Renin-Angiotensin System Blocker in COVID-19. A Single Center Study.

ABSTRACT: Early during the Coronavirus disease 2019 (Covid-19) pandemic, concerns were raised regarding potential adverse outcomes in patients taking angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs). These concerns were based on animal studies showing increased ACE-2 expression in mice treated with ACEI/ARB. This is a single-center, retrospective, cohort study of 289 patients diagnosed with 2019 Novel Coronavirus (SARS-CoV-2) hospitalized between March of 2020 and June of 2020. The study was intended to investigate the impact of ACEIs and/or ARBs on in-hospital mortality, intensive care unit (ICU) admission, postadmission hemodialysis requirement, and the need for mechanical ventilation in patients with COVID-19. This cohort of 289 patients included 139 of 289 women (48%) with a mean age of 61 ± 19 years. Patients using ACEIs/ARBs were older (69.68 vs. 57.9 years; P < 0.0001), more likely to have a history of hypertension (97% vs. 36%; P < 0.0001), diabetes mellitus (48% vs. 20.9%; P < 0.0001), chronic heart failure (11.39% vs. 4.29%; P < 0.0512), coronary artery disease (20.25% vs. 7.14%; P < 0.0025), stroke/Transient Ischemic Attack (7.59% vs. 2.38%; P < 0.0761), chronic kidney disease (11.39% vs. 3.33%; P < 0.0167), atrial fibrillation/flutter (18.99% vs. 7.14%; P < 0.0080), and dementia (22.7% vs. 11.4%; P < 0.0233) compared with the nonuser group. There was significantly higher in-hospital mortality in patients using ACEIs/ARBs than nonusers, respectively (32.9% vs. 15.2%; P < 0.0015). However, a multivariate logistics regression analysis performed to adjust for common confounders demonstrated no significant difference in all-cause in-patient mortality (P 0.7141). Admission to ICU, postadmission hemodialysis requirement, and mechanical ventilation showed no significant differences between the 2 groups (P = NS). This study suggests that the use of ACEIs and ARBs in patients with COVID-19 was not found to significantly increase all-cause in-hospital mortality, ICU admissions, and hemodialysis and mechanical ventilation requirements.

Cardiac Troponin-I and COVID-19: A Prognostic Tool for In-Hospital Mortality.

BACKGROUND: The number of fatalities due to coronavirus disease 2019 (COVID-19) is escalating with more than 800,000 deaths globally. The scientific community remains in urgent need of prognostic tools to determine the probability of survival in patients with COVID-19 and to determine the need for hospitalization. METHODS: This is a retrospective cohort study of patients with a diagnosis of COVID-19 admitted to a tertiary center between March 2020 and July 2020. Patients age 18 years and older were stratified into two groups based on their troponin-I level in the first 24 h of admission (groups: elevated vs. normal). The aim of the study is to explore the utility of cardiac troponin-I level for early prognostication of patients with COVID-19. RESULTS: This cohort of 257 patients included 122/257 (47%) women with a mean age of 63 ± 17 years. Patients with an elevated troponin-I level were more likely to be older (77 ± 13 vs. 58 ± 16 years, P < 0.0001), have a history of hypertension (P < 0.0001), diabetes mellitus (P = 0.0019), atrial fibrillation or flutter (P = 0.0009), coronary artery disease (P < 0.0001), and chronic heart failure (P = 0.0011). Patients with an elevated troponin-I level in the first 24 h of admission were more likely to have higher in-hospital mortality (52% vs. 10%, P < 0.0001). Troponin-I level in the first 24 h of admission had a negative predictive value of 89.7% and a positive predictive value of 51.9% for all-cause in-hospital mortality. CONCLUSIONS: Troponin-I elevation is commonly seen in patients with COVID-19 and is significantly associated with fatal outcomes. However, a normal troponin-I level in the first 24 h of admission had a high negative predictive value for all-cause in-hospital mortality, thereby predicting favorable survival at the time of discharge.

Outcomes of Urgent Transcatheter Aortic Valve Replacement in Patients With Acute Decompensated Heart Failure: A Single-Center Experience.

Background Data on urgent transcatheter aortic valve replacement (TAVR) as rescue therapy for acute decompensated heart failure (ADHF) due to severe aortic stenosis (AS) are limited. We sought to investigate the outcomes of patients who underwent urgent transcatheter aortic valve replacement (TAVR) in a single institution. Methods This is a retrospective cohort study of 602 patients with a history of heart failure (HF) due to AS who underwent TAVR between April 2012 and July 2017. We stratified patient cohort into urgent (n=139) and elective (n=463) TAVR. Urgent TAVR was defined as patients who were admitted for ADHF and underwent TAVR during the same hospitalization. Patients that underwent urgent TAVR for other reasons were excluded. Results Rates of postoperative intra-aortic balloon pump requirement, atrial fibrillation, dialysis requirement, vascular complications, and stroke were similar between the two groups. Compared with elective TAVR, patients undergoing urgent TAVR had a higher rate of cardiac arrest (5.7% vs 1.3%, p=0.005), longer length of stay (LOS) (11 vs. 5, p<0.001), and significant 30-day mortality (8.6% vs 4.1%, HR 2.1, 95% CI 1.04-4.22). Patients who underwent urgent TAVR were also associated with long-term mortality (Log-rank p = 0.0162). Conclusions In our study, urgent TAVR for ADHF was associated with both short-term and long-term mortality as compared to elective TAVR. Further randomized studies are needed to investigate the appropriate management of this population.

Implementation of the Surviving Sepsis Campaign in Patients With Heart Failure: Gender-Specific Outcomes.

Background Limited data exist about the impact of gender-specific outcomes in patients with heart failure (HF) who develop concomitant sepsis. Methods This is a retrospective cohort study of patients with HF who developed sepsis. Clinical outcomes, including in-hospital mortality, development of cardiogenic shock (CS), pulmonary edema requiring urgent intravenous diuretics (IVD), acute kidney injury (AKI), length of stay (LOS), and 30-day HF-related readmission, were evaluated in men vs. women. Results This cohort of 618 patients includes 272 (44%) women with a mean age of 75±14 years. Coronary artery disease (p<0.0001), diabetes mellitus (p=0.0213), stage ≥ 3 chronic kidney disease (p<0.0001), and HF with reduced ejection fraction (HFrEF) (p=0.0015) were more prevalent in men. The implementation of the Surviving Sepsis Campaign (i.e., intravenous (IV) crystalloids in the first six hours) was more aggressive in women (p=0.0192). There was no difference in in-hospital mortality (p=0.2385) between men and women. After adjusting for HF types, women with HF with preserved ejection fraction (HFpEF) developed more episodes of pulmonary edema requiring urgent IVD (p=0.0389), while men with HFpEF had more CS requiring inotropes (p=0.0400) and a longer LOS (p=0.0434). Conversely, women with HFrEF were most likely to develop CS requiring inotropes (p=0.0132). Conclusion Women with HF who developed sepsis receive a more aggressive implementation of the Surviving Sepsis Campaign than men, leading to more pulmonary edema events in women with HFpEF and more cardiogenic shock in women with HFrEF. A cautiously tailored approach is desperately needed for patients with HF who develop sepsis.

Impella to unload the left ventricle in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock: A systematic review and meta-analysis.

BACKGROUND AND AIM: Impella is frequently used to unload the left ventricle in patients with cardiogenic shock on venoarterial extracorporeal membrane oxygenation (VA-ECMO). There is limited data regarding the use of this strategy. This study aims to evaluate the safety and efficacy of the said strategy. METHODS: A systematic search for studies comparing Impella plus VA-ECMO (ECVAD) vs VA-ECMO alone was performed using Pubmed, Cochrane Library, and Scopus. Studies meeting inclusion criteria were then used to perform a meta-analysis. RESULTS: Three studies involving 448 patients were included in the final analysis. In total, 117 (26%) patients were female, mean age was 57 years. VA-ECMO was placed in 355 out of 448 (79%) patients, while ECVAD was placed in 93 out of 448 (21%). Death occurred in 49 out of 93 (52.6%) patients on ECVAD and 226 out of 355 (63.6%) on ECMO, relative risk (RR): 0.76, confidence interval (CI), 95% (0.62-0.94) P = .01. Hemolysis was present in 46 (49.4%) patients in the ECVAD vs 67 (18%) in the ECMO group, RR: 2.64, CI, 95% (1.97-3.55) P < .01. Bleeding was present in 42 (45.2.%) patients in the ECVAD group and 135 (38%) in the ECMO group, RR: 1.25, CI, 95% (0.95-1.63) P = .11. CVVHD was used on 31 (33.3%) patients in the ECVAD group while 89 (25%) in the ECMO group, RR 1.35, CI, 95% (0.95-1.91) P = .10. CONCLUSION: This study suggests that the use of Impella as an unloading strategy in patients with VA-ECMO decreased mortality, increased rate of hemolysis, neutral bleeding risk, and similar rates of acute kidney injury requiring CVVHD.

The Effect of Hydroxychloroquine on In-Hospital Mortality in COVID-19.

Background: Hydroxychloroquine (HCQ) is an antimalarial medication that has been tested against various viral illnesses. The available evidence regarding the role of HCQ in the coronavirus disease 2019 (COVID-19) remains controversial. Methods: This is a comparative retrospective cohort study that aims to evaluate the efficacy and safety of HCQ in hospitalized patients with COVID-19. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included ICU admission rate, mechanical ventilation, prolonged length of stay (LOS), QTc prolongation and cardiac arrest. Results: A cohort of 175 hospitalized patients with COVID-19 were included with a median (interquartile range [IQR]) age of 66 [48-79] years. Of whom, 82 (47%) patients received HCQ. The overall mortality rate was 34.1%; 95% CI [23.7-44.6] and 16.1%; 95% CI [8.5-23.7] in the HCQ group vs. the control group, respectively (p = 0.67). A Cox regression analysis was performed adjusting for age, gender, BMI, SpO2/FiO2 ratio and CXR findings, and demonstrated that the association between HCQ use and the all-cause in-hospital mortality was not statistically significant (HR = 1.15; 95% CI [0.54-2.48]; p-value = 0.72). Patients who received HCQ were more likely to be admitted to the intensive care unit, require mechanical ventilation and have a prolonged LOS compared to those who did not receive the medication. No statistically significant difference was found in the likelihood of QTc prolongation or cardiac arrest. Conclusions: The use of HCQ in patients hospitalized with COVID-19 confers no benefit in patient morbidity or mortality.

The utility of pulmonary function testing in the preoperative risk stratification of patients undergoing transcatheter aortic valve replacement.

BACKGROUND: The role of pulmonary function testing (PFT) as a predictor of clinically relevant endpoints in transcatheter aortic valve replacement (TAVR) is unclear. OBJECTIVE: To determine the utility of PFT in the preoperative risk stratification of patients undergoing TAVR. METHODS: An evaluation of PFT (i.e., FEV1), arterial blood gases (i.e., PO2), the diagnosis of chronic obstructive lung disease (COPD) by the Global Initiative for COPD (GOLD), and the diagnosis of chronic lung disease (CLD) by the Society of Thoracic Surgeons (STS) was performed to determine whether a relationship exists among these parameters and clinically relevant outcomes, including all-cause 30-day and 1-year mortality. RESULTS: A total of 513 patients underwent TAVR between March 2013 and December 2016. Per STS criteria, 269/513 (52%) had CLD with a mean FEV1 of 55.4 ± 12%. Per GOLD criteria, 158/513 (30%) of patients had COPD with a mean FEV1/forced vital capacity of 61.8 ± 8.2%. The severity of CLD was affected by changes in ejection fraction, albumin, creatinine, and B-type natriuretic peptide levels (p = .009, p < .001, p < .001, and p < .001, respectively), whereas the severity of COPD was not affected by these same variables, (p = .302, .079, .137, and .102, respectively). An increased A-a gradient (p = .035), increased PCO2 (p = .016), and decreased PO2 (p = <.001) demonstrated increased risk of 30-day mortality. Neither classification (COPD or CLD), nor PFT changes, showed association with 30-day and 1-year mortality (p = NS). CONCLUSION: This study suggests that isolated abnormalities in spirometry are a poor indicator of clinically relevant outcomes in TAVR. When classified correctly, COPD does not predict clinically relevant postoperative outcomes.

Long-term quality of life in octogenarians and nonagenarians with nonvalvular atrial fibrillation following WATCHMAN™ device implantation.

OBJECTIVES: To assess the impact of WATCHMAN™ on quality of life (QoL) in octogenarians and nonagenarians. BACKGROUND: QoL after WATCHMAN™ device in the elderly remains unknown. METHODS: This is a prospective and retrospective cohort study of patients that underwent WATCHMAN™ implantation in a tertiary cardiovascular center from April 1, 2015 to September 27, 2017. The primary outcome was a prospective assessment of QoL via the SF-12v2 Health Survey (SF-12v2) in those aged ≥80 and ≥90 years. Secondary outcomes include major bleeding, stroke, vascular complications, pericardial effusion, device related thrombus (DRT), prolonged length of stay (LOS), acute kidney injury (AKI), and recurrent hospitalizations. RESULTS: This cohort of 151 patients included 48/151 (32%) females with a mean age of 80 ± 7.7 years. Mean CHA2 DS2 -VASc was 4.38 ± 1.36 and mean HAS-BLED was 3.27 ± 1.17. Octogenarians 65/81(80%) and nonagenarians 16/81(20%) comprised 81/151(54%) of patients (mean age 86 ± 4.3 years) from which 36/65 (55%) octogenarians and 10/16 (63%) nonagenarians completed SF-12v2 evaluation at 22 ± 10 and 30 ± 10-months. Octogenarians demonstrated enhanced physical component scores (PCS), and nonagenarians equal PCS versus the age-adjusted norm (45.43 ± 9.84 versus 38.68 ± 11.04, P = 0.0003, and 41.26 ± 12.36 versus 38.68 ± 11.04, P = 0.6463, respectively). The mental component scores (MCS) of octogenarians and nonagenarians remained comparable (51.80 ± 9.56 and 48.97 ± 9.92 versus 50.06 ± 10.94, respectively, P = 0.4659). No stroke, vascular complications, pericardial effusions, or readmissions related to WATCHMAN™ occurred. No difference among patients <80, ≥80, and ≥90 years was found in major bleeding events, DRT, prolonged LOS, or AKI (P = 0.0569, 0.116, 0.498, and 0.795, respectively). CONCLUSIONS: Octogenarians and nonagenarians experience favorable long-term QoL after WATCHMAN™, with acceptable bleeding risk and low incidence of procedure-related complications.