Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Diagnostic accuracy of on-site coronary computed tomography-derived fractional flow reserve in the diagnosis of stable coronary artery disease

PURPOSE

Invasive fractional flow reserve (FFR), the reference standard for identifying significant coronary artery disease (CAD), can be estimated non-invasively by computed tomography-derived fractional flow reserve (CT-FFR). Commercially available off-site CT-FFR showed improved diagnostic accuracy compared to coronary computed tomography angiography (CCTA) alone. However, the diagnostic performance of this lumped-parameter on-site method is unknown. The aim of this cross-sectional study was to determine the diagnostic accuracy of on-site CT-FFR in patients with suspected CAD.

METHODS

A total of 61 patients underwent CCTA and invasive coronary angiography with FFR measured in 88 vessels. Significant CAD was defined as FFR and CT-FFR below 0.80. CCTA with stenosis above 50% was regarded as significant CAD. The diagnostic performance of both CT-FFR and CCTA was assessed using invasive FFR as the reference standard.

RESULTS

Of the 88 vessels included in the analysis, 34 had an FFR of ≤ 0.80. On a per-vessel basis, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 91.2%, 81.4%, 93.6%, 75.6% and 85.2% for CT-FFR and were 94.1%, 68.5%, 94.9%, 65.3% and 78.4% for CCTA. The area under the receiver operating characteristic curve was 0.91 and 0.85 for CT-FFR and CCTA, respectively, on a per-vessel basis.

CONCLUSION

On-site non-invasive FFR derived from CCTA improves diagnostic accuracy compared to CCTA without additional testing and has the potential to be integrated in the current clinical work-up for diagnosing stable CAD.

Coronary CT angiography for suspected acute coronary syndrome: sex-associated differences

Aim

The optimal diagnostic test in the work-up of suspected acute coronary syndrome (ACS) may differ between men and women. The aim of this study was to compare sex-associated differences between using a diagnostic strategy including early coronary computed tomography angiography (CCTA) and standard of care (SOC).

Methods

In total, 500 patients who presented with symptoms suggestive of ACS at the emergency department were randomised between a diagnostic strategy supplemented with early CCTA and SOC.

Results

Women were generally older than men (mean ± standard deviation 56 ± 10 vs 53 ± 10 years, p < 0.01) and were less often admitted to hospital (33% vs 44%, p = 0.02). Obstructive coronary artery disease on CCTA (> 50% luminal narrowing) was less frequently seen in women (14% vs 26%, p = 0.02), and ACS was diagnosed less often in women (5% vs 10%, p = 0.03). Women underwent less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS (p = 0.008).

Conclusion

Women had a lower incidence of obstructive CAD on CCTA and were less often admitted to hospital than men. They were subjected to less outpatient testing when early CCTA was used in the emergency department evaluation of suspected ACS.

Supplementary Information

The online version of this article (10.1007/s12471-021-01607-1) contains supplementary material, which is available to authorized users.

ONCOR: design of the Dutch cardio-oncology registry

BACKGROUND

The relative new subspecialty 'cardio-oncology' was established to meet the growing demand for an interdisciplinary approach to the management of cancer therapy-related cardiovascular adverse events. In recent years, specialised cardio-oncology services have been implemented worldwide, which all strive to improve the cardiovascular health of cancer patients. However, limited data are currently available on the outcomes and experiences of these specialised services, and optimal strategies for cardio-oncological care have not been established.

AIM

The ONCOR registry has been created for prospective data collection and evaluation of cardio-oncological care in daily practice.

METHODS

Dutch hospitals using a standardised cardio-oncology care pathway are included in this national, multicentre, observational cohort study. All patients visiting these cardio-oncology services are eligible for study inclusion. Data collection at baseline consists of the (planned) cancer treatment and the cardiovascular risk profile, which are used to estimate the cardiotoxic risk. Information regarding invasive and noninvasive tests is collected during the time patients receive cardio-oncological care. Outcome data consist of the incidence of cardiovascular complications and major adverse cardiac events, and the impact of these events on the oncological treatment.

DISCUSSION

Outcomes of the ONCOR registry may aid in gaining more insight into the incidence of cancer therapy-related cardiovascular complications. The registry facilitates research on mechanisms of cardiovascular complications and on diagnostic, prognostic and therapeutic strategies. In addition, it provides a platform for future (interventional) studies. Centres with cardio-oncology services that are interested in contributing to the ONCOR registry are hereby invited to participate.

Added value of computed tomography fractional flow reserve in the diagnosis of coronary artery disease

Multiple non-invasive tests are performed to diagnose coronary artery disease (CAD), but all are limited to either anatomical or functional assessments. Computed tomography derived Fractional Flow Reserve (CT-FFR) based on patient-specific lumped parameter models is a new test combining both characteristics simulating invasive FFR. This study aims to evaluate the added value of CT-FFR over other non-invasive tests to diagnose CAD. Patients with clinical suspicion of angina pectoris between 2010 and 2011 were included in this cross-sectional study. All underwent stress electrocardiography (X-ECG), SPECT, CT coronary angiography (CCTA) and CT-FFR. Invasive coronary angiography (ICA) and FFR were used as reference standard. Five models mimicking the clinical workflow were fitted and the area under receiver operating characteristic (AUROC) curve was used for comparison. 44% of the patients included in the analysis had a FFR of ≤ 0.80. The basic model including pre-test-likelihood and X-ECG had an AUROC of 0.79. The SPECT-strategy had an AUROC of 0.90 (p = 0.008), CCTA-strategy of 0.88 (p < 0.001), 0.93 when adding CT-FFR (p = 0.40) compared to 0.94 when combining CCTA and SPECT. This study shows adding on-site CT-FFR based on patient-specific lumped parameter models leads to an increased AUROC compared to the basic model. It improves the diagnostic work-up beyond SPECT or CCTA and is non-inferior to the combined strategy of SPECT and CCTA in the diagnosis of hemodynamically relevant CAD.

Diagnostic performance and clinical implications for enhancing a hybrid quantitative flow ratio and fractional flow reserve revascularization decision making strategy

Background

Fractional flow reserve (FFR) adoption persists low mainly due to procedural and operator related factors as well as costs. An alternative for FFR, quantitative flow ratio (QFR) achieves a high accuracy mainly outside the intermediate zone without the need for hyperemia and wire-use. Currently, no outcome trials assess the role of QFR in the guidance of revascularization. Therefore, we evaluate a QFR-FFR hybrid strategy in which FFR is measured inside of the intermediate zone.

Methods

This retrospective multi-center study included consecutive patients who underwent both invasive coronary angiography and FFR in the participating centers. QFR was calculated for all vessels in which FFR was measured. Diagnostic performance of QFR was assessed using an FFR cut-off of 0.80 as reference standard. The QFR-FFR hybrid approach was modeled using the intermediate zone of 0.77 to 0.87 assuming that lesions within the intermediate zone follow the FFR binary cutoff.

Results

In total, 381 vessels in 289 patients were analyzed. The sensitivity, specificity and accuracy on a per vessel-based analysis were 84.6%, 86.3% and 85.6% for QFR and 91.1%, 95.3% and 93.4% for the QFR-FFR hybrid approach. The diagnostic accuracy of QFR-FFR hybrid strategy with invasive FFR measurement is 93.4% and results in a FFR reduction of 56.7%.

Conclusion

QFR has a good correlation and agreement with invasive FFR and a high diagnostic accuracy. A hybrid QFR-FFR approach could extend the use of QFR and reduces the proportion of invasive FFR-measurements needed while maintaining a high accuracy.

Hybrid QFR-FFR strategy

Funding Acknowledgement

Type of funding source: None

P6176Added value of computed tomography fractional flow reserve (FFRCT) in the diagnosis of coronary artery disease (CAD)

Purpose

Multiple non-invasive tests are performed as part of the standard protocol to diagnose CAD, but all are limited to either anatomical or functional assessments. FFRCT is a new non-invasive test that combines anatomical and functional characteristics based on the principles of invasive FFR. This study aims to evaluate the added value of FFRCT beyond the currently used tests.

Methods

Patients having the clinical suspicion of angina pectoris between 2010 and 2011 were included in this cross-sectional study. All underwent exercise stress electrocardiography (X-ECG), SPECT, CT coronary angiography (CCTA) and FFRCT as part of the Horoscope study. Invasive coronary angiography (ICA) and FFR were used as reference standard. Missing values were multiple imputed and five combined models mimicking the clinical workflow were fitted. The area under the receiver operating characteristic (AUROC) curve and Akaike Information Criteria (AIC) were used for comparison.

Results

89 (44%) of the 202 patients included in the analysis had a FFR of ≤0.80, while positive tests were found for X-ECG, SPECT, CCTA and FFRCT in 41%, 47%, 53% and 50% of the cases. The model including pre-test-likelihood and X-ECG had an AUROC of 0.78 (AIC: 236), which significantly increases to 0.89 by adding SPECT (AIC: 170), to 0.87 by adding CCTA (AIC: 191), to 0.92 when adding FFRCT (AIC: 155) and to 0.94 when adding CCTA and SPECT (AIC: 1 40).

ROC-curves for all diagnostic models Model 1 Model 2 Model 3 Model 4 Model 5 Basic model + SPECT + CCTA + CCTA + FFRCT +SPECT + CCTA AIC 236.0 169.8 190.8 154.5 140.1 AUC 0.78 0.89 0.87 0.92 0.94 ROC-curves for all diagnostic models and its AIC and AUC. FFRCT has an improved AUC compared to the basic model and the models including SPECT or CCTA alone, while its AIC is decreased. The model including both SPECT and CCTA has the highest AUC and the lowest AIC and seems therefore the preferable strategy.

ROC curve

Conclusion

This study shows adding FFRCT leads to an increased AUROC and a decreased AIC compared to the basic model. It therefore improves the diagnostic work-up beyond SPECT or CCTA alone in the diagnosis of CAD.

Global longitudinal strain to predict left ventricular dysfunction in asymptomatic patients with severe mitral valve regurgitation: literature review

The optimal treatment strategy for asymptomatic patients with severe mitral valve regurgitation (MR) and preserved left ventricular (LV) function is challenging. This manuscript reviews the available literature on the value of left ventricular global longitudinal strain (LV-GLS) in predicting LV dysfunction after mitral valve surgery in these patients and discusses its current place in the treatment strategy. Studies were identified from Cochrane Library, SCOPUS, PubMed and Web of Science up to February 2018. The domain used was MR. The determinant was LV-GLS; other methods of deformation imaging were excluded. The examined outcome was LV dysfunction after surgery. A total of 144 articles were retrieved, of which 11 publications met the inclusion criteria, including a total of 2415 patients. Ten studies showed a significant correlation between preoperative LV-GLS and LV dysfunction postoperatively; one study reported a negative correlation. These studies suggest that LV-GLS is a predictor of LV dysfunction after surgery in asymptomatic patients with chronic MR. Hence, incorporation of LV-GLS for clinical decision-making in these patients might be of additional value. Further research is needed to confirm the role of LV-GLS in postoperative patients, and additionally in asymptomatic MR patients during a ‘watchful waiting’ strategy.

Effects of dose, intervention time, and radionuclide on sodium iodide symporter (NIS)-targeted radionuclide therapy

The sodium iodide symporter (NIS) mediates iodide uptake into thyrocytes and is the molecular basis of thyroid radioiodine therapy. We previously have shown that NIS gene transfer into the F98 rat gliomas facilitated tumor imaging and increased survival by radioiodine. In this study, we show that: (1) the therapeutic effectiveness of (131)I in prolonging the survival time of rats bearing F98/hNIS gliomas is dose- and treatment-time-dependent; (2) the number of remaining NIS-expressing tumor cells decreased greatly in RG2/hNIS gliomas post (131)I treatment and was inversely related to survival time; (3) 8 mCi each of (125)I/(131)I is as effective as 16 mCi (131)I alone, despite a smaller tumor absorbed dose; (4) (188)ReO(4), a potent beta(-) emitter, is more efficient than (131)I to enhance the survival of rats bearing F98/hNIS gliomas. These studies demonstrate the importance of radiopharmaceutical selection, dose, and timing of treatment to optimize the therapeutic effectiveness of NIS-targeted radionuclide therapy following gene transfer into gliomas.

Opposing effects of behavioural activity and light on neurons of the suprachiasmatic nucleus

The mammalian circadian pacemaker is located in the suprachiasmatic nuclei. It can be shifted in phase by photic cues and by the behavioural activity of the animal. When presented together, light and behavioural activity attenuate each others' phase-shifting effect. Still unclear is how behavioural activity affects the suprachiasmatic nuclei and how it interacts with photic information. Previously, we reported the occurrence of behaviourally induced suppressions of neuronal activity. The present study investigates the characteristics of these suppressions as a function of circadian time and, additionally, in the presence of photic cues. We performed long-term multiunit activity recordings of neurons in freely moving rats and found that these suppressions of neuronal firing in the suprachiasmatic nucleus occurred at every phase of the circadian cycle. The magnitude of the suppressions showed a circadian variation, with larger suppressions during subjective day. When a light pulse was applied during a suppression, light and activity appeared to oppose each others' effects within the recorded population of neurons. The resulting discharge level appeared to be the sum of both responses. The opposing effects of light and activity were also found in single unit recordings, indicating that photic and behavioural stimuli interact at the level of a single neuron.

Phase differences in electrical discharge rhythms between neuronal populations of the left and right suprachiasmatic nuclei

The circadian pacemaker of the suprachiasmatic nuclei is a complex multioscillator system, which controls circadian and seasonal rhythmicity. A number of clock genes have been identified that play a key role in the generation of circadian rhythms. These clock genes are expressed in a circadian manner as has been shown in mice, rats and hamsters. The time at which their expression reaches peak values differs among the several genes. Expression profiles for a specific gene may also differ among subdivisions of the suprachiasmatic nuclei. It has been shown that mPer1 peaks slightly out of phase in the left and right suprachiasmatic nuclei and that the rhythm in c-fos expression is significantly different between the dorsomedial and ventrolateral regions. In the special case that the animal shows splitting of its locomotor activity pattern, mPer1 in the left and right suprachiasmatic nuclei appeared to oscillate in antiphase. Whether the molecular organization within the suprachiasmatic nuclei plays a role in seasonal rhythmicity, allowing animals to track daylength and become reproductive at the proper phase of the annual cycle, receives increasing interest (). The differences in peak expression times that exist between different genes, and the spatial differences in peak time for single genes, are suggestive of a genetic mechanism underlying the multioscillator structure. It is unknown, however, whether phase differences that are observed at the molecular level exist at the level of electrical activity rhythms in the suprachiasmatic nuclei in order to become potentially functional. In this study we investigated the presence of phase differences in neuronal discharge rhythms in the suprachiasmatic nuclei of the rat. To this purpose we combined simultaneous electrophysiological recordings of neuronal populations in the left and right suprachiasmatic nuclei with a detailed analysis of the phase relationship between them. The results demonstrate that neuronal subpopulations of the suprachiasmatic nuclei show phase differences both in their peak and half-maximum times of up to 4 h. We propose that these phase differences may play a role in the plasticity of the circadian timing system.

Functional absence of extraocular photoreception in hamster circadian rhythm entrainment

The mammalian circadian pacemaker is entrainable by light via the retina. The putative role of extraocular light perception was investigated in blinded hamsters. These animals were shaved and exposed to a light-emitting pad for either 30 min or 3 h. The absence of any phase-shifting effects on wheel running activity rhythms indicates that extraocular light perception plays no functional role in photic entrainment of the circadian pacemaker in the hamster.

Neurons of the rat suprachiasmatic nucleus show a circadian rhythm in membrane properties that is lost during prolonged whole-cell recording

The suprachiasmatic nucleus is commonly considered to contain the main pacemaker of behavioral and hormonal circadian rhythms. Using whole-cell patch-clamp recordings, the membrane properties of suprachiasmatic nucleus neurons were investigated in order to get more insight in membrane physiological mechanisms underlying the circadian rhythm in firing activity. Circadian rhythmicity could not be detected either in spontaneous firing rate or in other membrane properties when whole-cell measurements were made following an initial phase shortly after membrane rupture. However, this apparent lack of rhythmicity was not due to an unhealthy slice preparation or to seal formation, as a clear day/night difference in firing rate was found in cell-attached recordings. Furthermore, in a subsequent series of whole-cell recordings, membrane properties were assessed directly after membrane rupture, and in this series we did find a significant day/night difference in spontaneous firing rate, input resistance and frequency adaptation. As concerns the participation of different subpopulations of suprachiasmatic nucleus neurons expressing circadian rhythmicity, cluster I neurons exhibited strong rhythmicity, whereas no day/night differences were found in cluster II neurons. Vasopressin-containing cells form a subpopulation of cluster I neurons and showed a more pronounced circadian rhythmicity than the total population of cluster I neurons. In addition to their strong rhythm in spontaneous firing rate they also displayed a day/night difference in membrane potential.

Light responsiveness of the suprachiasmatic nucleus: long-term multiunit and single-unit recordings in freely moving rats

The suprachiasmatic nuclei (SCN) of the hypothalamus contain a pacemaker that generates circadian rhythms in many functions. Light is the most important stimulus that synchronizes the circadian pacemaker to the environmental cycle. In this paper we have characterized the baseline neuronal firing patterns of the SCN as well as their response to light in freely moving rats. Multiunit and single-unit recordings showed that SCN neurons increase discharge during daytime and decrease discharge at night. Discharge levels of individual neurons that were followed throughout the circadian cycle appeared in phase with the population and were characterized by low discharge rates (often below 1 Hz), with a twofold increase during the day. The effect of light on the multiunit response was dependent on the duration of light exposure and on light intensity, with light thresholds of approximately 0.1 lux. The light response level showed a strong dependency on time of day, with large responsiveness at night and low responsiveness during day. At both phases of the circadian cycle, the response level could be raised by an increase in light intensity. Single-unit measurements revealed that the time-dependent light response of SCN neurons was present also at the level of single units. The results show that the basic light response characteristics that were observed at the multiunit level result from an integrated response of similarly behaving single units. Research at the single-unit level is therefore a useful approach for investigating the basic principles of photic entrainment.

Multiunit activity recordings in the suprachiasmatic nuclei: in vivo versus in vitro models

The suprachiasmatic nuclei (SCN) of the hypothalamus continue to oscillate when they are isolated in a brain slice preparation. We recorded multiunit activity in the SCN of the rat both in vivo and in vitro to determine the circadian discharge pattern. The variability of the discharge pattern is larger and the amplitude of the rhythm is smaller in vivo than in vitro. Moreover we found evidence for a direct effect of the animal's behavioural activity on electrical activity of the SCN in vivo. These findings may provide an electrophysiological basis for the known effects of behavioural stimuli on the circadian pacemaker. This study underscores the importance of recordings in intact preparations in addition to in vitro work when generalisations to physiological conditions are to be made.

Circadian rhythm in light response in suprachiasmatic nucleus neurons of freely moving rats

Long-term recordings of single SCN units were performed in freely moving rats simultaneously with multiunit recordings and evidence is presented for a daily change in light-responsiveness. SCN light response is high during the night and low during the day. We conclude that this difference is caused by a change in sensitivity, with higher sensitivities at night. Moreover, we demonstrate that the circadian rhythm in SCN light response is the result of the integrated behaviour of similarly behaving single SCN units.