabolites from lavage and interstitial lung cells after inhalation of endotoxin in guinea pigs

Airborne endotoxins play a role in a variety of occupational diseases such as byssinosis and humidifier's disease and are associated with pulmonary and systemic symptoms. An excess generation of oxygen free radicals (including superoxide anion, O2-) by inflammatory cells has been suggested in endotoxemia. We have studied the release of superoxide from guinea-pig lung lavage and interstitial cells and blood monocytes (BMs) at different times after an acute inhalation exposure to bacterial endotoxin. O2- generation was measured by the O2- dismutase-inhibitable reduction of ferricytochrome c, after stimulation with phorbol-myristate-acetate (PMA) or opsonized zymosan (OZ). After endotoxin exposure, the spontaneous release of O2- remained unchanged for the three cell types. From 4 h after exposure until 48 h afterwards, lung lavage cells produced more O2- after PMA or OZ stimulation than did cells from unexposed guinea pigs. The pattern of O2- generation by interstitial cells followed that of lung lavage macrophages. O2- production remained unchanged in BMs at all times. These results suggest that endotoxin inhalation induced a priming of lavage and interstitial cells, mainly macrophages, associated with an increase in O2- production. As O2- production by BMs remained unchanged, this cell is unlikely to be responsible for the systemic symptoms seen after endotoxin inhalation.

NARES: a model of inflammation caused by activated eosinophils?

Twenty patients were selected on the basis of perennial rhinitis, the absence of allergy and with an eosinophil count higher than 20% of total leucocytes in nasal secretions (NARES). Nasal endoscopy with biopsies from the middle turbinate and sinus CT were performed. Biopsies were processed for histological examination and for immunofluorescence. The clinical progress during treatment was scrutinized. An acute congestive aspect of the nasal mucosa was noted in 4 cases, and micropolyposis in 9 cases. Sinus CT showed opacity of the ethmoidal cells in 87% of cases (maxillary sinuses: 75%; frontal sinus: 46%; sphenoidal sinus: 31%). An eosinophilic infiltrate of the nasal mucosa was constituted in 9 cases: In 6 cases, the cells expressed the Fc epsilon RII receptor, recognized by the monoclonal antibody Bb10. Anti-H1 drugs usually failed to result in a clinical improvement and local eosinophilia was not changed. Local corticoids were more effective but not sufficient in some cases, so that oral corticotherapy was needed. Ethmoidectomy was performed in three cases. NARES seems to evolve in three stages: (1) migration of eosinophils from the vessels to the secretions; (2) retention of eosinophils in the mucosa which might be linked to activation of unknown origin; (3) nasal polyposis. Numerous interactions between irritation of the epithelium, release of substance P, and eosinophils, lead to the hypothesis of a neurogenic origin of NARES.

Nonallergic rhinitis with eosinophilia syndrome a precursor of the triad: nasal polyposis, intrinsic asthma, and intolerance to aspirin

Fifty-two cases of perennial rhinitis were studied, leading to the diagnosis of seven cases of nonallergic rhinitis with eosinophilia syndrome (NARES) a frequency of 13.5%. Symptoms of nasal hyperreactivity involving sneezing, rhinorrhea, nasal obstruction and pruritus were more severe than in other types of rhinitis. The frequency of hyposmia was very specific to NARES. Nasal endoscopy and sinus CT revealed an evolution towards nasal polyposis in four patients. The nasal challenge to house dust mites showed the absence of any increase in local eosinophilia. Bronchial hyperreactivity to carbachol occurred in one case. There was no case of intolerance to aspirin. There was particular adrenergic hyperreactivity among the seven patients, evidenced by study of the reactivity of the cardiovascular alpha and beta receptors. The authors emphasize the features that are shared by NARES and by the triad, which suggest that NARES is the early phase of the triad. They advance the pathogenic hypothesis of an autonomic nervous system dysregulation with a predominating adrenergic hyperreactivity. Inflammatory effects of local release of neurotransmitters induce a switch from a neurogenic to a self-sustaining inflammation. Tissue eosinophilia is regulated by chemical attractants and activating substances of various origins and plays a major part in the chronic inflammatory state.

Traumatic aneurysm of vertebral artery: a case report and review of the literature

A 64-year-old woman with a long-stand ing deformity of the neck presented with a rapidly enlarging neck mass following sud den turning of the head. Cervical radio graphs demonstrated a large erosion of the posterior elements of the cervical vertebra at the site of the deformity, and angiography revealed an aneurysmal sac of the left verte bral artery. The differential diagnoses of en larging neck masses associated with these ra diographic findings are discussed.