Tocilizumab as a Treatment for 'Cytokine Storm Syndrome' in COVID-19: A Case Report.

Coronavirus disease 19 (COVID-19) which is caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), has been a problem worldwide, particularly due to the high rate of transmission and wide range of clinical manifestations. Acute respiratory distress syndrome (ARDS) and multiorgan failure are the most common events observed in severe cases and can be fatal. Cytokine storm syndrome emerges as one of the possibilities for the development of ARDS and multiorgan failure in severe cases of COVID-19. This case report describes a case of a 53-year-old male patient who has been diagnosed with COVID-19. Further evaluation in this patient showed that there was a marked increase in IL-6 level in blood accompanied with hyperferritinemia, which was in accordance with the characteristic of cytokine storm syndrome. Patient was treated with tocilizumab, a monoclonal antibody and is an antagonist to IL-6 receptor. The binding between tocilizumab and IL-6 receptors effectively inhibit and manage cytokine storm syndrome. Although this case report reported the efficacy of tocilizumab in managing cytokine storm syndrome, tocilizumab has several adverse effects requiring close monitoring. Further clinical randomized control trial is required to evaluate the efficacy and safety of tocilizumab administration in participants with various clinical characteristics and greater number of subjects.

Association of Periodontitis and Arterial Stiffness in Type 2 Diabetic Patients.

BACKGROUND: periodontitis is a major cause of chronic infection in diabetic patients. Diabetic patients have four-fold risk of having cardiovascular disease. Chronic inflammation caused by periodontitis, a non-traditional cardiovascular risk factor is widely known to play a major role in atherogenesis. Among non-diabetics, an association has been found between periodontitis and arterial stiffness, but in diabetic patients the result is inconsistent. No study has investigated either the proportion of periodontitis or its correlation with arterial stiffness in type 2 diabetes population in Indonesia. METHODS: this study was a cross-sectional study involving 97 patients with type 2 diabetics, who were recruited on Endocrinology Clinic from April to August 2017. Periodontitis was measured for pocket depth, clinical attachment loss and bleeding on probing by a periodontist. Carotid-femoral PWV (Pulse Wave Velocity) was measured using SphygmoCor Xcel with cuff-based tonometry technique. RESULTS: periodontitis was found in 99% type 2 diabetic subjects and 78% of them had severe periodontitis. There was no significant correlation found between pocket depth, clinical attachment loss and cfPWV (r=0.024, p=0.407 and r=0.011, p=0.456); whereas there was a weak positive correlation between pocket depth and PWV (r=0.294, p=0.041) in well-controlled type 2 diabetics. CONCLUSION: most of type-2 diabetics had severe periodontitis; however, the correlation between periodontitis and arterial stiffness could not be concluded in this study.

Impact of Frailty on the First 30 Days of Major Cardiac Events in Elderly Patients with Coronary Artery Disease Undergoing Elective Percutaneous Coronary Intervention.

AIM: to obtain the proportion of frailty and the incidence of 30-day major adverse cardiovascular events (MACE) as well as to review the impact of frailty on the prognosis of elderly patients with coronary heart disease who underwent elective PCI. METHODS: this is a prospective cohort study to assess the frailty of elderly patients with coronary artery disease that underwent elective PCI in Cipto Mangunkusumo Hospital using the frailty phenotype criteria. They were subsequently followed-up for 30 days to see whether there was any MACE developed. RESULTS: there were 100 elderly patients with coronary artery disease who underwent elective PCI between September 2014 and June 2015. The mean age of patients was 66.95 (SD 4.875) years and 69% of the patients were males. Frailty was present in 61% of the patients. MACE were occurred in 8.19% of frail patients and 5.12% were occurred in non-frail patients. The association between frailty and MACE was demonstrated by the result of crude HR of 1.6 (CI 95% 0.31-8.24). In our study, the 30-day survival rate was 95% in frail patients and 98% in non-frail patients. CONCLUSION: there is a 1.6-fold increased risk of 30-day MACE in elderly frail patients undergoing elective PCI; however, it is not statistically significant.

Hyperuricemia as a Risk Factors of Major Adverse Cardiac Events in Patients with Acute Coronary Syndrome: a Retrospective Cohort Study.

AIM: to investigate the MACE-free survivals difference between hyperuricemic and normouricemic patients and to determine its role as risk factor for MACE occurrence in hospitalized acute coronary syndrome patients. METHODS: retrospective cohort study with survival analysis approach was conducted in 251 patients with acute coronary syndrome who were treated in ICCU Cipto Mangunkusumo Hospital during period from January 2009 to December 2011. Clinical data, laboratory results, electrocardiography result, echocardiography result, and coronary angiography were collected. Patients were observed and followed on major adverse cardiac event during 7 days of hospitalization in ICCU. Major adverse Cardiac Event is an event as a complication occur after acute coronary syndrome such as cardiogenic syock, acute heart failure, stoke, reinfarct during early ward treatment, sudden cardiac death, repeat PCI during ward ulang and perform coronary artery bypass graft (CABG) surgery. Difference in survival is shown in Kaplan-meier curve and difference in survival between groups were tested with Log-rank test, and multivariate analysis with Cox proportional hazard regression to calculate adjusted HR on major adverse cardiac event with confounding variables as covariates. RESULTS: there was a significant difference in survival between hyperuricemia group and non-hyperuricemia group (Log-rank test (p<0.001)) with crude HR 2.7 (CI 95% 1.6-4) and adjusted HR 2.67 (CI 95% 1.6-4.3).There was significant difference in survival between hyperuricemia group (mean survival 6.05 days with SE 0.2 (CI 95% 5.6-6.4) and non-hyperuricemia group (mean survival 7.33 days with SE 0.1 (CI 95% 7.0-7.6). CONCLUSION: survival of patients suffering from ACS with hyperuricemia is worse compared to those without hyperuricemia during ICCU hospitalization.

Extended Dual Antiplatelet for Diabetic Elderly Patients After Drug-eluting Stent Implantation: an Evidence-based Clinical Review.

Antiplatelet is an important drug for patients with coronary heart disease undergoing drug-eluting stent implantation. Current guidelines recommend dual antiplatelet with aspirin and a P2Y12 inhibitor for at least 12 months. Continuation of DAPT beyond 12 months may be considered for preventing very late stent thrombosis. Several patient-related factors that contribute to stent thrombosis have been recognized, including diabetes and advanced age, but the optimal DAPT duration for these patients is still controversial. This article reviews the efficacy of extended (>12 months) compared to standard (12 months) DAPT for reducing myocardial infarction and stent thrombosis rates, especially in diabetic elderly patients. Literature screening was conducted at PubMed and Cochrane database using "dual antiplatelet", "duration", "adult-onset diabetes mellitus", "elderly" and, "drug-eluting stent" as keywords. Article types were limited to meta-analysis, systematic review, randomized clinical trial, or clinical trial that compared the efficacy of extended to standard duration of DAPT. Clinical outcomes used were myocardial infarction and stent thrombosis. The initial search was done to find relevant studies specifically assessing diabetic and elderly patients, then widened to diabetic and non-diabetic patients of any age above eighteen years. A total of 5 clinical trials and 1 meta-analysis were reviewed, showing an overall risk reduction of stent thrombosis and myocardial infarction. This review has several limitations, such as its potential selection bias and under-represented proportion of diabetic and elderly patients. High-risk subgroups like diabetes mellitus has a tendency of increased ischemic risk, while advanced age could have both increased ischemic risk and bleeding risk. This review suggests that it is better to reserve extended dual antiplatelet therapy for patients with high ischemic risk and low bleeding risk (tailored therapy).

Transcatheter closure of post-operative residual ventricular septal defect using a patent ductus arteriosus closure device in an adult: a case report.

Transcatheter closure of perimembranous and muscular ventricular septal defect (VSD) has been performed widely and it has more advantages compare to surgery. However, transcatheter closure of residual VSD post operation of complex congenital heart disease is still challenging because of the complexity of anatomy and concern about device stability, so the operator should meticulously choose the most appropriate technique and device. We would like to report a case of transcatheter closure of residual VSD post Rastelli operation in a patient with double outlet right ventricle (DORV), sub-aortic VSD, severe infundibulum pulmonary stenosis (PS) and single coronary artery. The patient had undergone operations for four times, but he still had intractable heart failure that did not response to medications. On the first attempt. we closed the VSD using a VSD occluder, unfortunately the device embolized into the descending aorta, but fortunately we was able to snare it out. Then we decided to close the VSD using a patent ductus arteriosus (PDA occluder). On transesophageal echocardiography (TEE) and angiography evaluation, the device position was stable. Post transcatheter VSD closure, the patient clinical condition improved significantly and he could finally be discharged after a long post-surgery hospitalization. Based on this experience we concluded that the transcatheter closure of residual VSD in complex CHD using PDA occluder could be an effective alternative treatment.

Transcatheter closure of atrial septal defects in adolescents and adults: technique and difficulties.

AIM: to evaluate the results of transcatheter closure of atrial septal defect (ASD) in adolescents and adult. METHODS: a case series of patients undergoing transcatheter closure of ASD in RS Cipto Mangunkusumo, Jakarta during 2002 -2013. Transesophageal echocardiography, hemodynamic study, and angiography were performed before the procedure. Oxygen test was done if PA pressure was more than 2/3 of aortic pressure, followed by an occlusion test if no response observed to determine whether the device could be released. RESULTS: we enrolled 54 patients, of whom 26% were adolescents and 3% were males. Median body weight was 49 (26-75) kg and ASD size was 21 (9.4-39.6) mm. The procedure was done under general anesthesia in 26% of patients. Oxygen test was applied in 11% patients and occlusion test in 2% of patient. Transcatheter closure of ASD was successful in all patients using common technique (31%), right pulmonary vein-assisted (65%), left pulmonary assisted (2%), and cutting long sheath (2%). There was neither residual ASD nor complications observed. Mean fluoroscopy and procedure time were 29 (SD 18) and 109 (SD 36) minutes, respectively. Median hospital stay was 1 (1-3) day. CONCLUSION: transcatheter closure of ASD in adolescents and adults is safe and effective.

Cardiovascular disease prediction model for Indonesian adult population with prediabetes and diabetes mellitus: The Bogor Cohort study of Noncommunicable Diseases Risk Factors.

BACKGROUND AND AIMS: This study aims to develop a predictive model of cardiovascular events in dysglycemia among the Indonesian adult population. METHODS: This is a retrospective cohort study conducted on subjects over 25 years in the "The Bogor Cohort Study of Noncommunicable Diseases Risk Factors" from 2011 to 2018. Data associated with age, gender, blood pressure, body mass index, waist circumference, blood glucose, cholesterol, smoking habits, family history of cardiovascular disease, and physical activity were obtained. Cardiovascular events in six years were observed; this included coronary heart disease, stroke, or all-cause cardiovascular mortality. Cox proportional hazards regression models were used to determine independent predictors of cardiovascular events. RESULTS: A total of 1085 subjects with prediabetes and diabetes mellitus were included in this study, with 73.5% female. The cumulative incidence of cardiovascular events in six years was 9.7%. Predictors of cardiovascular events were age ≥45 years (HR = 2.737; 95% CI 1.565-4.787) and hypertension (HR = 2.580; 95% CI 1.619-4.112). CONCLUSIONS: Age ≥45 years and hypertension were predictors of cardiovascular events in six years among the adult Indonesian population with prediabetes and diabetes, necessitating targeted intervention among these subjects.