Comparison of STEMI Door-To-Device Time During the COVID-19 Crisis in a New Jersey Inner City Community Hospital.

As the novel COVID-19 pandemic was on the rise, its impact on the healthcare system was devastating. Patients became more reluctant to present to the hospital and elective procedures were being postponed for patient safety. We wanted to assess the effects of the COVID-19 pandemic on the door-to-device time in our small community hospital in the heart of Trenton, New Jersey. We created a retrospective study that evaluated all STEMI cases that presented to our institute from January 2018 until the end of May, 2021. Our primary outcome was the door-to-device time. Secondary outcomes were the length of hospital stay, ICU admission, length of ICU stay, cardiac arrest, and death during the hospitalization. We studied 114 patients that presented with STEMI to our emergency department, 77 of these patients presented pre-COVID-19, and 37 presented during the pandemic. Our median door-to-device for STEMI cases pre-COVID-19, and during the pandemic were 70 min (IQR 84-57) and 70 min (IQR 88-59) respectively with no significant difference found (P-value 0.55, Mann Whitney Test). It is, however, interesting to note that the number of STEMI admissions significantly decreased during the pandemic era. There are limitations to our study, most noticeably the number of STEMI cases at our small community hospital which limits its generalizability. Moreover, we did not assess other comorbidities which might have confounded our outcomes and we were also unable to follow patients post-discharge to assess the long-term sequela of their STEMI admission. Therefore, more dedicated studies of this clinical conundrum are required to further assess and implement guidelines for the future.

Therapeutic inefficacy of protocol driven intravenous unfractionated heparin infusion in the current era.

Unfractionated heparin (UFH) is commonly used for several life-threatening conditions requiring anticoagulant therapy but failure to reach therapeutic levels in 24 h can be associated with adverse outcomes. Use of low molecular weight heparin (LMWH) may provide an alternative while providing superior outcomes as compared to UFH. We studied 100 patients who underwent UFH therapy for >24 h and found that theoretically 80 % were eligible for LMWH therapy. Only 29 % and 40 % of the total aPTT draws were in the therapeutic window within the first 24 h and at 25-48 h respectively. This study reports that a vast majority of patients remain outside of therapeutic aPTT within first 24-48 h when anticoagulated with UFH. With high eligibility for LMWH therapy, its substitution can potentially lead to better patient outcomes, higher levels of therapeutic efficacy, and decrease in hospital resources.

Successful Management of Hemodynamically Unstable Takotsubo Cardiomyopathy With Milrinone.

Takotsubo cardiomyopathy (TTC) was initially reported in the 1990s as a reversible cause of cardiomyopathy induced by acute emotional stress. It is characterized by regional systolic dysfunction in the absence of coronary artery disease. We report a case of a 79-year-old woman who was admitted with acute respiratory failure due to pneumonia and was found to have a troponin elevation. Upon further evaluation, the patient was taken to the cardiac catheterization lab and underwent catheterization which showed apical ballooning concerning Takotsubo cardiomyopathy. She was placed on a norepinephrine drip but remained unstable. Milrinone-facilitated diuresis was then initiated with improvement and stabilization in hemodynamics. Takotsubo cardiomyopathy presenting with cardiogenic shock without left ventricular outflow tract obstruction requires treatment with inotropes. Although there is limited data to support the use of milrinone in cardiogenic shock due to TTC, its use in our case facilitated diuresis and improved the patient's outcome after norepinephrine failed to stabilize our patient's hemodynamics. Milrinone inhibits phosphodiesterase type 3 which increases the calcium influx thereby improving the myocardial contraction without any beta agonist action. Therefore, the use of milrinone which is a non-catecholamine inotrope could be considered a better alternative as compared to dobutamine given the underlying pathophysiology of TTC.

Remdesivir-Induced Extreme Sinus Bradycardia in COVID-19.

During the COVID-19 pandemic, there was an urgent need for any medication to help reduce the high death rate experienced during this deadly surge. Remdesivir is an FDA-approved drug for COVID-19 treatment, given its anti-inflammatory properties. Upon extensive literature search, we found two studies and four cases of COVID-19-induced pneumonia treated with remdesivir who were developing bradycardia. In most of these cases, the bradycardia resolved within one-to-two days of holding remdesivir, which correlated with the half-life of remdesivir. Remdesivir was shown to have benefits in COVID-19-induced pneumonia during the COVID-19 surge; however, its use has been controversial. According to the studies, the sinus bradycardia following remdesivir administration does not impact patients' prognosis in terms of ICU admission and in-hospital mortality. There are multiple case reports noted to report several remdesivir-induced cardiac side effects. In our case, prolonged use and high dosages may induce cardiotoxicity, manifesting as severe bradycardia. Several possible mechanisms for cardiac adverse effects with remdesivir need further investigation and research as COVID-19 remains an active global issue. We present a 53-year-old man hospitalized with COVID-19-induced pneumonia who experienced extreme sinus bradycardia that is likely attributable to remdesivir.

Early Manifestation of Clozapine-Induced Cardiotoxicity: Detection, Pathophysiology, and Management.

Schizoaffective disorder, bipolar type is a chronic mental health disorder that may manifest as mania. Clozapine is effective in treating acute mania and in achieving mood stabilization. However, on rare occasions, the use of clozapine has been associated with cardiotoxicity. Here, we present a case of a 31-year-old man who at baseline is known to have schizoaffective disorder, bipolar type, and cannabis dependence and was admitted to our hospital with a psychotic relapse. He was treated with clozapine, uptitrated to a maximum daily dose of 200mg twice daily by day 10. Thereafter he became febrile and experienced malaise, myalgias, and chest pain. He was noted on electrocardiogram to have sinus tachycardia without ischemic changes. In this context, he had a troponin leak, increased white blood cell count, serologies and cultures were negative and chest x-ray revealed no acute disease of the chest. Due to the suspicion of clozapine-induced cardiotoxicity, a transthoracic echocardiogram was done, which revealed mildly depressed left ventricular (LV) systolic function without pericardial effusion. Thereafter, clozapine was withdrawn and switched to lithium. Additionally, the cardioselective, metoprolol tartrate was initiated. Within 36-48 hours, he had resolution of symptoms and remained cardiovascularly stable. Clozapine uncommonly causes cardiotoxicity and early features may be non-specific. Awareness of this and recognizing early features aids in reducing the associated cardiovascular morbidity and mortality.

Nasal Nitric Oxide Levels in HIV Infection: A Cross-Sectional Study.

INTRODUCTION: Low levels of nasal NO have been associated with increased propensity to rhinosinusitis and respiratory tract infections. Our objective was to describe nasal NO levels in HIV-infected individuals versus healthy controls and determine possible risk factors for reduced nasal NO levels. MATERIALS AND METHODS: HIV-infected individuals and healthy controls were recruited. Participants underwent nasal NO testing by standardized methods using a CLD88 chemiluminescence analyzer and completed the Sinonasal Outcome Test-20 (SNOT-20) on symptoms of rhinosinusitis. RESULTS: Participants included 41 HIV-infected individuals with suppressed VL on antiretroviral therapy (ART group), 5 HIV-infected individuals with detectable VL off ART (viremic group), and 12 healthy controls (HC group). Mean nasal NO level was 253 (±77) nL/min in the ART group, 213 (±48) nL/min in the viremic group, and 289 (±68) nL/min in the HC group (p = 0.133; ANOVA). There was no correlation between nasal NO level and VL in viremic individuals (r = -0.200; p = 0.747). Differences were observed in mean total points on the SNOT-20 which were 19 (±16)/100, 18 (±26)/100, and 4 (±4)/100 in the ART, viremic, and HC groups, respectively (p = 0.013; ANOVA). CONCLUSION: Healthy individuals, HIV patients on ART, and viremic individuals off ART display similar nasal NO levels. However, rhinosinusitis symptoms remain prominent despite ART-treatment.