Prophylactic or therapeutic doses of heparins for COVID-19 infection? A retrospective study.

BACKGROUND: Coronavirus disease 19 (COVID-19) is a global outbreak. COVID-19 patients seem to have relevant coagulative abnormalities, even if they are not typical of disseminated intravascular coagulopathy (DIC) of the kind seen in septicaemia. Therefore, anticoagulant therapy with heparins is increasing in interest for a clinical approach to these patients, particularly if older. Studies comparing if prophylactic doses are more effective than therapeutic ones are still missing. METHODS: Data were collected in the Geriatric Section of the Dolo Hospital, ULSS 3 "Serenissima", Venice from 31st March to 01st May 2020. Heparins (calciparin, fondaparinux, enoxaparine) were divided into prophylactic or therapeutic doses. People previously treated with oral anticoagulants were removed. Vital status was assessed using administrative data. Cox's regression analysis, adjusted for potential confounders, was used for assessing the strength of the association between heparins and mortality. The data were reported as hazard ratio (HR) with 95% confidence intervals (CIs). RESULTS: 81 older people (mean age 84.1 years; females = 61.9%) were included. No significant differences in terms of demographic and clinical characteristics emerged between people treated with prophylactic or therapeutic doses, including age, gender, X-rays findings or severity of disease. Therapeutic doses were not associated to a better survival rate (HR 1.06; 95% CI 0.47-2.60; p = 0.89), even after adjusting for 15 confounders related to mortality (HR 0.89; 95% CI 0.30-2.71; p = 0.84). CONCLUSIONS: Our paper indicates that in older people affected by COVID-19 there is no justification for using therapeutic doses instead of prophylactic ones, having a similar impact on mortality risk.

How to define the therapeutic limits.

With the advance of technological progress and the increase in life expectancy, it is nowadays mandatory to define what is the therapeutic limit. Every day each physician must take therapeutic decisions on the basis of his scientific knowledge, but also of his own conscience and sense of limits. They can not avoid to consider the global risk of death, disability and morbidity in more advanced age, especially in the field of cardiology and cardiac surgery. In these subjects, both fit that frail, is necessary not only an evaluation for adequate risk assessment, but also a multidimensional assessment performed with advanced tools. The resilience of the subject, ability for which some patients considered out of therapy demonstrate the ability to adapt and overcome critical phases, must also be weighed. Where and what is the therapeutic limit should be evaluated individually with humility, competence and capacity for dialogue with other disciplines in a work team that respects the individual professionalism. In recent years, much has changed in the cardiology/cardiac surgery approach in old people. With the development of less or minimal invasive new techniques, there are no more insurmountable limits that can be connected only to the chronological age of the patients.

Effect of restoring sinus rhythm in hypertensive patients with atrial fibrillation undergoing electrical cardioversion.

INTRODUCTION: Little is known about the effects of atrial fibrillation (AF) on blood pressure (BP) levels in hypertensive patients. Some studies suggest a role for rhythm control in managing such patients' BP, but the improvement observed in cardiac performance after restoring sinus rhythm (SR) may coincide with an increase in BP. The aim of this study was to apply ambulatory BP monitoring to analyze BP changes in hypertensive patients after electrical cardioversion for persistent AF. METHODS AND RESULTS: The study included 54 hypertensive patients with persistent AF. Ambulatory BP monitoring was performed on the day before electrical cardioversion and again about a month later under conditions of stable medical treatment.Patients with a SR at follow-up (n=34) had significantly higher 24-h, night-time (P<0.05), and daytime (P=0.074) systolic BP, and significantly lower 24-h, daytime (P<0.05), and night-time (P=0.078) DBP. The number of patients with nocturnal dipping decreased from 20 to 14 and the number of those with reverse dipping increased from 1 to 7. Patients with recurrent AF at follow-up (n=20) showed no significant BP changes, except for a decrease in the mean night-time DBP. CONCLUSION: Restoring SR in hypertensive patients with AF led to a significant increase in their systolic BP (especially at night) and a decrease in their DBP. Hypertensive patients with AF should consequently undergo ambulatory BP monitoring after electrical cardioversion for the purpose of adjusting their antihypertensive treatment.

Reliability of Oscillometric Blood Pressure Monitoring in Atrial Fibrillation Patients Admitted for Electric Cardioversion.

The reliability of automated oscillometric blood pressure (BP) monitors in atrial fibrillation (AF) has been poorly investigated, only comparing different patients with AF and sinus rhythm (SR), and is a method influenced by individual characteristics. This study compared the reliability of the oscillometric device A&D TM-2430 (A&D Company, Tokyo, Japan) with that of a mercury sphygmomanometer in AF patients whose SR was restored after electric cardioversion (ECV). Three consecutive BP measurements were obtained on the day before and about 30 days after ECV in stable treatment conditions. Of the 100 patients studied, 63 reported an SR at follow-up, with a significant increase in systolic BP and a significant decrease in diastolic BP according to both devices. There were no significant differences between the systolic and diastolic biases before and after ECV using Bland Altman analysis (P > .05 each). The oscillometric device analyzed, using three repeated measurements, is reliable in measuring BP in AF patients.

Ambulatory blood pressure monitoring in elderly patients with chronic atrial fibrillation: is it absolutely contraindicated or a useful tool in clinical practice and research?

The aim of this study was to test whether ambulatory blood pressure monitoring (ABPM) in elderly patients with atrial fibrillation (AF) is as feasible and reliable as ABPM is in patients with normal sinus rhythm (SR). Studies of ABPM in the elderly remain limited, and the use of this method in patients with AF remains controversial. The Italian SIIA 2008 guidelines consider ABPM 'absolutely contraindicated' for AF patients. This study was conducted on 200 hospitalized patients aged ≥ 65 years (68% females; mean age 82.4 ± 6.3 years): 100 patients with SR and 100 patients with permanent AF. Each patient completed serial blood pressure (BP) measurements with a clinical sphygmomanometer (Sphyg) and ABPM. Differences in mean heart rate (HR) between patient groups were not statistically significant. A total of 99.5% of patients were hypertensive. There were no significant differences between SR and AF patients in mean systolic BP (SBP) and diastolic BP (DBP) values, as measured with the Sphyg or by ABPM. Compared with the Sphyg, errors associated with BP measurements obtained by ABPM did not significantly differ between the two groups. ABPM proved to be as feasible as Sphyg measurements in both AF patients (intraclass correlation coefficients=0.73, 0.67 and 0.74 for SBP, DBP and HR, respectively) and SR patients (intraclass correlation coefficients=0.74, 0.58 and 0.67 for SBP, DBP and HR, respectively). A Bland-Altman plot analysis confirmed that there was good agreement between the two methods. Stable AF (HR 60-100 b.p.m.) should not be considered as an absolute contraindication for the use of ABPM, even in the elderly; it could be a 'relative' contraindication for very unstable AF patients.

Hypothyroidism in the elderly: diagnostic pitfalls illustrated by a case report.

A diagnosis of hypothyroidism in the elderly can easily be overlooked if we rely exclusively on its clinical presentation because this may be highly non-specific, since the signs and symptoms of the disease are common to other diseases typical of old age, and even to the normal aging process. Imaging diagnostics (ultrasound or CT), when considered alone, are also of little use for the purpose of clarifying thyroid gland function. We report here on a case of primary hypothyroidism that was diagnosed late because the correlated signs and symptoms (asthenia, bradycardia, pleural effusions, hyponatremia, worsening renal and respiratory insufficiency, hoarseness) had previously been attributed to the normal aging process and to the patient's other health conditions (Parkinson's disease, PD; chronic obstructive pulmonary disease, COPD). After a couple of weeks of treatment with levothyroxine and liothyronine, there were clinical and laboratory evidences of an improvement in the patient's condition. She became more reactive, with a shriller voice. The pleural effusion disappeared, and so did the bradycardia. Laboratory tests showed normal sodium levels, and the renal insufficiency had improved. The lack of specificity of the clinical presentation of hypothyroidism in the elderly might justify the routine measurement of thyroid-stimulating hormone in these patients.