Impact of the COVID-19 pandemic on hospitalizations for acute coronary syndromes: a multinational study

BACKGROUND

COVID-19 has challenged the health system organization requiring a fast reorganization of diagnostic/therapeutic pathways for patients affected by time-dependent diseases such as acute coronary syndromes (ACS).

AIM

To describe ACS hospitalizations, management, and complication rate before and after the COVID-19 pandemic was declared.

DESIGN

Ecological retrospective study. Methods: We analyzed aggregated epidemiological data of all patients > 18 years old admitted for ACS in twenty-nine hub cardiac centers from 17 Countries across 4 continents, from December 1st, 2019 to April 15th, 2020. Data from December 2018 to April 2019 were used as historical period.

RESULTS

A significant overall trend for reduction in the weekly number of ACS hospitalizations was observed (20.2%; 95% confidence interval CI [1.6, 35.4] P = 0.04). The incidence rate reached a 54% reduction during the second week of April (incidence rate ratio: 0.46, 95% CI [0.36, 0.58]) and was also significant when compared to the same months in 2019 (March and April, respectively IRR: 0.56, 95%CI [0.48, 0.67]; IRR: 0.43, 95%CI [0.32, 0.58] p < 0.001). A significant increase in door-to-balloon, door-to-needle, and total ischemic time (p <0.04 for all) in STEMI patents were reported during pandemic period. Finally, the proportion of patients with mechanical complications was higher (1.98% vs. 0.98%; P = 0.006) whereas GRACE risk score was not different.

CONCLUSIONS

Our results confirm that COVID-19 pandemic was associated with a significant decrease in ACS hospitalizations rate, an increase in total ischemic time and a higher rate of mechanical complications on a international scale.

Post-COVID-19 syndrome: prospective evaluation of clinical and functional outcomes

Introduction

Coronavirus disease 2019 (COVID-19) is a highly pathogenic coronavirus characterized by by systemic inflammatory response with endothelial damage and a dysregulated coagulation system. Despite most patients survive the acute setting of COVID-19, their long-term clinical sequelae are highly unclear. We have sought to identify the impact of post-COVID-19 syndrome on mid-term follow-up and gain some additional insights about the potential explanation for persistence of dyspnea.

Methods

This is a 3-month prospective cohort study of previously hospitalised COVID-19 patients recruited from a single Spanish center, a small outpatient group without prior hospitalisation was also evaluated. Patients underwent serial testing with cardio-pulmonary exercise test (CPET), transthoracic echocardiogram, pulmonary lung test, six-minute walking test, serum biomarker analysis and quality of life questionaries. They were classify according to the presence of persistent dyspnea. Primary study outcome was predicted peak oxygen consumption (V02) according to CPET and predicted carbon monoxide diffusion capacity.

Results

Our study included 41 (58.6%) patients with dyspnea and 29 (41.4%) asymptomatic. Symptomatic patients had a higher proportion of females (73.2% vs. 51.7%), but comparable age and prevalence of cardiovascular risk factors. We did not observe differences among the assessed variables in transthoracic echocardiogram and pulmonary function test. Patients who referred dyspnea had smaller predicted peak O2 consumption (77.8 [64–92.5] vs. 99 [88–105]: p&lt;0.001), total distance in the 6-minute walking test (535 [467–600] vs. 611 [550–650] meters; p=0.001), and quality of life (KCCQ-23 60.1±18.6 vs. 82.8±11.3; p&lt;0.001). Additionally, abnormalities in CPET were suggestive of a ventilation/perfusion misthmach or hyperventilatory syndrome characterized by impaired ventilatory efficiency with a greater VE/VCO2 slope (32 [28.1–37.4] vs. 29.4 [26.9–31.4]; p=0.022) and low PETCO2 (34 [32–39] vs. 38 [36–40]; p=0.025).

Interpretation

In this study &gt;50% of COVID-19 survivors present a symptomatic functional impairment irrespective of age or prior hospitalization. Compared to asymptomatic patients, among those who referred dyspnea our findings suggest potential ventilatory inefficiency.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Gerencia Regional de Salud de Castilla y Leόn; Grant from the Spanish Society of Cardiology Tabla de resultados

Differences between Takotsubo and the working diagnosis of myocardial infarction with non-obstructive coronary arteries

Aims

Whether Takotsubo syndrome (TTS) should be classified within myocardial infarction with non-obstructive coronary arteries (MINOCA) is still controversial. The aim of this work was to evaluate the main differences between TTS and non-TTS MINOCA.

Methods and results

A cohort study based on two prospective registries: TTS from the XXXX1 registry (N:1055) and non-TTS MINOCA patients from contemporary records of acute myocardial infarction from 5 national centers (N:1080). Definitions and management recommended by the ESC were used. Survival analysis was based on Cox regression; propensity score matching was created to adjust prognostic variables.

TTS were more often women (85.9% vs. 51.9%; p&lt;0.001) and older (69.4±12.5 vs. 64.5±14.1 years; p&lt;0.001). Atrial fibrillation was more frequent in non-TTS MINOCA (10.4% vs. 14.4%; p 0.007). Psychiatric disorders were more prevalent in TTS (15.5% vs. 10.2%, p&lt;0.001). In-hospital mortality and complications were higher in TTS: 3.4 vs 1.8%, (p 0.015) and 25.8% vs. 11.5%, (p&lt;0.001).

Median follow-up was 32.4 months; TTS had less major adverse cardiovascular events (MACE): Hazard Ratio (HR) 0.59; 95% confidence interval (CI) 0.42 to 0.83. There were no differences in global mortality (HR 0.87; CI: 0.64 to 1.19), but TTS had lower cardiovascular mortality (HR 0.58; CI: 0.35 to 0.98).

Conclusions

Compared to the rest of MINOCA, TTS presents a different patient profile and a more aggressive acute phase. However, its long-term cardiovascular prognosis is better. These results support that TTS should be considered a separate entity with unique characteristics and prognosis.

Funding Acknowledgement

Type of funding sources: None. Central Illustration

Long-term prognostic impact of renin-angiotensin system blockade in tako-tsubo syndrome

Introduction

Medical therapy in TakoTsubo Syndrome (TTS) remains mainly empirical, given the lack of randomized studies evaluating different pharmacological strategies.

The prognostic benefit of angiotensin-converting-enzyme inhibitors and angiotensin II receptor blocker (ACEI/ARB) is not well established. The clinical data published so far are often based on small sample registries and offer opposite results, both in terms of survival and TTS recurrence.

Expert recommendations seem favorable to the prescription of ACEI and ARB. Nevertheless, clinical investigation is encouraged for validating the observed results.

Purpose

The aim of our study was to evaluate the long-term prognostic impact of renin-angiotesin blockers (ACEI or ARB) in terms of mortality and TTS recurrence.

Methods

The data analyzed in this study were obtained from the nationwide registry “RETAKO”. It included TTS post-discharge survivors, between January 1, 2003, and July 31, 2018. A total of 1062 patients were included for analysis. Cox regression analysis and inverse probability weighting (IPW) propensity score analysis were performed to asses the prognostic benefit of ACEI/ARB. Primary endpoint was a composite outcome of all-cause mortality and TTS recurrence.

Results

A total of 1062 TTS patients were included. ACEI or ARB were used in 639 patients (60.2%). During a mean follow-up of 2.7±3.5 years, there were 101 deaths (3.9 per 100 patients/year) and 34 recurrences of TTS (1.3 per 100 patients/year). We found no significant difference in follow-up mortality or TTS recurrence in unadjusted and adjusted Cox regression analysis (Hazard Ratio [HR] 0.69, 95% Confidence Interval [CI] 0.47–1.02) between patients treated and untreated with ACEI/ARB. After performing propensity score matching, differences in long term prognosis (all-cause mortality or recurrence) remained no statistically significant (HR 0.73, 95% CI 0.45–1.18).

Conclusions

In this observational study, we found that ACEI and ARB therapy was not significantly associated with improved long term survival free of recurrence in post-discharged TTS patients.

Funding Acknowledgement

Type of funding sources: None. Incidence of primary endpoint

Prognostic factors at admission on patients with cancer and COVID-19: Analysis of HOPE registry data

Background

Previous works seem to agree in the higher mortality of cancer patients with COVID-19. Identifying potential prognostic factors upon admission could help identify patients with a poor prognosis.

Methods

We aimed to explore the characteristics and evolution of COVID-19 cancer patients admitted to hospital in a multicenter international registry (HOPE COVID-19).

Our primary objective is to define those characteristics that allow us to identify cancer patients with a worse prognosis (mortality within 30 days after the diagnosis of COVID-19).

Results

5838 patients have been collected in this registry, of whom 770 had cancer among their antecedents. In hospital mortality reached 258 patients (33.51%). The median was 75 years (65–82). Regarding the distribution by sex, 34.55% of the patients (266/770) were women.

The distribution by type of cancer: genitourinary 238/745 (31.95%), digestive 124/745 (16.54%), hematologic 95/745 (12.75%).

In multivariate regression analysis, factors that are independently associated with mortality at admission are: renal impairment (OR 3.45, CI 97.5% 1.85–6.58), heart disease (2.32, 1.47–3.66), liver disease (4.69, 1.94–11.62), partial dependence (2.41, 1.34–4.33), total dependence (7.21, 2.60–21.82), fatigue (1.84, 1.16–2.93), arthromialgias (0.45, 0.26–0.78), SatO2 < 92% (4.58, 2.97–7.17), elevated LDH (2.61, 1.51–4.69) and abnormal decreased Blood Pressure (3.57, 1.81–7.15). Analitical parameters are also significant altered.

Conclusion

In patients with cancer from the HOPE registry, 30-day mortality from any cause is high and is associated with easily identifiable clinical factors upon arrival at the hospital. Identifying these patients can help initiate more intensive treatments from the start and evaluate the prognosis of these patients.

Prognostic factors at admission on patients with cancer COVID-19: Analysis of hope registry data

Background

Previous works seem to agree in the higher mortality of cancer patients with COVID-19. Identifying potential prognostic factors upon admission could help identify patients with a poor prognosis.

Methods

We aimed to explore the characteristics and evolution of COVID-19 cancer patients admitted to hospital in a multicenter international registry (HOPE COVID-19).

Our primary objective is to define those characteristics that allow us to identify cancer patients with a worse prognosis (mortality within 30 days after the diagnosis of COVID-19).

Results

5838 patients have been collected in this registry, of whom 770 had cancer among their antecedents. In hospital mortality reached 258 patients (33.51%). The median was 75 years (65–82). Regarding the distribution by sex, 34.55% of the patients (266/770) were women.

The distribution by type of cancer: genitourinary 238/745 (31.95%), digestive 124/745 (16.54%), hematologic 95/745 (12.75%).

In multivariate regression analysis, factors that are independently associated with mortality at admission are: renal impairment (OR 3.45, CI 97.5% 1.85–6.58), heart disease (2.32, 1.47–3.66), liver disease (4.69, 1.94–11.62), partial dependence (2.41, 1.34–4.33), total dependence (7.21, 2.60–21.82), fatigue (1.84, 1.16–2.93), arthromialgias (0.45, 0.26–0.78), SatO2 < 92% (4.58, 2.97–7.17), elevated LDH (2.61, 1.51–4.69) and abnormal decreased Blood Pressure (3.57, 1.81–7.15). Analitical parameters are also significant altered.

Conclusion

In patients with cancer from the HOPE registry, 30-day mortality from any cause is high and is associated with easily identifiable clinical factors upon arrival at the hospital. Identifying these patients can help initiate more intensive treatments from the start and evaluate the prognosis of these patients.

Shall be takotsubo tear apart from working diagnosis of myocardial infarction with non-obstructive coronary arteries?

Aims

Whether Takotsubo syndrome (TTS) should be classified within myocardial infarction with non-obstructive coronary arteries (MINOCA) is still controversial. The aim of this work is to evaluate main differences between TTS and non-TTS MINOCA.

Methods and results

A cohort study based on two prospective registries: TTS from the RETAKO registry (N:1055) and non-TTS MINOCA patients from contemporary records of acute myocardial infarction from 5 national centres (N:1080). Definitions and management recommended by the ESC were used. Survival analysis was based on Cox regression; propensity score matching was created to adjust prognostic variables.

TTS were more often women (85.9% vs. 51.9%; p&lt;0.001) and older (69.4±12.5 vs. 64.5±14.1 years; p&lt;0.001). Atrial fibrillation was more frequent in non-TTS MINOCA (10.4% vs. 14.4%; p 0.007). Psychiatric disorders were more prevalent in TTS (15.5% vs. 10.2%, p&lt;0.001). In-hospital mortality and complications were higher in TTS: 3.4 vs 1.8%, (p 0.015) and 25.8% vs. 11.5%, (p&lt;0.001).

Median follow-up was 32.4 months; TTS had less major adverse cardiovascular events (MACE): Hazard Ratio (HR) 0.59; 95% confidence interval (CI) 0.42 to 0.83. There were no differences in total mortality (HR 0.87; CI: 0.64 to 1.19), but TTS had lower cardiovascular mortality (HR 0.58; CI: 0.35 to 0.98).

Conclusions

TTS has a different patient's profile and a more aggressive acute phase than the rest of MINOCA. However, its long-term cardiovascular prognosis is better. These results support that TTS should be considered a distinct entity with unique characteristics and prognosis.

Funding Acknowledgement

Type of funding source: None

Long-term prognostic benefit of beta-blockers use after discharge in patients with Tako-Tsubo syndrome

Background

Tako-tsubo Syndrome (TS) seems to be associated with a catecholamine-mediated mechanism. However, the impact of beta-blockers (BB) in-hospital and after discharge still remain uncertain. Objectives: The purpose of the study was to examine whether BB use after discharge in patients with TS, was associated with lower long-term mortality and recurrence.

Methods

Using a national multicentre large-scale inpatient database (RETAKO Registry), we analysed patients with a definitive TS diagnosis.

Results

A total of 970 patients were analysed (568 with BB therapy and 402 no-BB therapy). After discharge and over a median of follow-up of 1.1 years, treatment with BB have no shown prognostic effectiveness in terms of mortality and TS recurrence in unadjusted and adjusted Cox analysis (HR 0.86; 95% CI: 0.59 to 1.27; and 0.95; 95% CI: 0.57–1.13, respectively).

Conclusions

This data suggests that use of beta-blockers after hospital discharge has not shown long-term prognostic benefit in patients with Tako-tsubo Syndrome.

Prognostic impact of BB in TS.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Retako webpage was funded by a non-conditioned Astrazeneca scholarship.

Electrocardiographic characteristics and associated outcomes in patients with Takotsubo syndrome. Insights from the RETAKO registry

Background

Our aim was to describe the prevalence and prognostic significance of electrocardiographic features in patients with Takotsubo syndrome (TTS).

Methods

Our data come from the Spanish Multicenter REgistry of TAKOtsubo syndrome (RETAKO). All patients with complete electrocardiogram were included.

Results

246 patients were studied, mean age was 71.3±11.5 and 215 (87.4%) were women. ST-segment elevation was seen in 143 patients (59.1%) and was present in ≥2 wall leads in 97 (39.8%). Exclusive elevation in inferior leads was infrequent (5 - 2.0%). After 48 hours, 198 patients (88.0%) developed negative T-waves in a median of 8 leads with a mean amplitude of 0.7±0.5 mV. Mean corrected QT interval was 520±72 ms and it was independently associated with the primary endpoint of all-cause death and nonfatal cardiovascular events (p=0.002) and all-cause death (p=0.008). A higher heart rate at admission was also an independent predictor of the primary endpoint (p=0.001) and of developing acute pulmonary edema (p=0.04). ST-segment elevation with reciprocal depression was an independent predictor of all-cause death (p=0.04). Absence of ST-segment deviation was a protective factor (p=0.005) for the primary endpoint. Arrhythmias were independently associated with cardiogenic shock (p&lt;0.001).

Conclusion

Prolonged corrected QT interval, arrhythmia, heart rate at admission and broader repolarization alterations are associated with a poor outcome in TTS.

Typical ECG at admission and after 48h.

Funding Acknowledgement

Type of funding source: None

A new era of ventricular assist device surgery: less invasive procedures

As the number of patients suffering of congestive heart failure is rising worldwide, the use of mechanical circulatory support to treat these patients has also grown enormously, surpassing the number of annual heart transplants. Moreover latest generation of left ventricular assist devices (LVADs) is characterized by improved technologies. Moreover the size of new LVAD systems is considerably reduced when compared to older generation devices. Therefore, less invasive surgery is now possible for the implantation, explantation, and exchange of LVADs. Although experience with these new techniques is still limited, minimally invasive procedures are thought to improve surgical outcomes by declining the rates of operative complications such as bleeding or wound infection. The miniaturization of LVADs will continue, so that minimally invasive techniques will be used for most LVAD-related procedures in the future. In this article, we summarize and describe minimally invasive surgical techniques, with a focus on the most common LVAD systems in adults.