Hypercoagulability, endotheliopathy, and inflammation approximating 1 year after recovery: Assessing the long-term outcomes in COVID-19 patients.

Sustained hypercoagulability and endotheliopathy are present in convalescent COVID-19 patients for up to 4 months from recovery. The hemostatic, endothelial, and inflammatory profiles of 39 recovered COVID-19 patients were evaluated up to 16 months after recovery from COVID-19. These values were compared with a control group of healthy volunteers (n = 124). 39 patients (71.8% males, median age 43 years) were reviewed at a mean of 12.7 ± 3.6 months following recovery. One patient without cardiovascular risk factors had post COVID-19 acute ischaemic limb. Elevated D-dimer and Factor VIII levels above normal ranges were noted in 17.9% (7/39) and 48.7% (19/39) of patients respectively, with a higher median D-dimer 0.34 FEU µg/mL (IQR 0.28, 0.46) (p < .001) and Factor VIII 150% (IQR 171, 203) (p = .004), versus controls. Thrombin generation (Thromboscreen) showed a higher median endogenous thrombin potential (ETP) of 1352 nM*min (IQR 1152, 1490) (p = .002) and a higher median peak height of 221.4 nM (IQR 170.2, 280.4) (p = 0.01) and delayed lag time 2.4 min (1.42-2.97) (p = 0.0002) versus controls. Raised vWF:Ag and ICAM-1 levels were observed in 17.9% (7/39) and 7.7% (3/39) of patients respectively, with a higher median VWF:Ag 117% (IQR 86, 154) (p = 0.02) and ICAM-1 54.1 ng/mL (IQR 43.8, 64.1) (p = .004) than controls. IL-6 was noted to be raised in 35.9% (14/39) of patients, with a higher median IL-6 of 1.5 pg/mL (IQR 0.6, 3.0) (p = 0.004) versus controls. Subgroup analysis stratifying patients by COVID-19 severity and COVID-19 vaccination preceding SARS-CoV-2 infection did not show statistically significant differences. Hypercoagulability, endothelial dysfunction, and inflammation are still detectable in some patients approximately 1 year after recovery from COVID-19.

Global haemostatic tests demonstrate the absence of parameters of hypercoagulability in non-hypoxic mild COVID-19 patients: a prospective matched study.

Severe COVID-19 patients demonstrate hypercoagulability, necessitating thromboprophylaxis. However, less is known about the haemostatic profile in mild COVID-19 patients. We performed an age and gender-matched prospective study of 10 severe and 10 mild COVID-19 patients. Comprehensive coagulation profiling together with Thromboelastography and Clot Waveform Analysis were performed. FBC, PT, APTT, D-dimer, fibrinogen and CWA were repeated every 3 days for both groups and repeat TEG was performed for severe patients up till 15 days. On recruitment, severe patients had markers reflecting hypercoagulability including raised median D-dimer 1.0 µg/mL (IQR 0.6, 1.4) (p = 0.0004), fibrinogen 5.6 g/L (IQR 4.9, 6.6) (p = 0.002), Factor VIII 206% (IQR 171, 203) and vWF levels 265.5% (IQR 206, 321). Mild patients had normal values of PT, aPTT, fibrinogen and D-dimer, and slightly elevated median Factor VIII and von Willebrand factor (vWF) levels. Repeated 3-day assessments for both groups showed declining trends in D-dimer and Fibrinogen. CWA of severe COVID-19 group demonstrated hypercoagulability with an elevated median values of aPTT delta change 78.8% (IQR 69.8, 85.2) (p = 0.001), aPTT clot velocity (min1) 7.8%/s (IQR 6.7, 8.3) (p = 0.001), PT delta change 22.4% (IQR 19.4, 29.5) (p = 0.004), PT min1 7.1%/s (IQR 6.3, 9.0) (p = 0.02), PT clot acceleration (min 2) 3.6%/s2 (IQR 3.2, 4.5) (p = 0.02) and PT clot deceleration (max2) 2.9%/s2 (IQR 2.5, 3.5) (p = 0.02). TEG of severe patients reflected hypercoagulability with significant increases in the median values of CFF MA 34.6 mm (IQR 27.4,38.6) (p = 0.003), CRT Angle 78.9° (IQR 78.3, 80.0) (p = 0.0006), CRT A10 67.6 mm (IQR 65.8, 69.6) (p = 0.007) and CFF A10 32.0 mm (IQR 26.8, 34.0) (p = 0.003). Mild COVID-19 patients had absent hypercoagulability in both CWA and TEG. 2 severe patients developed thromboembolic events while none occurred in the mild COVID-19 group. Mild COVID-19 patients show absent parameters of hypercoagulability in global haemostatic tests while those with severe COVID-19 demonstrated parameters associated with hypercoagulability on the global haemostatic tests together with raised D-Dimer, fibrinogen, Factor VIII and vWF levels.

ST-segment elevation myocardial infarction in post-COVID-19 patients: A case series.

Coronavirus disease 2019 (COVID-19) is associated with an increased risk of thromboembolic events in the acute setting. However, the abnormal thrombotic diathesis is not known to persist into the recovery phase of COVID-19 infection. We described 3 cases of ST-segment elevation myocardial infarction in healthy male patients who recovered from COVID-19 with no prior cardiovascular risk factors. They shared features of elevated von Willebrand factor antigen, factor VIII and D-dimer level. One patient had a borderline positive lupus anticoagulant. Intravascular ultrasound of culprit vessels revealed predominantly fibrotic plaque with minimal necrotic core. Clot waveform analysis showed parameters of hypercoagulability. They were treated with dual antiplatelet therapy, angiotensin-converting-enzyme inhibitor, beta blocker and statin. These cases highlight the strong thrombogenic nature of COVID-19 that persisted among patients who recovered from infection. Several suspected mechanisms could explain the association between vascular thrombosis in the convalescent period (endothelial dysfunction, hypercoagulability, systemic inflammatory response and vasculopathy). Additional studies on "long COVID" are essential for identifying endotheliopathy and thrombotic sequalae.

Tuberculous pericarditis with tamponade diagnosed concomitantly with COVID-19: a case report.

BACKGROUND: Tuberculous pericarditis is a rare manifestation of tuberculosis infection. COVID-19 pandemic poses a challenge in detecting uncommon diseases. CASE SUMMARY: A 47-year-old man was admitted with symptoms of COVID-19 infection. Rapid progression of cardiomegaly on radiograph with clinical deterioration were suggestive of pericardial tamponade. Urgent pericardiocentesis revealed haemoserous fluid, elevated adenosine deaminase, and positive tuberculous (TB) polymerase chain reaction (PCR). He was started on anti-TB therapy and Remdesivir with marked improvement of symptoms. Repeat echocardiogram and CT thorax showed resolution of pericardial fluid, and the patient remained well on discharge. DISCUSSION: This case highlights the difficulty in detecting a concomitant rare but important disease. The development of massive pericardial tamponade acutely is not pathognomonic for COVID-19, and a careful diagnostic process involving multi-modality imaging occurred to arrive at a diagnosis of tuberculosis.

Safety of electronic massagers in patients with cardiac implantable electronic devices.

BACKGROUND: Current recommendations by cardiac implantable electronic devices (CIEDs) manufacturers on electromagnetic interference (EMI) are based on extrapolations of studies exposing CIEDs to electromagnetic fields produced by Helmholtz coils and industrial equipment. There are currently little data whether commercially available electronic massagers can cause EMI in CIEDs in vivo. This is of interest as the use of electronic massagers is common in Asia. METHODS: The study evaluated CIED patients before, during and after a 10-minute exposure to a commercially available electronic backrest upper body massager. Post-exposure sensing, pacing threshold, and lead impedance were compared to baseline values. The presence of artefacts, EMI, and adverse clinical events during exposure was recorded. RESULTS: Eighty-six patients (59 pacemakers and 27 implantable cardioverter-defibrillators) with a total of 151 leads (60 atrial, 86 right ventricular, and 5 left ventricular) were evaluated. There was no incidence of EMI causing inappropriate inhibition of pacing or inappropriate defibrillation. There was no significant difference in the pacing threshold, sensing, and lead impedance post-exposure compared to baseline values. CONCLUSION: Our study, though limited by small numbers and exposure to only 1 type of electronic massager, shows that it is potentially safe for patients with CIEDs to use commercially available electronic massagers with similar characteristics as the one tested in this study.

Clinical characteristics, risk factors and outcomes of South-East Asian patients with acute pulmonary embolism.

BACKGROUND: The clinical features of acute PE have not been well studied in South-East Asia. We therefore sought to evaluate the clinical characteristics, risk factors and outcomes of patients diagnosed with acute pulmonary embolism (PE) in our region. METHODS: From January 2008 to March 2013, 343 patients were admitted to our tertiary institution with acute PE. Data were collected retrospectively on baseline clinical characteristics, presenting signs and symptoms, results of electrocardiographic and imaging studies, therapeutic modality and hospital course. RESULTS: 91% of the patients presented with submassive PE. 6.1% of patients had saddle PE. The most common presenting symptom was dyspnea (72.3%) followed by chest pain (12.8%), hemoptysis (2.6%), syncope (2.6%) and cardiovascular collapse (1.2%). Risk factors for PE were idiopathic cause (33.5%), immobilization (21%), malignancy (6.1%) and hypercoagulable state (2.9%). The overall in-hospital mortality was 5%. Factors associated with mortality were massive PE, tachycardia at presentation, right ventricular dysfunction and cardiogenic shock. Bleeding complications occurred in 10.2% of patients (major bleeding in 3.5%). CONCLUSION: Acute PE in the South-East Asian patients is associated with an overall mortality rate of 5%. The bleeding complications from treatment are also high.