Outcomes of COVID-19 in Patients With a History of Cancer and Comorbid Cardiovascular Disease.

BACKGROUND: Cancer and cardiovascular disease (CVD) are independently associated with adverse outcomes in patients with COVID-19. However, outcomes in patients with COVID-19 with both cancer and comorbid CVD are unknown. METHODS: This retrospective study included 2,476 patients who tested positive for SARS-CoV-2 at 4 Massachusetts hospitals between March 11 and May 21, 2020. Patients were stratified by a history of either cancer (n=195) or CVD (n=414) and subsequently by the presence of both cancer and CVD (n=82). We compared outcomes between patients with and without cancer and patients with both cancer and CVD compared with patients with either condition alone. The primary endpoint was COVID-19-associated severe disease, defined as a composite of the need for mechanical ventilation, shock, or death. Secondary endpoints included death, shock, need for mechanical ventilation, need for supplemental oxygen, arrhythmia, venous thromboembolism, encephalopathy, abnormal troponin level, and length of stay. RESULTS: Multivariable analysis identified cancer as an independent predictor of COVID-19-associated severe disease among all infected patients. Patients with cancer were more likely to develop COVID-19-associated severe disease than were those without cancer (hazard ratio [HR], 2.02; 95% CI, 1.53-2.68; P<.001). Furthermore, patients with both cancer and CVD had a higher likelihood of COVID-19-associated severe disease compared with those with either cancer (HR, 1.86; 95% CI, 1.11-3.10; P=.02) or CVD (HR, 1.79; 95% CI, 1.21-2.66; P=.004) alone. Patients died more frequently if they had both cancer and CVD compared with either cancer (35% vs 17%; P=.004) or CVD (35% vs 21%; P=.009) alone. Arrhythmias and encephalopathy were also more frequent in patients with both cancer and CVD compared with those with cancer alone. CONCLUSIONS: Patients with a history of both cancer and CVD are at significantly higher risk of experiencing COVID-19-associated adverse outcomes. Aggressive public health measures are needed to mitigate the risks of COVID-19 infection in this vulnerable patient population.

Risk and predictors of dyssynchrony cardiomyopathy in left bundle branch block with preserved left ventricular ejection fraction.

BACKGROUND: Left bundle branch block (LBBB) and left ventricular (LV) dyssynchrony likely contribute to progressive systolic dysfunction. The evaluation of newly recognized LBBB includes screening for structural heart abnormalities and coronary artery disease (CAD). In patients whose LV ejection fraction (EF) is preserved during initial testing, the incidence of subsequent cardiomyopathy is not firmly established. HYPOTHESIS: The risk of developing LV systolic dysfunction among LBBB patients with preserved LVEF is high enough to warrant serial imaging. METHODS: We screened records of 1000 consecutive patients with LBBB from our ECG database and identified subjects with an initially preserved LVEF (≥45%) without clinically relevant CAD or other cause for cardiomyopathy. Baseline imaging, clinical data, and follow-up imaging were recorded to determine the risk of subsequent LV systolic dysfunction (LVEF ≤40%). RESULTS: (Data are mean + SD) 784 subjects were excluded, the majority for CAD or depressed LVEF upon initial imaging. Of the remaining 216, 37 (17%) developed a decline in LVEF(≤40%) over a mean follow-up of 55 ± 31 months; 94% of these patients had a baseline LVEF≤60% and LV end systolic diameter (ESD) ≥ 2.9 cm indicating that these measures may be useful to define which patients warrant longitudinal follow-up. The negative predictive value of a LVEF>60% and LVESD <2.9 cm was 98%. CONCLUSIONS: Seventeen percent of patients with LBBB and initial preserved LVEF develop dyssynchrony cardiomyopathy. We believe the risk of developing dyssynchrony cardiomyopathy is high enough to warrant serial assessment of LV systolic function in this high-risk population.

Management of Cardiovascular Disease During Coronavirus Disease (COVID-19) Pandemic.

Patients with pre-existing cardiovascular disease and risk factors are more likely to experience adverse outcomes associated with the novel coronavirus disease-2019 (COVID-19). Additionally, consistent reports of cardiac injury and de novo cardiac complications, including possible myocarditis, arrhythmia, and heart failure in patients without prior cardiovascular disease or significant risk factors, are emerging, possibly due to an accentuated host immune response and cytokine release syndrome. As the spread of the virus increases exponentially, many patients will require medical care either for COVID-19 related or traditional cardiovascular issues. While the COVID-19 pandemic is dominating the attention of the healthcare system, there is an unmet need for a standardized approach to deal with COVID-19 associated and other traditional cardiovascular issues during this period. We provide consensus guidance for the management of various cardiovascular conditions during the ongoing COVID-19 pandemic with the goal of providing the best care to all patients and minimizing the risk of exposure to frontline healthcare workers.

Outcomes of Impella CP insertion during cardiac arrest: A single center experience.

OBJECTIVES: We sought to determine the outcomes of patients with an Impella CP percutaneous mechanical circulatory support (MCS) device deployed during a cardiac arrest. BACKGROUND: The Impella CP device is indicated for left ventricular support in patients with cardiogenic shock. The utility of percutaneous MCS in the setting of cardiac arrest during cardiopulmonary resuscitation (CPR) remains unclear. METHODS: We retrospectively examined data from patients supported with an Impella CP device for cardiogenic shock complicated by cardiac arrest between April 2015 and April 2017 at a single academic medical center. Patients with cardiac arrest who underwent Impella CP placement during CPR were compared to those who had return of spontaneous circulation (ROSC) prior to Impella CP placement. RESULTS: We identified 22 patients with cardiogenic shock complicated by cardiac arrest (average age 64 years, 23% female) who underwent placement of an Impella CP device. The majority of patients (68%) underwent support for cardiogenic shock secondary to an acute myocardial infarction. Seven of the 22 patients (32%) underwent Impella CP placement during CPR and 15 (68%) underwent Impella CP insertion following ROSC. The in-hospital mortality was 86% in the group of patients who had the Impella CP placed during CPR and 56% in the group with ROSC prior to Impella CP insertion, (p = 0.19). CONCLUSIONS: Based on our single center retrospective analysis, the mortality rate of patients undergoing placement of an Impella CP during CPR is 86%. Further study is necessary to better understand the utility of the Impella CP mechanical circulatory support device during a cardiac arrest.

Identifying patients for safe early hospital discharge following st elevation myocardial infarction.

OBJECTIVES: To examine whether the CADILLAC risk score is an effective method of patient stratification for early discharge following ST elevation myocardial infarction (STEMI). BACKGROUND: Patients with STEMI are typically hospitalized to monitor for serious complications such as arrhythmias, heart failure, and reinfarction. Optimal length of stay is unclear. Whether low risk patients can be safely discharged before 72 hr of hospitalization is unclear. METHODS: Patients with STEMI who underwent successful PCI were retrospectively stratified using CADILLAC risk score to low risk (n = 123) and intermediate to high risk (n = 105). The primary outcome was adverse clinical events at day 3 or later. Secondary outcomes were adverse clinical events on day 1 and mortality rates at 30 days and 31 to 365 days. RESULTS: Low risk patients had lower major adverse clinical events at day 3 or later (0 vs. 11.4%, P = 0.0002) and lower total mortality at 1 year (0 vs. 4.8%, P = 0.02) than patients with intermediate to high risk. Low risk patients were also less likely to have a cardiovascular event during the first 24 hr when compared to those with an intermediate to high risk score (3.3% vs. 13.3%, P = 0.006). CONCLUSION: Low risk patients identified using CADILLAC risk score with STEMI treated successfully with primary PCI have a low adverse event rate on the third day or later of hospitalization suggesting that an earlier discharge is safe in properly selected patients. Monitoring in a noncritical care setting following primary PCI for STEMI may be feasible for selected patients. © 2016 Wiley Periodicals, Inc.

Focused cardiopulmonary ultrasound for assessment of dyspnea in a resource-limited setting.

BACKGROUND: The diagnosis and management of acutely dyspneic patients in resource-limited developing world settings poses a particular challenge. Focused cardiopulmonary ultrasound (CPUS) may assist in the emergency diagnosis and management of patients with acute dyspnea by identifying left ventricular systolic dysfunction, pericardial effusion, interstitial pulmonary edema, and pleural effusion. We sought to assess the accuracy of emergency providers performing CPUS after a training intervention in a limited-resource setting; a secondary objective was to assess the ability of CPUS to affect change of clinician diagnostic assessment and acute management in patients presenting with undifferentiated dyspnea. METHODS AND RESULTS: After a training intervention for Haitian emergency providers, patients with dyspnea presenting urgently to a regional referral center in Haiti underwent a rapid CPUS examination by the treating physician. One hundred seventeen patients (median age of 36 years, 56 % female) were prospectively evaluated with a standardized CPUS exam. Blinded expert review of ultrasound images was performed by two board certified cardiologists and one ultrasound fellowship trained emergency physician. Inter-observer agreement was determined using an agreement coefficient (kappa). Sensitivity and Specificity with confidence intervals were calculated. Pre-test and post-test clinician impressions and management plans were compared to assess for a change. We enrolled 117 patients with undifferentiated dyspnea. Upon expert image review, prevalence of left ventricular systolic dysfunction was 40.2 %, and in those with systolic dysfunction, the average EF was 14 % (±9 %). The parasternal long axis (PLAX) single view was predictive of an overall abnormal echo with PPV of abnormal PLAX 95 % and NPV 93 % of normal PLAX. Weighted kappa for pericardial effusion between the Haitian physicians and two cardiology reviewers was 0.81 (95 % CI 0.75-0.87, p value <0.001) and for ejection fraction was 0.98 (95 % CI 0.98-0.99, p value <0.001). For lung ultrasound, a kappa statistic assessing agreement between the Haitian physician and the EP for pleural effusion was 0.73, and for interstitial syndrome was 0.49. Detailed test characteristics are detailed in Table 3. Overall, there was a change in treating clinician impression in 15.4 % (95 % CI 9-22 %) and change in management in 19.6 % (95 % CI 12-27 %) of patients following CPUS. A significant structural heart disease was common: 48 % of patients were noted to have abnormal right ventricular systolic function, 36 % had at least moderate mitral regurgitation, and 7.7 % had a moderate to large pericardial effusion. CONCLUSIONS: A focused training intervention in CPUS was sufficient for providers in a limited-resource setting to accurately identify left ventricular systolic dysfunction, pericardial effusion, evidence of interstitial syndrome, and pleural effusions in dyspneic patients. Clinicians were able to integrate CPUS into their clinical impressions and management plans and reported a high level of confidence in their ultrasound findings.

Clinical characteristics of tako-tsubo cardiomyopathy.

Tako-tsubo cardiomyopathy (TTC) is increasingly diagnosed in the United States, especially in the Caucasian population. To evaluate the clinical features and outcome of patients with TTC, we evaluated 34 patients (32 women and 2 men) 22 to 88 years of age (mean 66 +/- 14) who fulfilled the following criteria: (1) akinesia or dyskinesia of the apical and/or midventricular segments of the left ventricle with regional wall motion abnormalities that extended beyond the distribution of a single epicardial vessel and (2) absence of obstructive coronary artery disease. Twenty-five patients (74%) presented with chest pain, 20 patients (59%) presented with dyspnea, and 8 patients (24%) presented with cardiogenic shock. Twenty-two patients (65%) had ST-segment elevation and 14 patients (41%) had T-wave inversion on presentation. Twenty-five patients (74%) reported a preceding stressful event. Cardiac biomarkers were often mildly increased, with a mean troponin I (peak) of 13.9 +/- 24. Mean +/- SD left ventricular ejection fractions were 28 +/- 10% at time of presentation and 51 +/- 14 at time of follow-up (p <0.0001). Two patients (6%) died during the hospital stay. Average duration of hospital stay was 6.6 +/- 6.2 days. In conclusion, TTC is common in postmenopausal women with preceding physical or emotional stress. It predominantly involves the apical portion of the left ventricle and patients with this condition have a favorable outcome with appropriate medical management. The precise cause remains unclear.