Efficacy and Safety of Anticoagulant Therapy in COVID-19-Related Pulmonary Embolism with Different Extension.

Pulmonary embolism (PE) has been associated with SARS-CoV-2 infection, and its incidence is highly variable. The aim of our study was to describe the radiological and clinical presentations, as well as the therapeutic management, of PEs that occurred during SARS-CoV-2 infection in a cohort of hospitalized patients. In this observational study, we enrolled patients with moderate COVID-19 who developed PE during hospitalization. Clinical, laboratory, and radiological features were recorded. PE was diagnosed on clinical suspicion and/or CT angiography. According to CT angiography results, two groups of patients were further distinguished: those with proximal or central pulmonary embolism (cPE) and those with distal or micro-pulmonary embolism (mPE). A total of 56 patients with a mean age of 78 ± 15 years were included. Overall, PE occurred after a median of 2 days from hospitalization (range 0-47 days) and, interestingly, the majority of them (89%) within the first 10 days of hospitalization, without differences between the groups. Patients with cPE were younger (p = 0.02), with a lower creatinine clearance (p = 0.04), and tended to have a higher body weight (p = 0.059) and higher D-Dimer values (p = 0.059) than patients with mPE. In all patients, low-weight molecular heparin (LWMH) at anticoagulant dosage was promptly started as soon as PE was diagnosed. After a mean of 16 ± 9 days, 94% of patients with cPE were switched to oral anticoagulant (OAC) therapy, which was a direct oral anticoagulant (DOAC) in 86% of cases. In contrast, only in 68% of patients with mPE, the prosecution with OAC was indicated. The duration of treatment was at least 3 months from PE diagnosis in all patients who started OAC. At the 3-month follow-up, no persistence or recurrence of PE as well as no clinically relevant bleedings were found in both groups. In conclusion, pulmonary embolism in patients with SARS-CoV-2 may have different extensions. Used with clinical judgment, oral anticoagulant therapy with DOAC was effective and safe.

Prognostic Value of 12-Leads Electrocardiogram at Emergency Department in Hospitalized Patients with Coronavirus Disease-19.

Background: Electrocardiogram (ECG) offers a valuable resource easily available in the emergency setting. Objective: Aim of the study was to describe ECG alterations on emergency department (ED) presentation or that developed during hospitalization in SARS-CoV-2-infected patients and their association with 28-day mortality. Methods: A retrospective, single-center study including hospitalized patients with SARS-CoV-2 was conducted. ECG was recorded on ED admission to determine: heart rhythm, rate, and cycle; atrio-ventricular and intra-ventricular conduction; right ventricular strain; and ventricular repolarization. A specialized cardiologist blinded for the outcomes performed all 12-lead ECG analyses and their interpretation. Results: 190 patients were included, with a total of 24 deaths (12.6%). Age (p < 0.0001) and comorbidity burden were significantly higher in non-survivors (p < 0.0001). Atrial fibrillation (AF) was more frequent in non-survivors (p < 0.0001), alongside a longer QTc interval (p = 0.0002), a lower Tp-e/QTc ratio (p = 0.0003), and right ventricular strain (p = 0.013). Remdesivir administration was associated with bradycardia development (p = 0.0005) but no increase in mortality rates. In a Cox regression model, AF (aHR 3.02 (95% CI 1.03−8.81); p = 0.042), QTc interval above 451 ms (aHR 3.24 (95% CI 1.09−9.62); p = 0.033), and right ventricular strain (aHR 2.94 (95% CI 1.01−8.55); p = 0.047) were associated with higher 28-day mortality risk. Conclusions: QTc interval > 451 ms, right ventricular strain, and AF are associated with higher mortality risk in SARS-CoV-2 hospitalized patients. ECG recording and its appropriate analysis offers a simple, quick, non-expensive, and validated approach in the emergency setting to guide COVID-19 patients' stratification.

ECG evaluation in 11 949 Italian teenagers: results of screening in secondary school.

AIM: There is lack of evidence regarding the screening role of ECG for sudden cardiac death (SCD) prevention. Our aim was to evaluate the prevalence of ECG abnormalities among teenagers according to sport participation and competitive status. METHODS: Eleven thousand nine hundred and forty-nine Italian pupils from 179 secondary schools (13-19 years) were consecutively enrolled. ECG abnormalities were divided into minor and major. Medical history, clinical examination and sport activity information were acquired. Further evaluations were suggested in case of major ECG abnormalities. Follow-up was performed at 2 years. RESULTS: N = 1945 (16%) pupils had ECG abnormalities. Major ECG abnormalities were detected in 13% of the cohort, minor in 34%. ECG abnormalities were more common in nonathletes compared with athletes. A diagnosis of cardiac disease was reached in 25 (1.6%) of the pupils with major ECG abnormalities. CONCLUSION: ECG abnormalities are common among young populations and more prevalent in nonathletes. Among pupils with major ECG abnormalities 1.6% had a cardiac disease diagnosis. Our results are in line with the data supporting ECG screening in the general young population.

Combined therapy with subcutaneous implantable cardiac defibrillator and leadless pacemaker in a patient with persistent left superior vena cava and mega coronary sinus: A challenging case for the best treatment.

In a patient requiring pacing and defibrillation therapy, but without superior venous access, combined therapy with S-ICD and leadless pacemaker could be the best solution. An appropriate programming of both devices represents the technical challenge in order to avoid inappropriate shocks due to leadless pacing oversensing.

Bradyarrhythmias in patients with SARS-CoV-2 infection: A narrative review and a clinical report.

Several cardiovascular diseases and arrhythmic disorders have been described in COVID-19 era as likely related to SARS-CoV-2 infection. The prognostic relevance of bradyarrhythmias during the infection has not been yet described and no data are available about long-term heart conduction disorders. A review of literature concerning the association between hypokinetic arrhythmias and COVID-19 from January 2020 to February 2021 was performed. The key-words used for the research were: "sinus node disfunction," "sick sinus syndrome (SSS)," "sino-atrial block," "atrio-ventricular block (AVB)," "bradyarrhythmias," and "COVID-19″ or "SARS-CoV-2.″ Excluding "relative bradycardia," a total of 38 cases of bradyarrhythmia related to SARS-CoV-2 infection have been described, even in very young people, requiring in many cases a definitive pacemaker implantation. Furthermore, we report a case of non-hospitalized 47-years old man with a SSS developed as a consequence of mild SARS-CoV-2 infection. While in all described cases heart conduction disorders were found at presentation of the infection or during hospitalization for COVID-19, in our case the diagnosis of SSS was made after the resolution of the infection. Although rarely, heart conduction disorders may occur during COVID-19 and the present case highlights that a cardiological follow up may be desirable even after the resolution of infection, especially in the presence of symptoms suggesting a possible heart involvement.

The Choice of Antithrombotic Therapy in a Patient with New-Onset Atrial Fibrillation and High Coronary Thrombotic risk.

Current guidelines are mandatory in the choice of anticoagulant and/or antiplatelet therapy in patients with atrial fibrillation undergoing percutaneous transluminal coronary angioplasty and in patients with coronary artery disease and previous percutaneous transluminal coronary angioplasty that develop atrial fibrillation. However, in the real world there are crossroads with multiple choices, especially taking into account patient's peculiar characteristics and risk factors, which sometimes are not well represented in the guidelines. The reported clinical case focuses on the choice of anticoagulation therapy in a patient with chronic and severe coronary artery disease and new diagnosis of atrial fibrillation who, considering his specifically high coronary thrombotic risk, probably should continue antiplatelet therapy.

TNM-like classification: a new proposed method for heart failure staging.

Heart Failure (HF) is an acute or chronic syndrome, that causes a lot of damaging effects to every system. The involvement of different systems is variably related to age and others comorbidities. The severity of organ damage is often proportional to the duration of heart failure. The typology of HF and the duration determine which organs will be affected and vice versa the severity of organ damage supplies precious information about prognosis and outcome of patients with heart failure. Moreover, a classification based not only on symptomatic and syndromic typical features of heart failure, but also on functional data of each system, could allow us to apply the most appropriate therapies, to obtain a more accurate prognosis, and to employ necessary and not redundant human and financial resources. With an eye on the TNM staging used in oncology, we drawn up a classification that will consider the different involvement of organs such as lungs, kidneys, and liver in addition to psychological pattern and quality of life in HF patients. For all these reasons, it is our intention to propose a valid and more specific classification available for the clinical staging of HF that takes into account pathophysiological and structural changes that can remark prognosis and management of HF.

Heart failure and iron deficiency anemia in Italy: results from CARMES-1 registry.

AIMS: To assess the prevalence of anemia and iron deficiency anemia in heart failure (HF) patients, to evaluate the effectiveness of current iron deficiency treatment strategies after discharge, and to analyze hospital readmissions and mortality rates in patients with and without anemia. PATIENTS & METHODS: A patient registry-based, multicenter, retrospective, observational, cohort study of 418 hospitalized HF patients in Italy, monitored from 1 March 2010 to 30 March 2011. RESULTS: Among patients with HF, 35.9% had anemia at admission; only 51.3% were treated with current iron deficiency treatment strategies during hospitalization and then only 29% of patients who were anemic at discharge were treated with iron at home. After a 4-week follow-up, only 11% of these patients reached the hemoglobin target value (study primary end point). However, current iron deficiency treatment strategies were not significantly associated with reduced risk of rehospitalization, but with a significantly reduced mortality rate after a 6-month follow-up (study secondary end points: 11.7 vs 51.7%; p < 0.0001). CONCLUSION: In HF patients, there is poor attention paid to anemia, its causes and treatment. Current iron deficiency treatment strategies are mismanaged and CARMES-1 demonstrated that they appear to be insufficient at improving patient outcome in terms of rehospitalization rate reduction, generating high costs, which could be avoided through an optimized treatment strategy. Therefore, more efficacious, efficient and cost-effective treatment strategies are required in Italy for HF patients with iron deficiency anemia to meet this unmet medical need.