Effects of Multidisciplinary Rehabilitation Enhanced with Neuropsychological Treatment on Post-Acute SARS-CoV-2 Cognitive Impairment (Brain Fog): An Observational Study.

Concentration and memory impairment (named "brain fog") represents a frequent and disabling neuropsychological sequela in post-acute COVID-19 syndrome (PACS) patients. The aim of this study was to assess whether neurocognitive function could improve after a multidisciplinary rehabilitation program enhanced with individualized neuropsychological treatment. A prospective monocentric registry of PACS patients consecutively admitted to our Rehabilitation Unit was created. The Montreal Cognitive Assessment (MoCA) was used to assess cognitive impairment at admission and discharge. A total of sixty-four (64) PACS patients, fifty-six (56) of them with brain fog, were treated with a day-by-day individualized psychological intervention of cognitive stimulation (45 min) on top of a standard in-hospital rehabilitation program. The mean duration of the acute-phase hospitalization was 55.8 ± 25.8 days and the mean in-hospital rehabilitation duration was 30 ± 10 days. The mean age of the patients was 67.3 ± 10.4 years, 66% of them were male, none had a previous diagnosis of dementia, and 66% of the entire sample had experienced severe COVID-19. At admission, only 12% of the patients had normal cognitive function, while 57% showed mild, 28% moderate, and 3% severe cognitive impairment. After psychological treatment, a significant improvement in the MoCA score was found (20.4 ± 5 vs. 24.7 ± 3.7; p < 0.0001) as a result of significant amelioration in the following domains: attention task (p = 0.014), abstract reasoning (p = 0.003), language repetition (p = 0.002), memory recall (p < 0.0001), orientation (p < 0.0001), and visuospatial abilities (p < 0.0001). Moreover, the improvement remained significant after multivariate analysis adjusted for several confounding factors. Finally, at discharge, 43% of the patients with cognitive impairment normalized their cognitive function, while 4.7% were discharged with residual moderate cognitive impairment. In conclusion, our study provides evidence of the effects of multidisciplinary rehabilitation enhanced with neuropsychological treatment on improvement in the cognitive function of post-acute COVID-19 patients.

Personalized Management of Sudden Death Risk in Primary Cardiomyopathies: From Clinical Evaluation and Multimodality Imaging to Ablation and Cardioverter-Defibrillator Implant.

Sudden cardiac death represents the leading cause of death worldwide; although the majority of sudden deaths occur in an elderly population with coronary artery disease, some occur in young and otherwise healthy individuals, as is the case of cardiomyopathies. The aim of the present review is to provide a stepwise hierarchical approach for the global sudden death risk estimation in primary cardiomyopathies. Each individual risk factor is analyzed for its contribution to the overall risk of sudden death for each specific cardiomyopathy as well as across all primary myocardial diseases. This stepwise hierarchical and personalized approach starts from the clinical evaluation, subsequently passes through the role of electrocardiographic monitoring and multimodality imaging, and finally concludes with genetic evaluation and electro-anatomical mapping. In fact, the sudden cardiac death risk assessment in cardiomyopathies depends on a multiparametric approach. Moreover, current indications for ventricular arrhythmia ablation and defibrillator implantation are discussed.

Three-Dimensional Automated, Machine-Learning-Based Left Heart Chamber Metrics: Associations with Prevalent Vascular Risk Factors and Cardiovascular Diseases.

Background. Three-dimensional transthoracic echocardiography (3DE) powered by artificial intelligence provides accurate left chamber quantification in good accordance with cardiac magnetic resonance and has the potential to revolutionize our clinical practice. Aims. To evaluate the association and the independent value of dynamic heart model (DHM)-derived left atrial (LA) and left ventricular (LV) metrics with prevalent vascular risk factors (VRFs) and cardiovascular diseases (CVDs) in a large, unselected population. Materials and Methods. We estimated the association of DHM metrics with VRFs (hypertension, diabetes) and CVDs (atrial fibrillation, stroke, ischemic heart disease, cardiomyopathies, >moderate valvular heart disease/prosthesis), stratified by prevalent disease status: participants without VRFs or CVDs (healthy), with at least one VRFs but without CVDs, and with at least one CVDs. Results. We retrospectively included 1069 subjects (median age 62 [IQR 49−74]; 50.6% women). When comparing VRFs with the healthy, significant difference in maximum and minimum indexed atrial volume (LAVi max and LAVi min), left atrial ejection fraction (LAEF), left ventricular mass/left ventricular end-diastolic volume ratio, and left ventricular global function index (LVGFI) were recorded (p < 0.05). In the adjusted logistic regression, LAVi min, LAEF, LV ejection fraction, and LVGFI showed the most robust association (OR 3.03 [95% CI 2.48−3.70], 0.45 [95% CI 0.39−0.51], 0.28 [95% CI 0.22−0.35], and 0.22 [95% CI 0.16−0.28], respectively, with CVDs. Conclusions. The present data suggested that novel 3DE left heart chamber metrics by DHM such as LAEF, LAVi min, and LVGFI can refine our echocardiographic disease discrimination capacity.

Perceived Anxiety, Coping, and Autonomic Function in Takotsubo Syndrome Long after the Acute Event.

BACKGROUND: Anxiety and depressive disorders represent predisposing factors for the autonomic dysfunctions that characterize the acute phase of Takotsubo syndrome (TS). However, there is insufficient data on this relationship after the acute event. The present study aimed at evaluating the psychological and autonomic status of patients with a history of TS. METHODS: Ten TS patients whose acute event occurred at least 1 year prior to the evaluation and nine healthy age- and sex-matched subjects were evaluated. The cardiovascular assessment included a clinical examination, beat-to-beat heart rate monitoring to assess heart rate variability, and a psychological examination using the 16 Personality Factors-C Form (16PF), the Acceptance and Action Questionnaire-II, the Coping Orientations to Problems Experienced (COPE), the Beck Depression Inventory-II, and the State-Trait Anxiety Inventory (STAI). RESULTS: TS patients scored significantly higher on the STAI (i.e., Anxiety Trait), 16PF (i.e., Tension), and COPE (i.e., Transcendental Orientation). TS patients also showed lower heart rate variability. Moreover, a significant inverse correlation was found between sympathetic tone (LF/HF ratio) and coping orientation. CONCLUSIONS: Long after the acute event, TS patients are characterized by elevated anxiety, high tension, and a specific religious coping strategy.

DIGItal Health Literacy after COVID-19 Outbreak among Frail and Non-Frail Cardiology Patients: The DIGI-COVID Study.

BACKGROUND: Telemedicine requires either the use of digital tools or a minimum technological knowledge of the patients. Digital health literacy may influence the use of telemedicine in most patients, particularly those with frailty. We aimed to explore the association between frailty, the use of digital tools, and patients' digital health literacy. METHODS: We prospectively enrolled patients referred to arrhythmia outpatient clinics of our cardiology department from March to September 2022. Patients were divided according to frailty status as defined by the Edmonton Frail Scale (EFS) into robust, pre-frail, and frail. The degree of digital health literacy was assessed through the Digital Health Literacy Instrument (DHLI), which explores seven digital skill categories measured by 21 self-report questions. RESULTS: A total of 300 patients were enrolled (36.3% females, median age 75 (66-84)) and stratified according to frailty status as robust (EFS ≤ 5; 70.7%), pre-frail (EFS 6-7; 15.7%), and frail (EFS ≥ 8; 13.7%). Frail and pre-frail patients used digital tools less frequently and accessed the Internet less frequently compared to robust patients. In the logistic regression analysis, frail patients were significantly associated with the non-use of the Internet (adjusted odds ratio 2.58, 95% CI 1.92-5.61) compared to robust and pre-frail patients. Digital health literacy decreased as the level of frailty increased in all the digital domains examined. CONCLUSIONS: Frail patients are characterized by lower use of digital tools compared to robust patients, even though these patients would benefit the most from telemedicine. Digital skills were strongly influenced by frailty.

Digital literacy as a potential barrier to implementation of cardiology tele-visits after COVID-19 pandemic: the INFO-COVID survey.

BACKGROUND: During the COVID-19 pandemic, the implementation of telemedicine has represented a new potential option for outpatient care. The aim of our study was to evaluate digital literacy among cardiology outpatients. METHODS: From March to June 2020, a survey on telehealth among cardiology outpatients was performed. Digital literacy was investigated through six main domains: age; sex; educational level; internet access; availability of internet sources; knowledge and use of teleconference software programs. RESULTS: The study included 1067 patients, median age 70 years, 41.3% females. The majority of the patients (58.0%) had a secondary school degree, but among patients aged ≥ 75 years old the most represented educational level was primary school or none. Overall, for internet access, there was a splitting between "never" (42.1%) and "every day" (41.0%), while only 2.7% answered "at least 1/month" and 14.2% "at least 1/week". In the total population, the most used devices for internet access were smartphones (59.0%), and WhatsApp represented the most used app (57.3%). Internet users were younger compared to non-internet users (63 vs. 78 years old, respectively) and with a higher educational level. Age and educational level were associated with non-use of internet (age-per 10-year increase odds ratio (OR) = 3.07, 95% CI: 2.54-3.71, secondary school OR = 0.18, 95% CI: 0.12-0.26, university OR = 0.05, 95% CI: 0.02-0.10). CONCLUSIONS: Telemedicine represents an appealing option to implement medical practice, and for its development it is important to address the gaps in patients' digital skills, with age and educational level being key factors in this setting.

Anxiety disorders and stressful events in Takotsubo syndrome.

BACKGROUND: Anxiety disorders are more common in Takotsubo syndrome (TS) than in acute coronary syndrome patients. The aim of this study was to investigate whether pre-existing anxiety disorders predispose to TS triggered by exclusively emotional stressful events. METHODS: Triggering events were compared in 58 TS patients with and without pre-existing anxiety disorders; clinical, electrocardiographic and echocardiographic data were also collected. RESULTS: Thirty-one (53%) patients had a previous history of anxiety disorders. The exclusively emotional stressful event-rate was higher in TS patients with pre-existing anxiety disorder (74% vs. 30%, p = 0.001), while TS caused by an undetermined trigger were significantly higher in patients without anxiety disorders (33% vs. 10%, p = 0.027). Moreover, in TS patients without a previous history of anxiety disorders, a trend of higher prevalence of physical events was found (16% vs. 37%, p = 0.07). CONCLUSIONS: In patients with pre-existing anxiety disorders, TS was predominantly triggered by exclusively emotional stressful events, thereby suggesting a possible relationship between anxiety and emotional cardiac frailty in TS patients.