Effect of Triple Combination Therapy With Lopinavir-Ritonavir, Azithromycin, and Hydroxychloroquine on QT Interval and Arrhythmic Risk in Hospitalized COVID-19 Patients.

INTRODUCTION: No data are provided about the effect of triple combination therapy with Lopinavir/Ritonavir (LPN/RTN), hydroxychloroquine (HQ) and azithromycin (AZT) on corrected QT (QTc) interval and arrhythmic risk, in COVID-19 patients. This study aims to describe the incidence of extreme QTc interval prolongation among COVID-19 patients on this experimental treatment and to identify the clinical features associated with extreme QTc prolongation. MATERIALS AND METHODS: Data of 87 COVID-19 patients, treated with triple combination including LPN/RTN, HQ and AZT, were analyzed. QT interval was obtained by the tangent method and corrected for heart rate using Bazett's formula. Extreme QTc interval prolongation was considered an absolute QTc interval ≥ 500 ms or an increase in QTc intervals of 60 ms or greater (ΔQTc ≥ 60 ms) compared with baseline. RESULTS: Hypertension (66.7%) and diabetes (25.3%) were the most prevalent cardiovascular comorbidities. Twenty patients (23%) showed extreme QTc interval prolongation; no clinical, electrocardiographic or pharmacological characteristics have been associated to extreme QTc prolongation, except the history of ischemic stroke (P= 0,007). One torsade de pointes (TdP) in patient with QTc extreme prolongation (QTc: 560 ms) after 5 days of therapy was recorded. CONCLUSIONS: We observed a high incidence of extreme QTc interval prolongation among COVID-19 patients on triple combination therapy. Since the incidence of malignant arrhythmias seems to be not negligible, a careful electrocardiographic monitoring would be advisable.

Infective Endocarditis: Echocardiographic Imaging and New Imaging Modalities.

Infective endocarditis (IE) is a rare disease with a significant impact and an increasing mortality despite earlier diagnosis and surgical intervention. It is related to several and the main etiological agents are the Gram-positive cocci. The new guidelines propose new diagnostic criteria that consider the potentiality on integrated multimodality imaging. Echocardiography (TTE) plays a key role for the diagnosis of IE and must be performed as soon as IE is suspected. It allows to identify vegetation, abscess, new dehiscence of prosthetic valve and assesses the number, size, shape, location, echogenicity and mobility of vegetations so it also useful for prediction embolic risk. Transesophageal echocardiography (TEE) is indicated when TTE is positive or non diagnostic, in case of suspected complications and when intracardiac device leads are present. We underline the increasing role of three-dimensional (3D) echocardiography in overcoming the limit of 2DTEE in selecting the maximum true diameter of irregular masses (ie, vegetation). We also underline the diagnostic value of multislice computed tomograpfy (MSCT), cerebral magnetic resonance (RMI) and nuclear imaging and also emphasize the emerging role of particular types of endocarditis specially Lead Endocarditis. The aim of this review is to provide an overview of the imaging techniques useful for the diagnosis and identification of any complications. In our opinion, the management of IE is complex, based on an "Endocarditis team " composed by several specialist and an integrated multimodality imaging is essential for the diagnostic approach.

Visceral adiposity and arterial stiffness: echocardiographic epicardial fat thickness reflects, better than waist circumference, carotid arterial stiffness in a large population of hypertensives.

AIMS: Relationship between obesity and cardiovascular (CV) disease depends not only on the amount of body fat, but also on its distribution. For example, individuals with increased fat accumulation in the abdominal region have atherogenic lipid profiles and are at increased CV risk. The loss of elasticity in medium and large arteries is an early manifestation of atherosclerosis. The aim of this study was to evaluate whether echocardiographic epicardial adipose tissue, an index of cardiac adiposity, is related to carotid stiffness and carotid intima-media thickness (IMT), indexes of subclinical atherosclerosis, better than waist circumference in hypertensive patients. METHODS AND RESULTS: We studied 459 patients with Grade I and II essential hypertension who were referred to our outpatient clinic over a period from May 2007 to March 2008. The population was first sorted by waist circumference and then by epicardial fat < or = 7 or >7 mm. We measured epicardial fat thickness, waist circumference, carotid artery stiffness, and carotid IMT in all patients. Patients divided according to waist circumference showed no statistical differences in carotid artery stiffness between the two groups. Subjects with epicardial fat >7 mm were older, had higher systolic, diastolic, and pulse pressure, increased left ventricular mass index, carotid IMT, diastolic parameters, and stiffness parameters compared with those with epicardial fat < or = 7 mm (P < 0.001). A positive correlation was found between epicardial fat and age, pulse pressure, stiffness parameters, carotid IMT, systolic blood pressure, and duration of hypertension, and a negative correlation was found with diastolic parameters. Age, carotid IMT, and stiffness parameters were independently related to epicardial fat. CONCLUSION: Our findings indicate that epicardial fat reflects carotid artery stiffness in hypertension-induced organ damage.

Evaluation of retinal abnormalities in essential hypertension: qualitative fundoscopy versus central retinal artery resistance index as indicators of target organ damage.

PURPOSE: To compare qualitative fundoscopy with resistance index (RI) of the central retinal artery determined using color Doppler examination as indicators of target organ damage in a large population of patients with essential hypertension. METHOD: We compared qualitative fundoscopy and central retinal artery RI (CRARI) in 459 patients with grade I and II essential hypertension. Correlations with left ventricular mass, carotid structural changes, and diastolic function were investigated. The results were analyzed according to the degree of retinopathy (grade I versus grade II) and CRARI (<0.70 versus >or=0.70). All patients underwent carotid sonography, echocardiography, diastolic function, a sonographic examination of the eye with measurement of CRARI, and examination of the fundus oculi. RESULTS: There was no statistical difference in the parameters studied between patients with grade I and patients with grade II retinopathy on fundoscopy. Patients with CRARI >or=0.70 were older and had higher systolic and pulse pressure, more years of hypertension, increased left ventricular mass index, carotid intima media thickness, and diastolic parameters compared with patients with CRARI <0.70 (p < 0.001). A positive correlation was found between CRARI and age, pulse pressure, carotid intima media thickness, systolic blood pressure, and duration of hypertension, whereas a negative correlation was found between CRARI and diastolic parameters. Age, pulse pressure, carotid intima media thickness, and left ventricular mass index were independently related to CRARI. CONCLUSION: Our findings indicate that CRARI is more reliable than traditional fundoscopy in the evaluation of hypertension-induced organ damage and should be used to measure global cardiovascular risk for tailored therapy.

Feasibility, accuracy, and clinical relevance of a rapid thyroid evaluation during carotid duplex ultrasonography in hypertensive patients.

Carotid ultrasonography can detect thyroid nodules without increasing examination duration. The authors analyzed whether management is influenced by reporting such findings during routine carotid ultrasonography in hypertensive patients vs waiting for 6 months to repeat them. This is a population-based study of 1216 hypertensive patients. During carotid ultrasonography, nodule cystic/solid characteristics and size of thyroid changes were recorded. Patients with nodules were divided into those with nodules reported at the moment of diagnosis (group A) and those reported 6 months after diagnosis (group B). The authors monitored patients who underwent thyroid treatment 12 months after carotid ultrasonography. A total of 255 participants had thyroid nodules detected on screening and 99 patients started therapy after discovery. Six months later, as expected, there were more patients undergoing thyroid treatment in the group with nodules reported at time of diagnosis. This difference between groups was not significant, however, 6 months after reporting the nodules, in group B, because the number of patients on therapy significantly increased. Thyroid nodules cannot be ignored during carotid ultrasonography, and reporting their presence is valuable to general practitioners. Thyroid screening during carotid ultrasonography is cost-effective, rapid, sensitive, and specific and may affect the patient's diagnostic and therapeutic management.