Cardiovascular manifestations secondary to COVID-19: A narrative review

The coronavirus disease 2019 (COVID-19) pandemic has spread rapidly, becoming a major threat to global health. In addition to having required the adaptation of healthcare workers for almost 2 years, it has been much talked about, both in the media and among the scientific community. Beyond lung damage and respiratory symptoms, the involvement of the cardiovascular system largely explains COVID-19 morbimortality. In this review, we emphasize that cardiovascular involvement is common and is associated with a worse prognosis, and that earlier detection by physicians should lead to better management. First, direct cardiac involvement will be discussed, in the form of COVID-19 myocarditis, then secondary cardiac involvement, such as myocardial injury, myocardial infarction and arrhythmias, will be considered. Finally, worsening of previous cardiovascular disease as a result of COVID-19 will be examined, as well as long-term COVID-19 effects and cardiovascular complications of COVID-19 vaccines.

Cardiovascular Comorbidities and Covid-19 in Women

Background

While women account for 40-50 % of patients hospitalized for coronavirus disease 2019 (Covid-19), no specific data have been reported in this population.

Purpose

Assess the burden of cardiovascular comorbidities on outcomes in women hospitalized for Covid-19.

Methods

We conducted a retrospective observational multicenter study from February 26 to April 20, 2020 in 24 French hospitals including all adults admitted for Covid-19. Primary composite outcome included transfer to intensive care unit (ICU) or in-hospital death.

Results

Among 2878 patients hospitalized for Covid-19, 1212 (42.1 %) were women. Women were significantly older (68.3 ± 18.0 vs. 65.4 ± 16.0 years, P < 0.001) but had less prevalent cardiovascular comorbidities than men. Among women, 276 (22.8 %) experienced the primary outcome, including 161 (13.3 %) transfer to ICU and 115 (9.5 %) deaths without transfer to ICU. The survival free from death or transfer to ICU was higher in women (HR 0.63, 95 %CI 0.53-0.73, P < 0.001), whereas the observed difference in in-hospital deaths did not reach statistical significance (P = 0.18). The proportion of women that experienced the primary outcome were 37.8 % in women with heart failure (n = 112), 30.9 % in women with coronary artery disease (n = 81), 29.1 % in women with diabetes (n = 254), 26.1 % in women with dyslipidemia (n = 315), and 26.0 % in women with hypertension (n = 632). Age (HR 1.05, 5 years increments, 95 %CI 1.01-1.10), body mass index (HR 1.06, 2 units increments, 95 %CI 1.02-1.10), chronic kidney disease (HR 1.57, 95 %CI 1.11-2.22), and heart failure (HR 1.52, 95 %CI 1.04-2.22) were independently associated with the primary outcome (Fig. 1).

Conclusions

Women hospitalized for Covid-19 were older and had less prevalent cardiovascular comorbidities than men. While female sex was associated with a lower risk of transfer to ICU or in-hospital death, Covid-19 remains associated with considerable morbi-mortality in women, especially in those with cardiovascular diseases.

Pulmonary Embolism in Covid-19 patients: A French Multicentre Cohort Study

Background

While pulmonary embolism (PE) appears to be a major issue in Covid-19, data remain sparse.

Purpose

We aimed to describe the risk factors and baseline characteristics of patients with PE in a large cohort of Covid-19 patients.

Methods

In a retrospective multicentric observational study, we included consecutive hospitalised patients for Covid-19. Patients without computed tomography pulmonary angiography (CTPA)-proven PE diagnosis, those who were directly admitted to an intensive care unit (ICU), and those still hospitalised without PE experience were excluded.

Results

Among 1240 patients (58.1% men, mean age 64 ± 17 years), 103 (8.3%) patients had PE confirmed by CTPA. The ICU transfer requirement and mechanical ventilation requirement were significantly higher in the PE group (P < 0.001 and P < 0.001, respectively). In an univariable analysis, traditional venous thromboembolic risk factors were not associated with PE (P > 0.05), while patients under therapeutic-dose anticoagulation before hospitalisation or prophylaxis-dose anticoagulation introduced during hospitalisation had lower PE occurrence (OR 0.40, 95%CI(0.14-0.91); P = 0.04 and OR 0.11, 95%CI(0.06-0.18); P < 0.001, respectively). In a multivariable analysis, the following variables (also statistically significant in univariable analysis) were associated with PE: male gender (OR 1.03, 95%CI(1.003-1.069); P = 0.04), anticoagulation with prophylaxis-dose (OR 0.83, 95%CI(0.79-0.85), P < 0.001) or therapeutic-dose (OR 0.87, 95%CI(0.82-0.92), P < 0.001), C-reactive protein (OR 1.03, 95%CI(1.01-1.04), P = 0.001) and time from symptom onset to hospitalisation (OR 1.02, 95%CI(1.006-1.038), P = 0.002) (Table 1).

Conclusion

Pulmonary embolism risk factors in Covid-19 context do not include traditional thromboembolic risk factors but rather independent clinical and biological findings at admission, including a major contribution to inflammation.

P2558PDE4 regulates cardiac pacemaker function

Background

Numerous epidemiological and clinical studies have revealed a positive correlation between heart rate (HR) and cardiovascular morbimortality. The autonomic nervous system is the major extracardiac determinant of HR. During sympathetic stimulation, the activation of β-adrenergic receptors (βAR) induces an increase in cAMP levels, leading to positive chronotropic effect. Among the 5 cardiac cAMP-PDE families, PDE4 is critical for controlling excitation-contraction coupling (ECC) during βAR stimulation in atrial and ventricular cells. PDE4 may also be important for automaticity. 3 genes encode for PDE4s: pde4a, pde4b, pde4d. Their respective contribution to the regulation of pacemaker activity remains ill-defined.

Purpose

Define the role of PDE4 isoforms in the regulation of cardiac pacemaker activity

Methods

Total PDE activity was determined in mouse sinoatrial node (SAN) tissue as the cAMP-hydrolytic activity measured in the absence of PDE inhibitor and the fraction corresponding to PDE4 activity was assessed by including the PDE4 inhibitor Ro-20-1724. The in vitro pacemaker activity was assessed by measuring spontaneous Ca2+ transients in Fluo4-loaded-SAN tissue. Images were obtained using confocal microscopy.

Results

Ro-20-1724 increased beating rate of intact SAN and increased PKA-phosphorylation of key ECC actors (ryanodine receptor, phospholamban and contractile proteins). PDE4 activity was found to account for 60% of the total cAMP-PDE activity in SAN (n=3 independent experiments). PDE4A, PDE4B and PDE4D isoforms were found to be expressed in mouse SAN (n=5 independent experiments). In PDE4D-, but not in PDE4B-deficient mice, Ca2+ homeostasis was altered in control conditions (ctrl) and after βAR stimulation with isoprenaline (iso). Indeed, ablation of PDE4D induced decreased beating rate (ctrl: 1.00±0.08 s–1 vs 1.57±0.05 s–1; iso: 1.71±0.17 s–1 vs 2.39±0.08 s–1, p<0.0001) and increased Ca2+ spark frequency (ctrl: 15.9±5.2 sparks/s/100 μm vs 1.9±0.4 sparks/s/100 μm; iso: 22.9±7.1 sparks/s/100 μm vs 0.6±0.2 sparks/s/100 μm, p<0.0001) (Figure).

Calcium Homeostasis in SAN cells

Conclusion

PDE4 controls pacemaker function in mice and PDE4D ablation strongly perturbs normal SAN activity.

Acknowledgement/Funding

ANR, Fondation Lefoulon Delalande, CORDDIM

P5679Utility of late iodine enhancement computed tomography with image subtraction in the evaluation of cardiac resynchronization therapy response

Background

Despite the impressive results of the large CRT trials, it has been observed that, on an individual basis, about 30% of patients fail to respond to cardiac resynchronization therapy (CRT). The evaluation of left ventricular (LV) dyssynchrony, myocardial scar, and coronary venous anatomy by image subtraction in Late Iodine Enhancement Computed Tomography (LIE-CT) has the potential to comprehensively characterize non-responders.

Purpose

To assess the feasibility and the utility of image subtraction in LIE-CT in CRT patients and compare findings between responders and non-responders.

Methods

Monocentric prospective study of CRT patients at least 6 months after implantation who underwent post-procedural CT between March and October 2018. CRT-responders were defined as patients with an absolute increase in LV ejection fraction >5%.

CT-derived residual global and segmental dyssynchrony metrics, extent and location of myocardial scar, coronary venous anatomy, and position of LV lead relative to scar and segment of latest mechanical contraction were analyzed.

Results

Among the 29 patients (mean age 71±12 years; 72% men), 18 were responders (62%). All CT metrics evaluating residual dyssynchrony such as wall motion indexand wall thickness indexwere worse in non-responders (p<0.0001 for both). In LIE-CT, predictive factors of CRT-non-response were an LV lead localized in an region of myocardial scar (p=0.0007), in a region with akinesia or dyskinesia (p=0.007), and with myocardial thickness <6mm (p=0.002). Percentage of fibrosis of the myocardial mass and the presence of fibrosis in postero-lateral region were not predictive of CRT-non-response (p=0.9 and p=0.3, respectively). Of the 11 non-responder patients, 8 (73%) had at least one other coronary venous branch visualized by CT; and among those, 3 (38%) were located in an non-akinetic area with late segmental contraction.

Wall Motion and LIE-CT

Conclusion

Image subtraction in LIE-CT in patients who had CRT is feasible and allows better characterization of CRT-non-responders, who have a greater amount of residual dyssynchrony than responders. Distribution of fibrosis in relation to the LV lead and presence of alternative venous branches may help patient management.

[Pulmonary embolism as a complication of nephrotic syndrome--case report and therapeutic management]

A case of a 41-year-old man, who was treated due to severe steroid and immunoresistant nephrotic syndrome is described. During the pulsed steroid therapy the patient underwent a pulmonary embolism and developed the post-infarction cavern and abscess of the lung. In this study the case history, complications, diagnostic procedures and therapeutic management were described. The probable mechanism of the described complications was carefully discussed.