Quantification of hs-Troponin Levels and Global Longitudinal Strain among Critical COVID-19 Patients with Myocardial Involvement.

Background. Myocardial involvement among critically ill patients with coronavirus disease 2019 (COVID-19) often has worse outcomes. An imbalance in the oxygen supply causes the excessive release of pro-inflammatory cytokines, which results in increased ventilation requirements and the risk of death in COVID-19 patients. Purpose. We evaluated the association between the hs-troponin I levels and global longitudinal strain (GLS) as evidence of myocardial involvement among critical COVID-19 patients. Methods. We conducted a prospective cohort study from 1 February to 31 July 2021 at RSUD Dr. Soetomo, Surabaya, as a COVID-19 referral center. Of the 65 critical COVID-19 patients included, 41 (63.1%) were men, with a median age (interquartile range) of 51.0 years (20.0-75.0). Subjects were recruited based on WHO criteria for severe COVID-19, and myocardial involvement in the form of myocarditis was assessed using CDC criteria. Subjects were examined using echocardiography to measure the GLS, and blood samples were taken to measure the hs-troponin. Subjects were then followed for their need for mechanical ventilation and in-hospital mortality. Results. Severe COVID-19 patients with cardiac injury were associated with an increased need for intubation (78.5%) and an increased incidence of myocarditis (50.8%). There was a relationship between the use of intubation and the risk of death in patients (66.7% vs. 33.3%, p-value < 0.001). Decreased GLS and increased hs-troponin were associated with increased myocarditis (p values < 0.001 and 0.004, respectively). Decreased GLS was associated with a higher need for mechanical ventilation (12.17 + 4.79 vs. 15.65 + 4.90, p-value = 0.02) and higher mortality (11.36 + 4.64 vs. 14.74 + 4.82; p-value = 0.005). Elevated hs-troponin was associated with a higher need for mechanical ventilation (25.33% vs. 3.56%, p-value = 0.002) and higher mortality (34.57% vs. 5.76%, p-value = 0.002). Conclusions. Critically ill COVID-19 patients with myocardial involvement and elevated cardiac troponin levels are associated with a higher need for mechanical ventilation and higher mortality.

ECG abnormality and predictor of new-onset atrial fibrillation in hypertension and diabetes mellitus population: An observational analytic study from cardiovascular outpatient clinic at a National Cardiovascular Center in Indonesia.

Background: Population-based studies have also found that diabetes mellitus (DM) and hypertension (HT) are independent risk factors for atrial fibrillation (AF). However, less is known about new-onset atrial fibrillation (NOAF) risk factors and its correlation with DM and HT. The aim of this study was to determine the prevalence and pattern of ECG abnormalities, and the predictor of NOAF in patients with HT and DM. Methods: This cross-sectional study was conducted at a tertiary hospital from May until December 2021. All medical record data from outpatients who had both diagnoses HT and DM were included in this study. Data from patients with unstable hemodynamics and lack of complete medical record data were excluded. Then, patient history, medical records, ECG, and laboratory information were reviewed. Results: There were 162 patients included in this study. Arrhythmia was found in 14.2% of the population, with new-onset AF (NOAF) as the most common finding with 8.6% incidence, followed by PVC (3.1%) and PAC (2.5%). Bivariate analysis showed that valvular heart disease, random blood glucose, LVEF, and infection status were associated with a higher incidence of NOA. Model from multivariate logistic regression showed that valvular heart disease and random blood glucose level were independently correlated with NOAF (p = .009). Conclusion: It can be concluded that random blood glucose level at a certain point and valvular heart disease can be used as a risk predictor of NOAF in the hypertension population with concomitant DM.

The Impact of Classical Cardiovascular Risk Factors on Hospitalization and Mortality among Hajj Pilgrims.

Background: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality during Hajj. The objective of the present study was to examine the effect of classical cardiovascular disease risk factors on mortality and hospitalization among Hajj pilgrims from East Java, Indonesia, during 2017, 2018, and 2019. Methods: This study was a retrospective cohort of Hajj pilgrims from East Java, Indonesia, from 2017 to 2019. The data on risk factors were obtained from the pre-embarkation Hajj screening records. The diagnosis of hospitalization and cause of death during the Hajj period were obtained from the medical report and hospital/flight doctor death certificate. Results: A total of 72078 eligible subjects were included in this study. 33807 (46.9%) were men, and 38271 (53.1%) were women, and the majority (35%) were aged between 50 and 59 years. A total of 42446 pilgrims (58.9%) were classified as high risk due to underlying health conditions such as hypertension, diabetes, or if they were aged 60 years or older. The overall hospitalization rate is 971 per 100,000 pilgrims and the overall death rate is 240 deaths per 100,000 pilgrims. Multivariate analysis using logistic regression showed that male gender, age > 50 years, hypertension grade II-III, diabetes, overweight, and obesity were associated with a higher risk of hospitalization. Moreover, male gender, diabetes, and overweight were associated with a higher risk of mortality. Of all hospitalized patients, 92 patients (13.1%) had an initial diagnosis of CVD, and CVD is the main cause of mortality (38.2%) of pilgrims. Conclusion: Pilgrims with classical cardiovascular risk factors were associated with increased hospitalization and mortality.

Rapid Atrial Fibrillation in the Emergency Department.

Atrial fibrillation (AF) is the most common rhythm disorder seen in doctors' offices and emergency departments (EDs). In both settings, an AF holistic pathway including anticoagulation or stroke avoidance, better symptom management, and cardiovascular and comorbidity optimization should be followed. However, other considerations need to be assessed in the ED, such as haemodynamic instability, the onset of AF, the presence of acute heart failure and pre-excitation. Although the Advanced Cardiovascular Life Support guidelines (European Society of Cardiology guidelines, Acute Cardiac Care Association/European Heart Rhythm Association position statements) and several recent AF publications have greatly assisted physicians in treating AF with rapid ventricular response in the ED, further practical clinical guidance is required to improve physicians' skill and knowledge in providing the best treatment for patients. Herein, we combine multiple strategies with supporting evidence-based treatment and experiences encountered in clinical practice into practical stepwise approaches. We hope that the stepwise algorithm may assist residents and physicians in managing AF in the ED.

Low molecular weight heparin is associated with better outcomes than unfractionated heparin for thromboprophylaxis in hospitalized COVID-19 patients: a meta-analysis.

AIMS: This study aimed to compare the outcomes of the administration of LMWH and UFH in hospitalized COVID-19 patients. METHODS AND RESULTS: We systematically searched several databases and included observational studies or clinical trials that compared the outcomes of the administration of LMWH and UFH in hospitalized COVID-19 patients. A total of nine studies comprising 9637 patients were included. Metanalysis showed that LMWH administration was associated with a lower in-hospital mortality and 28/30-day mortality compared with UFH administration {[relative risk (RR) 0.44; 95% confidence interval (95% CI) 0.32-0.61; I2: 87.9%] and (RR 0.45; 95% CI 0.24-0.86; I2: 78.4%), respectively}. Patient with LMWH had shorter duration of hospital and ICU length of stay compared with UFH {[weighted mean difference (WMD) -2.20; 95% CI -3.01 to -1.40; I2:0%] and (WMD -1.41; 95% CI -2.20 to -0.63; I2: 0%), respectively}. The risk of ICU admission or mechanical ventilation was lower in patients who received LMWH than in those who received UFH (RR 0.67; 95% CI 0.55-0.81; I2: 67.3%). However, there was no difference in the incidence of bleeding with LMWH compared with UFH (RR 0.27; 95% CI 0.07-1.01; I2: 64.6%). CONCLUSION: Our meta-analysis showed that administration of LMWH was associated with better outcomes compared with UFH in hospitalized COVID-19 patients. Prospective cohorts and RCTs are urgently needed to explore the definitive effect of LMWH to provide direct high-certainty evidence. PROSPERO registration number: CRD42021271977.

Purulent pericarditis in advanced thymoma: A case report.

Thymoma is the most common primary anterior mediastinum mass with various clinical manifestations, and one of the manifestations is pericardial effusion. While pericardial effusion in thymoma is usually serous, it can become purulent when an infection occurs in a nearby organ, albeit rare. In this report, we present a rare case of a 27-year-old woman who had purulent pericarditis secondary to an advanced thymoma. The patient came to the emergency department with the chief complaints of worsening chest discomfort, non-productive cough, and fever in the past 2 weeks. The patient was diagnosed with thymoma 5 months prior. Based on the examinations, it was discovered that the patient had pericarditis. After the pericardiocentesis was performed and the fluid was examined, the patient was diagnosed with purulent pericarditis secondary to thymoma. The patient was then treated with intravenous antibiotic and pericardial drain. Unfortunately, the patient's condition deteriorated, and the patient died on the fifth day of hospitalization. This case highlights an infrequent but potentially life-threatening complication of thymoma. In addition, thymic pathologies should be included as a rare etiology in the differential diagnosis of purulent pericardial effusion.

The role of preoperative dutasteride in reducing bleeding during transurethral resection of the prostate: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Bleeding is one of the most common complications of transurethral resection of the prostate (TURP). Several previous studies reported that administering dutasteride before surgery could reduce perioperative bleeding. We aimed to evaluate the efficacy of preoperative dutasteride treatment in benign prostatic hyperplasia patients undergoing TURP by performing a meta-analysis of relevant randomized controlled trials (RCTs). METHODS: A comprehensive literature search was performed through the electronic databases including Medline, Cochrane Library, Google Scholar, and ClinicalTrial.gov in October 2020. RCTs evaluating the role of dutasteride for TURP were screened using the eligibility criteria and the quality of RCTs was assessed using the Cochrane Risk of Bias Tool. The heterogeneity was assessed using I 2 statistic. The measured outcomes were hemoglobin (Hb) levels, perioperative blood loss, blood transfusion, microvessel density (MVD), and operation time. Data were pooled as mean difference (MD) and odds ratio (OR). RESULTS: A total of 11 RCTs consisting of 627 samples from the treatment group and 615 samples from the placebo group were analyzed. Patients that received dutasteride had less reduction in Hb levels (MD -1.10, 95% confidence interval [CI] -1.39 to -0.81, p<0.00001). Dutasteride also significantly reduced the operation time (MD -1.79, 95% CI -2.97 to -0.61, p=0.003) and transfusion rate after surgery (OR 0.34, 95% CI 0.15 to 0.77, p=0.009) compared to the control group. However, the MVD (MD -3.60, 95% CI -8.04 to 0.84, p=0.11) and perioperative blood loss in dutasteride administration for less than 4 weeks (MD 46.90, 95% CI -144.60 to 238.41, p=0.63) and more than 4 weeks (MD -190.13, 95% CI -378.05 to -2.21, p=0.05) differences were insignificant. CONCLUSION: Preoperative administration of dutasteride is able to reduce bleeding during TURP, as indicated by less reduction in Hb level, lower transfusion rate, and less operation time.

Enhancement of EPC migration by high-dose lisinopril is superior compared to captopril and ramipril.

Background: Angiotensin-converting enzyme (ACE) inhibitors have been shown to promote endothelial progenitor cell (EPC) function. However, the efficacies of different ACE inhibitors in improving the migratory capabilities of ECPs in coronary artery disease (CAD) patients is unclear. This study compared the effectiveness of captopril, lisinopril, and ramipril toward the migration capability of impaired EPCs from CAD patients. Methods: We isolated peripheral blood mononuclear cells (PBMCs), separated EPCs from PBMCs, and divided them into an untreated group (control) and treated groups of captopril, lisinopril, and ramipril at doses of 1mM, 10mM, and 100mM. EPC migration was evaluated using the Boyden chamber assay. Analysis of variance (ANOVA) was performed using SPSS 25.0. Results: This study showed that treatment with captopril, lisinopril, and ramipril starting at the lowest dose (1 mM) increased EPC migration (65,250 ± 6,750 cells; 60,750± 5,030 cells; and 49,500 ± 8,400 cells, respectively) compared to control (43,714 ± 7,216 cells). Increased migration of EPCs was observed by increasing the treatment dose to 10 mM with captopril, lisinopril, and ramipril (90,000 ± 16,837 cells; 79,071 ± 2,043 cells; and 64,285 ± 11,824 cells, respectively). The highest EPC migration was shown for lisinopril 100 mM (150,750 ± 16,380 cells), compared to captopril and ramipril at the same dose (105,750 ± 8112 cells and 86,625 ± 5,845 cells, respectively). Conclusions: Captopril, ramipril, and lisinopril were shown to increase EPC migration in a dose-dependent manner. Low-dose (1 mM) and medium-dose (10 mM) captopril had a larger effect on ECP migration than lisinopril and ramipril. Meanwhile, high-dose lisinopril (100mM) had the highest migration effect, suggesting it may be preferable for promoting EPC migration in CAD patients.

Electrocardiography on admission is associated with poor outcomes in coronavirus disease 2019 (COVID-19) patients: A systematic review and meta-analysis.

BACKGROUND: Electrocardiogram (ECG) is a widely accessible diagnostic tool that can easily be obtained on admission and can reduce excessive contact with coronavirus disease 2019 (COVID-19) patients. A systematic review and meta-analysis were performed to evaluate the latest evidence on the association of ECG on admission and the poor outcomes in COVID-19. METHODS: A literature search was conducted on online databases for observational studies evaluating ECG parameters and composite poor outcomes comprising ICU admission, severe illness, and mortality in COVID-19 patients. RESULTS: A total of 2,539 patients from seven studies were included in this analysis. Pooled analysis showed that a longer corrected QT (QTc) interval and more frequent prolonged QTc interval were associated with composite poor outcome ([WMD 6.04 [2.62-9.45], P = .001; I 2:0%] and [RR 1.89 [1.52-2.36], P < .001; I 2:17%], respectively). Patients with poor outcome had a longer QRS duration and a faster heart rate compared with patients with good outcome ([WMD 2.03 [0.20-3.87], P = .030; I 2:46.1%] and [WMD 5.96 [0.96-10.95], P = .019; I 2:55.9%], respectively). The incidence of left bundle branch block (LBBB), premature atrial contraction (PAC), and premature ventricular contraction (PVC) were higher in patients with poor outcome ([RR 2.55 [1.19-5.47], P = .016; I 2:65.9%]; [RR 1.94 [1.32-2.86], P = .001; I 2:62.8%]; and [RR 1.84 [1.075-3.17], P = .026; I 2:70.6%], respectively). T-wave inversion and ST-depression were more frequent in patients with poor outcome ([RR 1.68 [1.31-2.15], P < .001; I 2:14.3%] and [RR 1.61 [1.31-2.00], P < .001; I 2:49.5%], respectively). CONCLUSION: Most ECG abnormalities on admission are significantly associated with an increased composite poor outcome in patients with COVID-19.

Biomarkers of endothelial dysfunction and outcomes in coronavirus disease 2019 (COVID-19) patients: A systematic review and meta-analysis.

BACKGROUND: Several studies have reported that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can directly infect endothelial cells, and endothelial dysfunction is often found in severe cases of coronavirus disease 2019 (COVID-19). To better understand the prognostic values of endothelial dysfunction in COVID-19-associated coagulopathy, we conducted a systematic review and meta-analysis to assess biomarkers of endothelial cells in patients with COVID-19. METHODS: A literature search was conducted on online databases for observational studies evaluating biomarkers of endothelial dysfunction and composite poor outcomes in COVID-19 patients. RESULTS: A total of 1187 patients from 17 studies were included in this analysis. The estimated pooled means for von Willebrand Factor (VWF) antigen levels in COVID-19 patients was higher compared to healthy control (306.42 [95% confidence interval (CI) 291.37-321.48], p < 0.001; I2:86%), with the highest VWF antigen levels was found in deceased COVID-19 patients (448.57 [95% CI 407.20-489.93], p < 0.001; I2:0%). Meta-analysis showed that higher plasma levels of VWF antigen, tissue-type plasminogen activator (t-PA), plasminogen activator inhibitor-1 antigen (PAI-1) antigen, and soluble thrombomodulin (sTM) were associated with composite poor outcome in COVID-19 patients ([standardized mean difference (SMD) 0.74 [0.33-1.16], p < 0.001; I2:80.4%], [SMD 0.55 [0.19-0.92], p = 0.003; I2:6.4%], [SMD 0.33 [0.04-0.62], p = 0.025; I2:7.9%], and [SMD 0.55 [0.10-0.99], p = 0.015; I2:23.6%], respectively). CONCLUSION: The estimated pooled means show increased levels of VWF antigen in COVID-19 patients. Several biomarkers of endothelial dysfunction, including VFW antigen, t-PA, PAI-1, and sTM, are significantly associated with increased composite poor outcomes in patients with COVID-19. PROSPERO REGISTRATION NUMBER: CRD42021228821.

Diagnostic test accuracy of Xpert MTB/RIF for tuberculous pericarditis: a systematic review and meta-analysis.

Introduction: Xpert MTB/RIF is a rapid diagnostic instrument for pulmonary tuberculosis (TB). However, studies reported varied accuracy of Xpert MTB/RIF in detecting Mycobacterium tuberculosis in pericardial effusion. Methods: We performed a systematic review of literature in PubMed, published up to February 1, 2020, according to PRISMA guidelines. We screened cross-sectional studies, observational cohort studies, and randomized control trials that evaluated the accuracy of Xpert MTB/RIF in diagnosing TB pericarditis. Papers with noninterpretable results of sensitivity and specificity, non-English articles, and unpublished studies were excluded. The primary outcomes were the sensitivity and specificity of Xpert MTB/RIF. We conducted a quality assessment using QUADAS-2 to evaluate the quality of the studies. A bivariate model pooled the overall sensitivity, specificity, positive likelihood ratios (PLRs), and negative likelihood ratios (NLRs) of included studies. Results: In total, 581 subjects from nine studies were analyzed in this meta-analysis. Our pooled analysis showed that the overall sensitivity, specificity, PLRs and NLRs of included studies were 0.676 (95% CI: 0.580-0.759), 0.994 (95% CI: 0.919-1.000), 110.11 (95% CI: 7.65-1584.57) and 0.326 (95% CI: 0.246-0.433), respectively. Conclusions: Xpert MTB/RIF had a robust specificity but unsatisfactory sensitivity in diagnosing TB pericarditis. These findings indicated that although positive Xpert MTB/RIF test results might be valuable in swiftly distinguishing the diagnosis of TB pericarditis, negative test results might not be able to rule out TB pericarditis. Registration: PROSPERO CRD42020167480 28/04/2020.