Clinical Presentation and 6-Month Outcomes of Patients with Peripartum Cardiomyopathy in Indonesia.

Background: Due to the rarity of peripartum cardiomyopathy (PPCM) globally, baseline characteristic data for PPCM patients are still scarce. Therefore, this study aims to determine the baseline characteristics and 6-month outcomes of PPCM patients in Indonesia. Methods: From January 2014 to December 2021, all PPCM patients aged ≥18 years who were admitted to Dr. Hasan Sadikin General Hospital in Bandung, Indonesia, participated in this single-center, prospective cohort study. All patients were re-evaluated within 6 months of PPCM diagnosis. Results: A total of 138 patients with PPCM were admitted to Dr. Hasan Sadikin General Hospital in Bandung. The mean age of all patients was 30.4 ± 6.4 years old. Approximately 60% patients were multipara and had preeclampsia. All guideline-directed medical therapy for heart failure was received by most patients, excluding mineralocorticoid receptor antagonists (25.2%) and bromocriptine (14.1%). The neonatal mortality rate was 5.1%. Among those who survived, 61.2% had normal weight, 31.8% had low birth weight, and 7% had very low birth weight. At the 6-month follow-up, 6.7% of the patients died, 63.3% recovered, and 1.9% were rehospitalized. Conclusion: The present study found a high incidence of PPCM in Indonesia. Our patients frequently had preeclampsia, which contributed to the higher rate of miscarriage and low birth weight. Our liberal use of beta-blockers and ACEi/ARB may have contributed to the higher 6-month recovery rate than that in other countries.

Predicting poor left ventricular function recovery in Peripartum cardiomyopathy.

INTRODUCTION: Peripartum cardiomyopathy (PPCM) is a rare type of cardiomyopathy that manifests as acute heart failure associated with pregnancy. Delays in early identification result in poor recovery of left ventricular (LV) function; however, no risk prediction model exists. We sought to yield a scoring system known as the Padjadjaran Peripartum CardioMyopathy Recovery (PPCM recovery) score to predict the probability of poor LV function recovery in PPCM patients. METHODS: All baseline and clinical parameters were prospectively collected from a cohort of patients with PPCM admitted to Dr. Hasan Sadikin General Hospital in Bandung, Indonesia between January 2014 and December 2021. Logistic regression analyses were performed to investigate the relationship between each variable and the risk of poor LV function recovery in PPCM patients. RESULTS: This prospective cohort study included 113 patients with PPCM (84 recovered and 29 non-recovered patients). Significant mitral regurgitation (MR), left ventricular ejection fraction (LVEF) <30%, left ventricular end-diastolic diameter (LVEDD) ≥56 mm, and New York Heart Association functional class (NYHA FC) IV were all strong predictors of poor LV function recovery. These variables were integrated into the PPCM recovery score (AUC of 0.85). Patients with a score of ≥8 were nearly 18 times more likely to have poor LV function recovery (sensitivity 57%, specificity 93%). CONCLUSION: PPCM recovery score is a convenient scoring system based on clinical and echocardiography assessment that may assist in distinguishing which patients are more likely to develop poor LV function recovery; therefore, these patients should be immediately referred to a tertiary referral hospital.

Predictors of In-Hospital Mortality in Patients with Acute Coronary Syndrome in Hasan Sadikin Hospital, Bandung, Indonesia: A Retrospective Cohort Study.

BACKGROUND: Acute coronary syndrome (ACS) is a world health problem with a high mortality rate and is expected to continue to rise in number. The high ACS mortality rate in the hospital is influenced by demographic characteristics, cardiovascular risk factors, clinical presentation, and management. This study aimed to determine the predictors of ACS death at Dr. Hasan Sadikin Hospital Bandung as the highest referral center in West Java. METHODS: This study is a retrospective cohort study on all ACS patients undergoing treatment at Dr. Hasan Sadikin Hospital Bandung from January 2018 to December 2019. Multivariate analysis was performed using a logistic regression test with the backward method to assess predictors of patient outcomes. RESULTS: This study involved 919 patients with the in-hospital mortality rate was 10.6%. Multivariate analysis showed that age >65 years was a demographic factor that play a role as a predictor of mortality mortality (AOR 2.143; 95% CI = 1.079-4.256; p = 0.030). Clinical presentation of cardiac arrest arrest (AOR 48.700; 95% CI =14.289-165.980; p<0.001), SBP <90 mmHg (AOR: 4.972; 95% CI =1.730-14.293; p=0.003, heart rate >100 beats per minute (AOR 4.285; 95% CI =2.209-8.310; p<0,001), cardiogenic shock (AOR: 5.433; 95% CI= 2.257-13.074; p<0.001). Cardiovascular management can reduce the risk of in-hospital mortality. Multivariate analysis showed statins (AOR 0.155; 95% CI=0.040-0.594; p=0.007), beta blockers (AOR 0.304; 95% CI=0.162-0.570; p<0,001) and Percutaneous Coronary Intervention (AOR 0.352; 95% CI=0.184-0.673; p=0.002) significantly reduce in-hospital mortality. Interestingly, smoking is associated with a lower mortality rate (OR 0.387; p <0.001). CONCLUSION: Clinical presentation of cardiac arrest has the highest risk of death, the sequence is cardiogenic shock, heart rate >100 beats per minute, and age >65 years. Administration of statins, beta-blockers, PCI, and smoking are factors that reduce the risk of death.

Global and Regional Longitudinal Strain Reduction in Breast Cancer Patients After First Chemotherapy Cycle With Fluorouracil, Adriamycin, and Cyclophosphamide Regimen.

BACKGROUND: Chemotherapy with fluorouracil, adriamycin, and cyclophosphamide (FAC) regimen in breast cancer patients may cause myocardial injury and necrosis, thereby attenuating global and regional longitudinal strain (GLS and RLS). It is unclear whether the first chemotherapy cycle would cause GLS and RLS reduction and which segment would be most affected by the chemotherapy. The purpose of the study was to investigate the effect of the first chemotherapy cycle on GLS and RLS reduction. METHODS: This was a prospective single-center cohort study of patients with breast cancer who underwent the first chemotherapy cycle with a FAC regiment. The GLS and RLS were measured using speckle tracking echocardiography and left ventricular ejection fraction (LVEF) measured with Simpson's biplane. The echocardiography was performed before and 3 weeks after the first chemotherapy cycle. We compared the value of GLS, RLS, and LVEF before and after chemotherapy using paired t-test analysis. RESULTS: Thirty-six breast cancer patients were enrolled in the study. The GLS and RLS were reduced significantly at 3 weeks compared to baseline. The RLS of the basal anteroseptal, basal anterolateral, mid anterolateral, mid inferolateral, and all apical segments declined significantly from baseline. The largest RLS decline was detected in the apicoanterior segment. The post-chemotherapy GLS but not LVEF was significantly lower than that before treatment. CONCLUSION: The GLS and RLS of patients who underwent first cycle chemotherapy with FAC declined significantly than that before treatment, especially at the apicoanterior segment. LVEF was not altered after first cycle chemotherapy.

In-hospital use of statins is associated with a reduced risk of mortality in coronavirus-2019 (COVID-19): systematic review and meta-analysis.

BACKGROUND AND AIMS: The idea of treating COVID-19 with statins is biologically plausible, although it is still controversial. The systematic review and meta-analysis aimed to address the association between the use of statins and risk of mortality in patients with COVID-19. METHODS: Several electronic databases, including PubMed, SCOPUS, EuropePMC, and the Cochrane Central Register of Controlled Trials, with relevant keywords up to 11 November 2020, were used to perform a systematic literature search. This study included research papers containing samples of adult COVID-19 patients who had data on statin use and recorded mortality as their outcome of interest. Risk estimates of mortality in statin users versus non-statin users were pooled across studies using inverse-variance weighted DerSimonian-Laird random-effect models. RESULTS: Thirteen studies with a total of 52,122 patients were included in the final qualitative and quantitative analysis. Eight studies reported in-hospital use of statins; meanwhile, the remaining studies reported pre-admission use of statins. In-hospital use of statin was associated with a reduced risk of mortality (RR 0.54, 95% CI 0.50-0.58, p < 0.00001; I2: 0%, p = 0.87), while pre-admission use of statin was not associated with mortality (RR 1.18, 95% CI 0.79-1.77, p = 0.415; I2: 68.6%, p = 0.013). The funnel plot for the association between the use of statins and mortality were asymmetrical. CONCLUSION: This meta-analysis showed that in-hospital use of statins was associated with a reduced risk of mortality in patients with COVID-19.

Left and right ventricular longitudinal strains are associated with poor outcome in COVID-19: a systematic review and meta-analysis.

BACKGROUND: This systematic review and meta-analysis aimed to assess whether ventricular longitudinal strain can be used as a prognostication tool in patients with coronavirus disease 2019 (COVID-19). METHODS: Systematic literature searches of PubMed, Embase, and EuropePMC databases were performed on 16 November 2020. Left ventricular global longitudinal strain (LV-GLS) refers to LV contraction measurement using the speckle tracking-based method refers to the mean of strain values of the RV free wall (three segments) measured using echocardiography. The main outcome was poor outcome, defined as a composite of mortality and severe COVID-19. RESULTS: Seven studies comprising of 612 patients were included in meta-analysis. Six studies have mortality as their outcome, and 1 study has severity as their outcome. Patients with poor outcome have lower LV-GLS (SMD 1.15 (0.57, 1.72), p < 0.001; I2 70.4%). Each 1% decrease in LV-GLS was associated with 1.4x increased risk of poor outcome (OR 1.37 (1.12, 1.67), p = 0.002; I2 48.8%). Patients with poor outcome have lower RV-LS (SMD 1.18 (0.91, 1.45), p < 0.001; I2 0%). Each 1% decrease in RV-LS was associated with 1.3x increased risk of poor outcome (OR 1.25 (1.15, 1.35), p < 0.001; I2 11.8%). Subgroup analysis showed that for every 1% decrease in LV-GLS and RV-LS is increased mortality with OR of 1.30 (1.12, 1.50) and OR of 1.24 (1.14, 1.35), respectively. CONCLUSION: This study shows that lower LV-GLS and RV-LS measurements were associated with poor outcome in patients with COVID-19. TRIAL REGISTRATION: PROSPERO CRD42020221144.

The effect of prophylactic carvedilol on subclinical left ventricular dysfunction after 1 cycle FAC chemotherapy in breast cancer patients.

BACKGROUND: Despite its efficacy, FAC regimen may cause fatal cardiotoxicity. Carvedilol may also exert additional antioxidant effects. This study aimed to assess the effect of carvedilol in preventing decline of left ventricular function in breast cancer patients receiving FAC regimen chemotherapy. METHODS: The study was a quasi-experimental study. The study subjects were consisted of breast cancer patients currently receiving post-first cycle FAC chemotherapy regimen in period of March - May 2019. The study subjects were divided into 2 groups: control and intervention group. In intervention groups, the patients consumed up titrated carvedilol with initial dose of 2 × 6.25 mg daily, follow-up echocardiography was performed for the patients in order to assess GLS score of left ventricle. RESULT: Eighty patients were enrolled to the study, with each group consisted of 40 patients. Patient baseline characteristics were not significantly different between both groups. Left ventricular function was assessed using speckle tracking echocardiography and assessing the change of GLS score. Decrease of GLS score was higher in the intervention group compared to the control group, although the decrease was not statistically significant (0.767 ± 0.355 vs. 0.897 ± 0.526; p = 0.838). Percentage wise, similar findings were reported, albeit no significant (3.34 ± 1.65 vs. 3.46 vs. 2.58; p = 0.968). CONCLUSIONS: Carvedilol was not able to prevent the decline of subclinical left ventricular function after such chemotherapy cycle. However, it maybe more likely that the benefits appear in patients whose given larger cumulative dose of anthracycline and have multiple risk factors.

Lethal Arrhythmia (Torsade de Pointes) in COVID-19: An Event Synergistically Induced by Viral Associated Cardiac Injury, Hyperinflammatory Response, and Treatment Drug?

Arrhythmias in patients with coronavirus disease 2019 (COVID-19) are prevalent and deserve special attention because they are associated with an increased risk of fatal outcome. The mechanism of arrhythmia in COVID-19 remains unclear. Here, we report our first case of confirmed COVID-19 with documented Torsade de Pointes (TdP). A 64-year-old woman, previously healthy, presented to our emergency department with progressive shortness of breath, dry cough, and 1 week of fever. She was treated with chloroquine phosphate, meropenem, and ciprofloxacin. After 5 days of admission, her condition deteriorated and she was admitted to the intensive care unit. The patient had two episodes of malignant arrhythmias within 24 hours. The former was TdP, and the latter was a fatal pulseless ventricular tachycardia that occured even after chloroquine was discontinued. There was evidence of cardiac injury shown by increased serum level of troponin I. We propose a synergistic concept of lethal arrhythmia due to direct severe acute respiratory syndrome coronavirus (SARS-CoV)-2-associated cardiac injury, hyperinflammatory response, and drug-induced arrhythmia.

A novel de novo mutation in Lamin A/C gene in Emery Dreifuss Muscular Dystrophy patient with atrial paralysis.

We present a 26 year old female Indonesian patient with full spectrum Emery Dreifuss Muscular Dystrophy (EDMD) characterized with contracture of elbows, heel cord and pelvic muscle wasting and weakness and atrial paralysis, as rare cardiac findings in EDMD . A novel de novo pathogenic heterozygous missense mutation (NM_170707.3: c.122G>T, p.Arg41Leu) in exon 1 was detected. Preventing atrial paralytic patients from systemic embolism is important. Early diagnosis, intervention, targeted management and counseling are necessary for a better health and life quality of individuals with EDMD.

Cardiometabolic risk factors and acute kidney injury based on urinary neutrophil gelatinase associated lipocalin (NGALu) in acute coronary syndrome patients.

AIM: to analyze the association between cardiometabolic risk factors and acute kidney injury (AKI) based on urinary neutrophil gelatinase associated lipocalin (NGALu) in patients with acute coronary syndrome (ACS). METHODS: a cross-sectional study was conducted on the ACS patients who were admitted to the Emergency Room in Hasan Sadikin Hospital. Urinary samples were obtained at the time of the arrival and considered AKI if the urinary NGAL level 150 ng/ml. The cardiometabolic risk factors were in accord with the IDF criteria for MetS. RESULTS: there were 60 subjects that consisted of 39 men (65%) and 21 women (35%) and the average of was 58.47 (SD 9.9) years. There were 30 subjects (50%) considered AKI based on NGAL level. There were two significant CMR risk factors associated with AKI; blood pressure (hypertension) and HDL (p 0.05). HDL being the most significant cardiometabolic factor (p=0.037; OR 5.137 (95% CI 1.102-23.95)). The number of factors was also associated with the incidence of AKI; the more factors existed in a person the greater the incidence of AKI (p=0.03). CONCLUSION: blood pressure and HDL were cardiometabolic risk factors associated with AKI in ACS patients. The more cardiometabolic factors existed in a person the greater the incidence of AKI.

Comparison of pro B-natriuretic peptide in hypertensive patients with and without diastolic dysfunction.

AIM: to evaluate whether pro BNP can be used for detection of diastolic dysfunction. METHODS: thirty nine hypertensive patients with normal systolic function, consecutively referred for echocardiography examination between October and December 2004 were recruited in the study. Diastolic dysfunction was diagnosed when echocardiographic mitral flow pattern demonstrated impaired relaxation, pseudonormalization or restrictive like patterns. NT-pro BNP levels were assessed using electro chemiluminescence Immunoassay (ECLIA) method. Unpaired t test was used to analyze the results. RESULTS: twelve out of thirty nine subjects had normal diastolic function. All base line characteristics, except for uric acid, were equally distributed between normal and abnormal diastolic function group. NT-pro BNP levels were nearly significantly higher in the diastolic dysfunction group (P=0.053). CONCLUSION: NT-pro BNP levels trends to be higher in hypertensive subjects with diastolic dysfunction.