Global incidence, prevalence, years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Detailed, comprehensive, and timely reporting on population health by underlying causes of disability and premature death is crucial to understanding and responding to complex patterns of disease and injury burden over time and across age groups, sexes, and locations. The availability of disease burden estimates can promote evidence-based interventions that enable public health researchers, policy makers, and other professionals to implement strategies that can mitigate diseases. It can also facilitate more rigorous monitoring of progress towards national and international health targets, such as the Sustainable Development Goals. For three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has filled that need. A global network of collaborators contributed to the production of GBD 2021 by providing, reviewing, and analysing all available data. GBD estimates are updated routinely with additional data and refined analytical methods. GBD 2021 presents, for the first time, estimates of health loss due to the COVID-19 pandemic.

METHODS

The GBD 2021 disease and injury burden analysis estimated years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) for 371 diseases and injuries using 100 983 data sources. Data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. HALE estimates were produced using YLDs per capita and age-specific mortality rates by location, age, sex, year, and cause. 95% uncertainty intervals (UIs) were generated for all final estimates as the 2·5th and 97·5th percentiles values of 500 draws. Uncertainty was propagated at each step of the estimation process. Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021. Here we report data for 2010 to 2021 to highlight trends in disease burden over the past decade and through the first 2 years of the COVID-19 pandemic.

FINDINGS

Global DALYs increased from 2·63 billion (95% UI 2·44-2·85) in 2010 to 2·88 billion (2·64-3·15) in 2021 for all causes combined. Much of this increase in the number of DALYs was due to population growth and ageing, as indicated by a decrease in global age-standardised all-cause DALY rates of 14·2% (95% UI 10·7-17·3) between 2010 and 2019. Notably, however, this decrease in rates reversed during the first 2 years of the COVID-19 pandemic, with increases in global age-standardised all-cause DALY rates since 2019 of 4·1% (1·8-6·3) in 2020 and 7·2% (4·7-10·0) in 2021. In 2021, COVID-19 was the leading cause of DALYs globally (212·0 million [198·0-234·5] DALYs), followed by ischaemic heart disease (188·3 million [176·7-198·3]), neonatal disorders (186·3 million [162·3-214·9]), and stroke (160·4 million [148·0-171·7]). However, notable health gains were seen among other leading communicable, maternal, neonatal, and nutritional (CMNN) diseases. Globally between 2010 and 2021, the age-standardised DALY rates for HIV/AIDS decreased by 47·8% (43·3-51·7) and for diarrhoeal diseases decreased by 47·0% (39·9-52·9). Non-communicable diseases contributed 1·73 billion (95% UI 1·54-1·94) DALYs in 2021, with a decrease in age-standardised DALY rates since 2010 of 6·4% (95% UI 3·5-9·5). Between 2010 and 2021, among the 25 leading Level 3 causes, age-standardised DALY rates increased most substantially for anxiety disorders (16·7% [14·0-19·8]), depressive disorders (16·4% [11·9-21·3]), and diabetes (14·0% [10·0-17·4]). Age-standardised DALY rates due to injuries decreased globally by 24·0% (20·7-27·2) between 2010 and 2021, although improvements were not uniform across locations, ages, and sexes. Globally, HALE at birth improved slightly, from 61·3 years (58·6-63·6) in 2010 to 62·2 years (59·4-64·7) in 2021. However, despite this overall increase, HALE decreased by 2·2% (1·6-2·9) between 2019 and 2021.

INTERPRETATION

Putting the COVID-19 pandemic in the context of a mutually exclusive and collectively exhaustive list of causes of health loss is crucial to understanding its impact and ensuring that health funding and policy address needs at both local and global levels through cost-effective and evidence-based interventions. A global epidemiological transition remains underway. Our findings suggest that prioritising non-communicable disease prevention and treatment policies, as well as strengthening health systems, continues to be crucially important. The progress on reducing the burden of CMNN diseases must not stall; although global trends are improving, the burden of CMNN diseases remains unacceptably high. Evidence-based interventions will help save the lives of young children and mothers and improve the overall health and economic conditions of societies across the world. Governments and multilateral organisations should prioritise pandemic preparedness planning alongside efforts to reduce the burden of diseases and injuries that will strain resources in the coming decades.

FUNDING

Bill & Melinda Gates Foundation.

Advanced Heart Failure Therapies in The Eastern Mediterranean Region: Current Status, Challenges, and Future Directions

While there has been a global decrease in rates of heart failure (HF) prevalence between 1990 and 2019, the Eastern Mediterranean region (EMR) is experiencing an increase. In 2019, approximately 1,229,766 individuals lived with moderate to severe HF in the EMR. Despite the growth in the utilization of advanced heart failure (AHF) therapies in the EMR in the past two decades, current volumes are yet to meet the growing AHF burden in the region. Heart Transplantation (HT) volumes in EMR have grown from 9 in the year 2000 to 179 HTs in 2019. However, only a few centers provide the full spectrum of AHF therapies, including durable mechanical circulatory support (MCS) and HT. Published data on the utilization of left ventricular assist devices (LVAD) in the EMR are scarce. Notably, patients undergoing LVAD implantation in the EMR are on average, 13 years younger, and have a higher likelihood of presenting with critical cardiogenic shock, as compared to their counterparts in the Western world. Furthermore, AHF care in the region is hampered by the paucity of multidisciplinary HF programs, inherent costs of AHF therapies, limited access to short and long-term MCS, organ shortage, and lack of public awareness and acceptance of AHF therapeutics. All stakeholders in the EMR should work together to strategize tackling the challenging AHF burden in the region.

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950-2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020-21 COVID-19 pandemic period.

METHODS

22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.

FINDINGS

Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5-65·1] decline), and increased during the COVID-19 pandemic period (2020-21; 5·1% [0·9-9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98-5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50-6·01) in 2019. An estimated 131 million (126-137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7-17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8-24·8), from 49·0 years (46·7-51·3) to 71·7 years (70·9-72·5). Global life expectancy at birth declined by 1·6 years (1·0-2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67-8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4-52·7]) and south Asia (26·3% [9·0-44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.

INTERPRETATION

Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic.

FUNDING

Bill & Melinda Gates Foundation.

Infectious aortic aneurysms: A case report and review of cases from the Middle East and North Africa (MENA) region

An infectious aortic aneurysm is a rare disease entity. We report a challenging case of a 29-year-old male presenting with chest pain and constitutional symptoms. The patient was found to have three pseudoaneurysms of the aorta on imaging, significant pathological findings of necrotizing granulomatous lymphadenitis from a supraclavicular lymph node biopsy, and a highly suggestive clinical picture of tuberculous aortitis. He was referred to vascular surgery for intervention and discharged on antituberculous therapy for 6 months. To the best of our knowledge, only five cases of tuberculous aortic aneurysms have been reported from the Middle East and North Africa (MENA) region, all with favorable outcomes. A high index of suspicion, early detection, and prompt intervention are essential in managing such cases.

Red Flags in Acute Myocarditis

Acute myocarditis is an inflammatory disease of the heart that may occur in the setting of infection, immune system activation or exposure to certain drugs. Often, it is caused by viruses, whereby the clinical course is usually benign; however, it may also present with rapidly progressive fulminant myocarditis, which is associated with high morbidity and mortality. This review highlights the critical red flags - from the clinical, biochemical, imaging and histopathological perspectives - that should raise the index of suspicion of acute myocarditis. We also present an illustrative case of a young female patient with rapidly progressive cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation as a bridge to orthotopic heart transplantation. The patient showed no clinical or echocardiographic recovery signs and eventually underwent orthotopic heart transplantation. Furthermore, we elaborate on the classifications of acute myocarditis based on clinical presentation and histopathology classifications, focusing on identifying key red flags that will inform early diagnosis and appropriate management in such challenging cases.

Worldwide and Country-Specific Impact of the COVID-19 Pandemic on Heart Transplantation Volumes: A Longitudinal Analysis of 2020 and 2021

COVID-19 pandemic hampered operational efficiency of heart transplant (HT) programs worldwide. Little is known about the global and country-specific changes in HT volumes during the pandemic years 2020-2021. We aimed to describe the global and country-level impact of the COVID-19 pandemic on HT volumes in 2020-2021. This is a cross-sectional study of the Global Observatory on Donation and Transplantation, including the years 2019-2021. Among 60 countries that reported HT data in the years 2019-2020, we analyzed 52 countries with ≥1 transplant during each year. Overall, the number of HTs decreased during 2020 by 9.3% (1.82 to 1.65 PMP). While 75% (n = 39/52) of countries experienced a decrease in HT volumes in 2020, volumes were maintained/increased in the remaining countries. Countries with maintained HT volumes had a higher organ donation rate in 2020 compared to those with decreased volumes (P = 0.03), the only significant predictor of change in HT volumes (P = 0.005). In 2021, a 6.6% recovery from the previous year's drop in global HT rate was noticed, reaching 1.76 HT PMP. Only 1 in 5 countries with reduced volumes in 2020 recovered their baseline volumes in 2021. Only 30.8% of countries with maintained volumes in 2020 had continued growth in HT volumes in 2021. The latter group encompassed the United States of America, the Netherlands, Poland, and Portugal. Further work should define underlying causes of this heterogeneity in HT volume during the pandemic. Identifying policies and practices that helped certain countries mitigate the effect of the pandemic on HT activities may help other countries during similar health crises in the future.

Global burden of peripheral artery disease and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Peripheral artery disease is a growing public health problem. We aimed to estimate the global disease burden of peripheral artery disease, its risk factors, and temporospatial trends to inform policy and public measures.

METHODS

Data on peripheral artery disease were modelled using the Global Burden of Disease, Injuries, and Risk Factors Study (GBD) 2019 database. Prevalence, disability-adjusted life years (DALYs), and mortality estimates of peripheral artery disease were extracted from GBD 2019. Total DALYs and age-standardised DALY rate of peripheral artery disease attributed to modifiable risk factors were also assessed.

FINDINGS

In 2019, the number of people aged 40 years and older with peripheral artery disease was 113 million (95% uncertainty interval [UI] 99·2-128·4), with a global prevalence of 1·52% (95% UI 1·33-1·72), of which 42·6% was in countries with low to middle Socio-demographic Index (SDI). The global prevalence of peripheral artery disease was higher in older people, (14·91% [12·41-17·87] in those aged 80-84 years), and was generally higher in females than in males. Globally, the total number of DALYs attributable to modifiable risk factors in 2019 accounted for 69·4% (64·2-74·3) of total peripheral artery disease DALYs. The prevalence of peripheral artery disease was highest in countries with high SDI and lowest in countries with low SDI, whereas DALY and mortality rates showed U-shaped curves, with the highest burden in the high and low SDI quintiles.

INTERPRETATION

The total number of people with peripheral artery disease has increased globally from 1990 to 2019. Despite the lower prevalence of peripheral artery disease in males and low-income countries, these groups showed similar DALY rates to females and higher-income countries, highlighting disproportionate burden in these groups. Modifiable risk factors were responsible for around 70% of the global peripheral artery disease burden. Public measures could mitigate the burden of peripheral artery disease by modifying risk factors.

FUNDING

Bill & Melinda Gates Foundation.

The prevalence of cardiorenal anemia syndrome among patients with heart failure and its association with all-cause hospitalizations: a retrospective single-center study from the Middle East

Background and aim

Little is known about the burden of cardiorenal syndrome (CRS) and cardiorenal anemia syndrome (CRAS) in the Middle East Region. Furthermore, whether the occurrence rates of CRAS differ across heart failure (HF) phenotypes is not widely investigated. We aimed to examine the prevalence of CRS and CRAS in patients with HF, compare characteristics of patients with CRAS-HFrEF vs. CRAS-HFpEF, and investigate anemia association with 1-year all-cause hospitalizations.

Methods

HF patients who visited a multidisciplinary HF clinic at a single center between 10-2015 and 06-2022 (n = 968) were retrospectively included. Differences in rates of CRAS prevalence, and patients' characteristics of those with CRAS-HFrEF vs. CRAS-HFpEF were determined using appropriate testing methods. Generalized estimating equation (GEE) models were used to determine if anemia was associated with higher rates of hospitalization.

Results

CRS was prevalent in 34.4% of subjects, while 25.3% had CRAS. CRAS prevalence rates among patients with HFpEF vs. HFrEF were comparable (27.2% vs. 24.2%, p = 0.3). Compared to patients with HFrEF-CRAS, those with HFpEF-CRAS were more likely females (p < 0.001), had a higher burden of hypertension (p = 0.01), and lower hemoglobin (p = 0.02). In an adjusted GEE model, anemia was associated with an average increase of 1.8 admissions in CRS patients (p = 0.015).

Conclusion

In patients with HF, 1 in 3 patients presented with CRS, and 1 in 4 patients had CRAS. The prevalence of CRAS was comparable among those HFpEF and HFrEF. Anemia was associated with an increased rate of 1-year all-cause hospitalization in CRS patients.

The burden of ischemic heart disease and the epidemiologic transition in the Eastern Mediterranean Region: 1990-2019

It has been estimated that in the next decade, IHD prevalence, DALYs and deaths will increase more significantly in EMR than in any other region of the world. This study aims to provide a comprehensive description of the trends in the burden of ischemic heart disease (IHD) across the countries of the Eastern Mediterranean Region (EMR) from 1990 to 2019. Data on IHD prevalence, disability-adjusted life years (DALYs), mortality, DALYs attributable to risk factors, healthcare access and quality index (HAQ), and universal health coverage (UHC) were extracted from the Global Burden of Disease (GBD) database for EMR countries. The data were stratified based on the social demographic index (SDI). Information on cardiac rehabilitation was obtained from publications by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR), and additional country-specific data were obtained through advanced search methods. Age standardization was performed using the direct method, applying the estimated age structure of the global population from 2019. Uncertainty intervals were calculated through 1000 iterations, and the 2.5th and 97.5th percentiles were derived from these calculations. The age-standardized prevalence of IHD in the EMR increased from 5.0% to 5.5% between 1990 and 2019, while it decreased at the global level. In the EMR, the age-standardized rates of IHD mortality and DALYs decreased by 11.4% and 15.4%, respectively, during the study period, although both rates remained higher than the global rates. The burden of IHD was found to be higher in males compared to females. Bahrain exhibited the highest decrease in age-standardized prevalence (-3.7%), mortality (-65.0%), and DALYs (-69.1%) rates among the EMR countries. Conversely, Oman experienced the highest increase in prevalence (14.5%), while Pakistan had the greatest increase in mortality (30.0%) and DALYs (32.0%) rates. The top three risk factors contributing to IHD DALYs in the EMR in 2019 were high systolic blood pressure, high low-density lipoprotein cholesterol, and particulate matter pollution. The trend analysis over the 29-year period (1990-2019) revealed that high fasting plasma glucose (64.0%) and high body mass index (23.4%) exhibited increasing trends as attributed risk factors for IHD DALYs in the EMR. Our findings indicate an increasing trend in the prevalence of IHD and a decrease in mortality and DALYs in the EMR. These results emphasize the need for well-planned prevention and treatment strategies to address the risk factors associated with IHD. It is crucial for the countries in this region to prioritize the development and implementation of programs focused on health promotion, education, prevention, and medical care.

The Pandemic of Coronary Heart Disease in the Middle East and North Africa: What Clinicians Need to Know

PURPOSE OF REVIEW

Coronary heart disease (CHD) is the leading cause of morbidity, mortality, and disability in the Middle East and North Africa (MENA). While the prevention, diagnosis, and management of CHD have been detailed in international guidelines, we aimed in this review to quantify the pandemic of CHD in the MENA region and highlight regional patient characteristics, clinical challenges, and future directions to optimize CHD care in the region.

RECENT FINDINGS

Patients with CHD in the MENA feature younger age at presentation and worse prognosis in women. Despite the high burden of CHD risk factors, many of these factors remain underrecognized, undertreated, and uncontrolled. Additionally, CHD care is hampered by poor patient awareness, inefficient preventive strategies, and limited access to guideline-recommended therapeutics. All stakeholders involved in healthcare should work together to develop and execute strategies aimed at tackling the burden of CHD in the MENA.

Early Identification and Management of Heart Failure in Patients with Diabetes Mellitus in the United Arab Emirates: A Call to Action

Heart failure (HF) is a common and serious complication of diabetes mellitus (DM) that remains widely under-recognized. Multidisciplinary management protocols for patients with concurrent DM and HF are not widely utilized in the Middle East/Gulf region, particularly in the United Arab Emirates. Since early identification of patients with DM and HF will likely lead to initiation of therapies known to prevent adverse cardiovascular events and subsequently improve patient prognosis, we aim to highlight the importance of early recognition of HF in diabetic patients. We will also describe existing management challenges in the region, especially the lack of multidisciplinary care and emphasize the role of newer anti-diabetic therapies in preventing and treating HF. Most importantly, this call-to-action proposes a collaborative approach to the care of diabetic patients with HF involving primary care physicians, endocrinologists, and cardiologists.

Management of acute aortic services during the COVID-19 pandemic: a retrospective cohort study from the Middle East

COVID-19 created a challenging situation for cardiac surgery and associated acute care programs around the world. While non-urgent cases might be postponed, operating on life-threatening conditions, including type A aortic dissection (TAAD), must be sustained despite the ongoing pandemic. Therefore, the authors investigated the impact of the COVID-19 pandemic on their urgent aortic program.

Methods

The authors included consecutive patients presenting with TAAD (n=36) in the years 2019 and 2020 [pre-pandemic period (2019; n=16) and the pandemic era (2020; n=20)] at a tertiary care centre. Patient characteristics, TAAD presenting symptoms, operative techniques, postoperative outcomes, and length of stay were determined retrospectively using chart review and were compared between both years.

Results

An increase occurred in the absolute number of TAAD referrals during the pandemic era. Patients were featured by younger age of presentation (pre-pandemic group: 47.6±18.7, and the pandemic group: 50.6±16.2 years, P=0.6) in contrast to Western data but showed similar male predominance (4:1) in both groups. There was no statistical difference in baseline comorbidities between the groups. Length of hospital stay [20 (10.8-56) vs. 14.5 (8.5-53.3) days, P=0.5] and intensive care unit stay [5 (2.3-14.5) vs. 5 (3.3-9.3) days, P=0.4] were comparable between both groups. Low rates of postoperative complications were registered in both groups with no significant between-group difference. There was no significant difference in the rates of in-hospital mortality between both groups [12.5% (2) vs. 10% (2), P=0.93].

Conclusions

Compared with the pre-pandemic era (2019), there was no difference in resource utilisation and clinical outcomes of patients presenting with TAAD during the first year of COVID-19 pandemic (2020). Structural departmental re-configuration and optimal personal protective equipment utilisation warrant maintained satisfactory outcomes in critical healthcare scenarios. Future studies are required to further investigate aortic care delivery during such challenging pandemics.

Trends in the burden and determinants of hypertensive heart disease in the Eastern Mediterranean region, 1990-2019: an analysis of the Global Burden of Disease Study 2019

Background

Hypertensive heart disease (HHD), one of the end-organ damage consequences of hypertension, is an important public health issue worldwide. Data on the HHD burden in the Eastern Mediterranean region (EMR) are scarce. We aimed to investigate the burden of HHD in the EMR, its member countries, and globally from 1990 to 2019.

Methods

We used 2019 Global Burden of Disease (GBD) data to report the HHD age-standardised prevalence, disability adjusted life years (DALYs), years of life lost (YLLs), and mortality, as well as HHD risk factors attribution percent with their 95% uncertainty interval (UI). Global data are reported alongside EMR data, and its 22 respective countries. We compared the burden of HHD by socio-demographic index (SDI), sex, age groups, and countries.

Findings

The age-standardised prevalence rate (per 100,000 population) of HHD was higher in the EMR (281.7; 95% UI: 204.5-383.4) in 2019, compared with the global prevalence (233.8; 95% UI: 170.5-312.9). The EMR age-standardised DALYs (per 100,000 population) for HHD in 2019 was 561.9 (361.0-704.1), compared with 268.2 (204.6-298.1) at the global level. There was an increase in HHD prevalence, reduction in mortality, and DALYs between 1990 and 2019 (4.01%, -7.6%, and -6.5%, respectively) in EMR. Among EMR countries, the highest versus lowest rates of age-standardised prevalence, mortality, and DALYs in 2019 [estimate (95% UI)] were in Jordan [561.62 (417.9-747.6)] versus Saudi Arabia [94.9 (69.5-129.0)]; Afghanistan [74.5 (23.7-112.3)] versus Saudi Arabia [4.3 (3.3-5.9)]; and Afghanistan [1374.1 (467.2-2020.7)] versus Qatar [87.11 (64.40-114.29)], respectively.

Interpretation

HHD remains a significant problem in the EMR, with a higher burden than global levels. Serious efforts toward high-quality management and prevention are strongly recommended. Based on this study, our recommendation for the EMR is to adopt effective preventive strategies. For example, promoting healthy dietary patterns and prompt screening for undiagnosed HTN in public places, promoting regular blood pressure measurements at home, and creating community awareness about early detection of HTN.

Funding

None.

Sustaining Life versus Altering Life-Saving Drugs: Insights to Explain the Paradoxical Effect of Extracorporeal Membrane Oxygenation on Drugs

There has been a substantial increase in the use of extracorporeal membrane oxygenation (ECMO) support in critically ill adults. Understanding the complex changes that could affect drugs' pharmacokinetics (PK) and pharmacodynamics (PD) is of suitable need. Therefore, critically ill patients on ECMO represent a challenging clinical situation to manage pharmacotherapy. Thus, clinicians' ability to predict PK and PD alterations within this complex clinical context is fundamental to ensure further optimal and, sometimes, individualized therapeutic plans that balance clinical outcomes with the minimum drug adverse events. Although ECMO remains an irreplaceable extracorporeal technology, and despite the resurgence in its use for respiratory and cardiac failures, especially in the era of the COVID-19 pandemic, scarce data exist on both its effect on the most commonly used drugs and their relative management to achieve the best therapeutic outcomes. The goal of this review is to provide key information about some evidence-based PK alterations of the drugs used in an ECMO setting and their monitoring.

Implementation of a multidisciplinary inpatient heart failure service and its association with hospitalized patient outcomes: First experience from the Middle East and North Africa region

BACKGROUND

Multidisciplinary care models have been associated with improved clinical outcomes and an increase in adherence to guideline-directed medical therapy among patients hospitalized with heart failure (HF).

OBJECTIVE

This study aims to evaluate the association between the creation of a multidisciplinary inpatient HF service and patient outcomes at a tertiary care center in the Middle East/ North Africa.

METHODS

We used electronic health records to retrospectively identify patients hospitalized for acute HF between June-2015 and June-2018. Patients were categorized by whether they were hospitalized before (n = 71) or after (n = 86) the implementation of a multidisciplinary HF team (HF-MDT), starting on 1/1/2017. The groups were compared for optimal use of guideline-directed medical therapy, hospital length of stay, 30-day hospital readmission, and in-hospital mortality.

RESULTS

The creation of the HF-MDT was associated with significantly better adherence to GDMT at discharge (27.5% vs. 55.4%, (OR 3.3, 95% CI [1.65-6.5]), P<0.001), shorter median hospital length of stay (8, IQR [4.8 - 19] vs. 5, IQR [3- 9], P = 0.02) and a reduction in 30-day hospital readmission (26.5% vs. 11%; OR 0.3, 95% CI [0.1-0.8], P = 0.02). However, there was no difference in-hospital mortality (10.5% vs. 3.5%; OR 0.3, 95% CI [0.1-1.2], P = 0.1).

CONCLUSIONS

Implementing an HF-MDT in the care of patients hospitalized with HF is associated with better adherence to GDMT on discharge, reduced hospital length of stay, and lower 30-day readmission rates. The current data support the broader adoption of dedicated HF programs in the Middle East to improve outcomes of patients with HF.

Outcomes of Transcatheter Aortic Valve Replacement in the United Arab Emirates: Real-world, Single-centre Experience from an Emerging Programme

Background

Data on outcomes of transcatheter aortic valve replacement (TAVR) in the Middle East, particularly in the United Arab Emirates (UAE), are limited. Whether centres with a low volume of patients requiring the procedure can achieve similar outcomes as those reported in pivotal clinical trials remains unclear. This study evaluates procedural outcomes of patients undergoing TAVR in a newly established programme in the UAE.

Methods

Procedural outcomes of consecutive patients who underwent transfemoral TAVR at a single centre in the UAE between January 2016 and November 2021 were compared with those at centres in the lowest quartile (Q1) of procedural volume in the Transcatheter Valve Therapy Registry, which covers centres in the US.

Results

Among the 183 patients included in the study, the median age was 76 years (interquartile range [IQR] 71-82), and 42.1% of patients were women, with a median Society of Thoracic Surgeons predicted risk of mortality score of 4.6 (IQR 2.9-7.5). Most of the patients (93.3%) received a balloon-expandable valve. All-cause death within 30 days, stroke and major vascular complications occurred in 0.6%, 0.6% and 2.2% of patients, respectively, compared with 3.1%, 2.2% and 4% in patients treated at Q1 hospitals.

Conclusion

Patients undergoing transfemoral TAVR at an emerging centre in the Middle East had favourable outcomes compared with those performed at Q1 hospitals in the US. These findings suggest that careful patient selection for TAVR is critical and may help optimise patient outcomes, especially when procedural volumes are low.

Management of Patients With Tricuspid Valve Endocarditis and Ongoing Intravenous Drug Abuse

Right-sided infective endocarditis in patients with intravenous drug abuse portends a worse prognosis. Data on optimal management strategy in this situation are scarce. We describe outcomes of 2 different treatment strategies, including a patient treated conservatively with favorable intermediate-term results and another who was treated surgically and developed recurrent endocarditis. (Level of Difficulty: Intermediate.).

Age-sex differences in the global burden of lower respiratory infections and risk factors, 1990-2019: results from the Global Burden of Disease Study 2019

BACKGROUND

The global burden of lower respiratory infections (LRIs) and corresponding risk factors in children older than 5 years and adults has not been studied as comprehensively as it has been in children younger than 5 years. We assessed the burden and trends of LRIs and risk factors across all age groups by sex, for 204 countries and territories.

METHODS

In this analysis of data for the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we used clinician-diagnosed pneumonia or bronchiolitis as our case definition for LRIs. We included International Classification of Diseases 9th edition codes 079.6, 466-469, 470.0, 480-482.8, 483.0-483.9, 484.1-484.2, 484.6-484.7, and 487-489 and International Classification of Diseases 10th edition codes A48.1, A70, B97.4-B97.6, J09-J15.8, J16-J16.9, J20-J21.9, J91.0, P23.0-P23.4, and U04-U04.9. We used the Cause of Death Ensemble modelling strategy to analyse 23 109 site-years of vital registration data, 825 site-years of sample vital registration data, 1766 site-years of verbal autopsy data, and 681 site-years of mortality surveillance data. We used DisMod-MR 2.1, a Bayesian meta-regression tool, to analyse age-sex-specific incidence and prevalence data identified via systematic reviews of the literature, population-based survey data, and claims and inpatient data. Additionally, we estimated age-sex-specific LRI mortality that is attributable to the independent effects of 14 risk factors.

FINDINGS

Globally, in 2019, we estimated that there were 257 million (95% uncertainty interval [UI] 240-275) LRI incident episodes in males and 232 million (217-248) in females. In the same year, LRIs accounted for 1·30 million (95% UI 1·18-1·42) male deaths and 1·20 million (1·07-1·33) female deaths. Age-standardised incidence and mortality rates were 1·17 times (95% UI 1·16-1·18) and 1·31 times (95% UI 1·23-1·41) greater in males than in females in 2019. Between 1990 and 2019, LRI incidence and mortality rates declined at different rates across age groups and an increase in LRI episodes and deaths was estimated among all adult age groups, with males aged 70 years and older having the highest increase in LRI episodes (126·0% [95% UI 121·4-131·1]) and deaths (100·0% [83·4-115·9]). During the same period, LRI episodes and deaths in children younger than 15 years were estimated to have decreased, and the greatest decline was observed for LRI deaths in males younger than 5 years (-70·7% [-77·2 to -61·8]). The leading risk factors for LRI mortality varied across age groups and sex. More than half of global LRI deaths in children younger than 5 years were attributable to child wasting (population attributable fraction [PAF] 53·0% [95% UI 37·7-61·8] in males and 56·4% [40·7-65·1] in females), and more than a quarter of LRI deaths among those aged 5-14 years were attributable to household air pollution (PAF 26·0% [95% UI 16·6-35·5] for males and PAF 25·8% [16·3-35·4] for females). PAFs of male LRI deaths attributed to smoking were 20·4% (95% UI 15·4-25·2) in those aged 15-49 years, 30·5% (24·1-36·9) in those aged 50-69 years, and 21·9% (16·8-27·3) in those aged 70 years and older. PAFs of female LRI deaths attributed to household air pollution were 21·1% (95% UI 14·5-27·9) in those aged 15-49 years and 18·2% (12·5-24·5) in those aged 50-69 years. For females aged 70 years and older, the leading risk factor, ambient particulate matter, was responsible for 11·7% (95% UI 8·2-15·8) of LRI deaths.

INTERPRETATION

The patterns and progress in reducing the burden of LRIs and key risk factors for mortality varied across age groups and sexes. The progress seen in children younger than 5 years was clearly a result of targeted interventions, such as vaccination and reduction of exposure to risk factors. Similar interventions for other age groups could contribute to the achievement of multiple Sustainable Development Goals targets, including promoting wellbeing at all ages and reducing health inequalities. Interventions, including addressing risk factors such as child wasting, smoking, ambient particulate matter pollution, and household air pollution, would prevent deaths and reduce health disparities.

FUNDING

Bill & Melinda Gates Foundation.

An overview of radiation-induced heart disease

Radiation therapy (RT) has dramatically improved cancer survival, leading to several inevitable complications. Unintentional irradiation of the heart can lead to radiation-induced heart disease (RIHD), including cardiomyopathy, pericarditis, coronary artery disease, valvular heart disease, and conduction system abnormalities. Furthermore, the development of RIHD is aggravated with the addition of chemotherapy. The screening, diagnosis, and follow-up for RIHD in patients who have undergone RT are described by the consensus guidelines from the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE). There is compelling evidence that chest RT can increase the risk of heart disease. Although the prevalence and severity of RIHD are likely to be reduced with modern RT techniques, the incidence of RIHD is expected to rise in cancer survivors who have been treated with old RT regimens. However, there remains a gap between guidelines and clinical practice. Currently, therapeutic modalities followed in the treatment of RIHD are similar to the non-irradiated population. Preventive measures mainly reduce the radiation dose and radiation volume of the heart. There is no concrete evidence to endorse the preventive role of statins, angiotensin-converting enzyme inhibitors, and antioxidants. This review summarizes the current evidence of RIHD subtypes and risk factors and suggests screening regimens, diagnosis, treatment, and preventive approaches.

The impact of COVID-19 pandemic on type A aortic dissection care

Funding Acknowledgements

Type of funding sources: None.

Introduction

COVID-19 created a challenging situation for cardiac surgery and associated acute care programs around the world. While non-urgent cases might be postponed, operating on life-threatening conditions, including type A aortic dissection (TAAD), must be sustained despite the ongoing pandemic. Therefore, we investigated the impact of the COVID-19 pandemic on our urgent aortic program.

Methods

36 individuals presenting with TAAD in a single centre were analysed from the pre-pandemic period (2019, n=16) and the pandemic era (2020, n=20). Retrospective data review was conducted on patient characteristics, TAAD presenting symptoms, operative techniques, postoperative outcomes and length of stay. A comparison was made between both eras applying appropriate testing methods, and a p-value <0.05 was considered statistically significant.

Results

A 25% increase in TAAD referrals occurred during the pandemic era. Patients were featured by younger age of presentation in contrast to Western data (pre-pandemic group: 47.6 ± 18.7, and the pandemic group: 50.6 ± 16.2 years, p=0.6) but showed similar male predominance (4:1) in both groups. There was no statistical difference in baseline comorbidities between the groups. Length of hospital and intensive care unit stays were comparable between both groups. Low rates of postoperative complications were registered in both groups with no significant between-group difference.

Conclusion

Emergent surgical management remains essential in patients with TAAD regardless of the pandemic. Furthermore, temporary structural departmental re-configuration and optimal personal protective equipment utilisation warrant maintained satisfactory outcomes in such critical healthcare scenarios.

Abstract 32: Temporal Trends And Drivers Of Growth In Heart Transplantation Volumes In A Globally Representative Sample

Background: The need to handle a growing number of advanced heart failure (HF) patients has fueled growth in heart transplantation (HT) activities and development of effective strategies to increase the availability of donors in the last two decades. The impact of these changes on global HT volumes has not been previously described.

Methods: Using data from the Global Observatory of Donation and Transplantation (GODT) for the years (2000-2019), we obtained the annual number of HT performed in each country per million population (PMP), number of brain-dead donors, and number of officially registered HT centers. We also identified WHO countries with sustained HT activities (HT data in ≥ 5 years). Data on health expenditures and on the prevalence of severe HF were collected from the World Health Expenditure and Global Burden of Disease (GBD) databases, respectively. Average annual percentage change (AAPC) in number of HT PMP was calculated using JoinPoint software. The contribution of the above-mentioned variables on change in HT volumes over time was determined using a linear mixed-effects regression model.

Results: In a sample of 55/194 countries with sustained HT activities, the absolute number of HT increased by 92% (from 4504 in 2000 to 8646 in 2019), or 0.05 to 0.09 HT PMP with an AAPC of 3.6% (95% CI [2.7, 4.5]) in HT/PMP. Temporal trends in HT volumes varied considerably among countries, such that as significant growth in HT was seen in 41 (74.5%) countries (AAPC 5.6%; 95% CI [5, 6.2]), while the remaining 14 countries experienced a decline (AAPC -0.7%; 95% CI [-1.1, -0.2]) ( Figure A ). In an adjusted model, donor availability, HF prevalence, and health expenditure, but not the number of HT centers, significantly predicted an increase in HT over time ( Figure B ).

Conclusion: Despite near doubling of HT worldwide in the last two decades, there remain unmet needs to face the growing burden of HF, specifically maximizing organ utilization in brain-dead donors.

Early impact of COVID-19 pandemic on heart transplant volumes in Asia and Oceania: results from the Global Observatory on Donation and Transplantation (GODT)

Funding Acknowledgements

Type of funding sources: None.

Introduction

Massive demand for healthcare services worldwide following the emergence of coronavirus disease 2019 (COVID-19) has limited the availability of healthcare resources needed for certain high-complexity procedures, including orthotopic heart transplantation (OHT). Whereas the negative impact of COVID-19 pandemic on several elective procedures has been well-documented, data on regional changes in OHT volumes after COVID-19 are limited. Therefore, we aimed to quantify the impact of COVID-19 pandemic on OHT volumes in Asia and Oceania.

Methods

Using data from the Global Observatory on Donation and Transplantation (GODT), the world"s most comprehensive source of data on organ donation and transplantation, we recorded the number of OHT procedures performed in years 2019 (pre-COVID-19 era) and 2020 (COVID-19 era). The analysis was limited to countries with reported OHT data within Asia and Oceania (Australia, China, India, Iran, Israel, Japan, New Zealand, Russian Federation, Saudi Arabia, Thailand, Turkey, and the United Arab Emirates). OHT rates were reported for each country per million population (PMP), and change in the COVID-19 era was reported as percentage of the pre-COVID-19 rates. The association of total COVID-19 cases with relative reduction in OHT was evaluated using linear regression.

Results

Across the Asia/Oceania region, number of OHT in COVID-19 era (median 0.64 procedures PMP, IQR 0.28, 2.15) was significantly lower compared with the pre-COVID-19 era (median 1.18 procedures PMP, IQR 0.49, 2.50), with a median change of -0.29 (IQR -0.70, -0.08; P = 0.04). The impact of COVID-19 on OHT was most pronounced in Turkey, United Arab Emirates, and India, where OHT volumes decreased by 75.4%, 60.8%, and 53%, respectively. Country-level reduction in OHT volumes was not associated with total number of COVID-19 cases during the year 2020 in that country (r = 0.31; P-value = 0.3).

Conclusion

The number of heart transplants during the early phase of COVID-19 pandemic significantly decreased in ­­­most countries of the Asia/Oceania region. Furthermore, the change in OHT volumes did not correlate with the total number of recorded COVID-19 cases, suggesting the pandemic’s impact on OHT numbers extended beyond limiting availability of resources. Identifying factors leading to OHT deferral during COVID-19 pandemic will advance our understanding of the pandemic’s true impact on the care of advanced heart failure patients in the region.

The association of preoperative dialysis with troponin trends and short term outcomes among advanced kidney disease patients undergoing coronary artery bypass grafting

Funding Acknowledgements

Type of funding sources: None.

Introduction

Coronary artery disease continues to be the leading cause of death in patients with stage IV-V chronic kidney disease (CKD IV-V). However, the prognosis and early outcomes for advanced CKD patients undergoing coronary artery bypass grafting (CAB) worsen as the estimated glomerular filtration rate (eGFR) deteriorates. Therefore, we compared postoperative clinical outcomes and troponin trends in patients having advanced CKD according to preoperative dialysis status in a single centre experience.

Methods

A total of 51 patients with CKD IV and V who underwent CAB between 2016-2021 were included in the study. Data on patient characteristics and postoperative outcomes were collected retrospectively, and independently for our Society of Thoracic Surgeons database. Characteristics were compared between patients having CKD IV vs. CKD V. The differences in postoperative cardiac troponin trends and outcomes were evaluated between patients who did vs. did not undergo preoperative dialysis. The statistical analysis was conducted applying appropriate parametric or non-parametric (for skewed variables) testing methods, and a p value &lt; 0.05 was considered to be statistically significant.

Results

47% (24) of subjects had CKD IV, while the rest featured CKD V. Patients with CKD IV tended to be older (61.8 ± 9.2 vs. 56.3 ± 11.5 years, p = 0.07), more obese (BMI: 31.4 ± 6.8, 27.4 ± 4.9 kg/m2, p = 0.02) and had significantly higher preoperative GFR (23 ± 4.9 vs. 9 ± 3.3 mL/min, p &lt; 0.001) (Table.1). When comparing patients who underwent preoperative dialysis vs. those who did not, troponin levels were the highest at 18h postoperative in both groups, however, troponin levels were comparable between both groups at all time points (Table.2). Although, there was no difference in hospital length of stay and mortality between these groups, patients who did not undergo preoperative dialysis had longer intensive care unit length of stay (ICU LOS).

Conclusion

In this single centre experience preoperative dialysis was not associated with a significant difference in trends of postoperative cardiac enzymes. Although preoperative dialysis was associated with shorter ICU LOS, complex pre-procedural surgical risk assessment remains paramount in reducing complications and mortality in this high-risk population. Abstract Figure.  Abstract Figure.

Description of cardiovascular imaging abnormalities among hospitalized COVID-19 patients with elevated cardiac biomarkers

Funding Acknowledgements

Type of funding sources: None.

Background and aims

Myocardial injury is commonly encountered among severely-ill COVID-19 patients. Underlying mechanisms, however, remain incompletely understood. Describing cardiovascular imaging (CVI) abnormalities in this population will provide additional insight into mechanisms of myocardial injury with COVID-19 and may potentially guide management for these patients. Therefore, we aimed to describe CVI abnormalities in COVID-19 patients with elevated  high-sensitivity cardiac troponin (hs-cTn).

Methods

Consecutive hospitalized COVID-19 patients (n = 694) between February and July 2020 were retrospectively identified, including 409 patients with available hs-cTn (≥14 ng/dL was considered abnormal) Abnormality with any CVI—including transthoracic echocardiography (TTE), cardiac CT angiography, cardiac MR or invasive coronary angiography (ICA)—were identified through review of electronic records.

Results

Hospitalized COVID-19 patients with abnormal hs-cTn (107/409; 26.2%) had more frequent utilization of CVI compared with those with normal hs-cTn (61.7% vs. 30.5%, OR:3.7, 95%CI [2.3,5.8]) or those without available hs-cTn data (61.7% vs. 29.9%, OR:3.8, 95%CI [2.4,6]). Most utilized CVI modalities were TTE (63/107; 58.9%) followed by ICA (6/107; 5.6%). Echocardiographic abnormalities detected include right or left ventricular systolic dysfunction (22%), pericardial effusion (11%), while coronary artery disease was identified in 83.3% of patients who underwent ICA.

Conclusion

In this single center experience, cardiac biomarker elevation in hospitalized COVID-19 patients was associated with a 3-fold increase in the likelihood of CVI utilization, most commonly TTE. Ventricular systolic dysfunction and severe coronary artery disease were commonly encountered in patients with abnormal hs-cTn. However, these results need to be interpreted in the context of inconsistent use of CVI in patients with elevated cardiac biomarkers, which may preclude arrival at definitive conclusions. Prospective studies with standardized use of CVI in high-risk COVID-19 patients are warranted to advance our understanding of cardiac toxicity with COVID-19.

Changes in aortic valve hemodynamics and ventricular functional measurements in patients undergoing transcatheter and surgical aortic valve replacement: a head-to-head comparison

Introduction

Both surgical and transcatheter aortic valve replacement are effective interventions for treatment of patients with severe aortic stenosis. Data from landmark randomized trials have shown comparable improvement in aortic valve hemodynamics and left ventricular remodeling. Whether similar patterns will be observed in real-world practice has not been completely investigated.

Purpose

To compare the impact of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) on short- and intermediate-term changes in aortic valve hemodynamics and left ventricular reverse-remodeling.

Methods

A total of 213 patients with severe AS were referred for TAVR (n=137) or SAVR (n=76) at a single center (August/ 2015-Feb/ 2021). Patient demographics and echocardiographic parameters of aortic valve stenosis severity were collected retrospectively. Changes over-time in aortic valve area, mean gradient, dimensionless index, left ventricular ejection fraction (EF), and ventricular septal thickness were examined using linear mixed models.

Results

Patients undergoing TAVR were older with higher STS risk scores and a greater burden of comorbidities (Table). Over a median follow-up of 13 months (IQR 4–31), both groups experienced a significant reduction in aortic valve mean gradient (25.7 mmHg with TAVR and 18.8 mmHg with SAVR), with no significant between-group difference (P=0.15). Aortic valve dimensionless index significantly increased in TAVR and SAVR groups (0.23 and 0.13, respectively) and was more pronounced in the TAVR group (P=0.01). Similarly, aortic valve area increased significantly in both groups (0.66 cm2 and 0.42 cm2, respectively) without a significant across-group difference (P=0.07). On the other hand, left ventricular ejection fraction did not change significantly over time (−0.61 and 1.15 EF points, respectively) with no significant between-group difference at 12 months (P=0.06). Ventricular septal thickness was significantly reduced in both groups, with no significant between group difference (P=0.4; Figure).

Conclusion

In this real-world experience, both TAVR and SAVR were associated with significant improvement in aortic valve hemodynamic parameters and modest reverse left ventricular remodeling. Furthermore, these changes were comparable with both modalities, adding to available evidence from randomized clinical trials on beneficial effects of both TAVR and SAVR.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Heart failure and COVID-19

Heart failure is a common disease state that can be encountered at different stages in the course of a COVID-19 patient presentation. New or existing heart failure in the setting of COVID-19 can present a set of unique challenges that can complicate presentation, management, and prognosis. A careful understanding of the hemodynamic and diagnostic implications is essential for appropriate triage and management of these patients. Abnormal cardiac biomarkers are common in COVID-19 and can stem from a variety of mechanisms that involve the viral entry itself through the ACE2 receptors, direct cardiac injury, increased thrombotic activity, stress cardiomyopathy, and among others. The cytokine storm observed in this pandemic can be a culprit in many of the observed mechanisms and presentations. A correct understanding of the two-way interaction between heart failure medications and the infection as well as the proposed COVID-19 medications and heart failure can result in optimal management. Guideline-directed medical therapy for heart failure should not be interrupted for theoretical concerns but rather based on tolerance and clinical presentation. Initiating specific cardiac or heart failure medications to prevent the infection or mitigate the disease is also not an evidence-based practice at this time. Heart failure patients on advanced therapies including those with heart transplantation will particularly benefit from involving the advanced heart failure team members in the overall management if they contract the virus.