RESUMO
BACKGROUND AND AIMS: Early identification of cardiac structural abnormalities indicative of heart failure is crucial to improving patient outcomes. Chest X-rays (CXRs) are routinely conducted on a broad population of patients, presenting an opportunity to build scalable screening tools for structural abnormalities indicative of Stage B or worse heart failure with deep learning methods. In this study, a model was developed to identify severe left ventricular hypertrophy (SLVH) and dilated left ventricle (DLV) using CXRs. METHODS: A total of 71 589 unique CXRs from 24 689 different patients completed within 1 year of echocardiograms were identified. Labels for SLVH, DLV, and a composite label indicating the presence of either were extracted from echocardiograms. A deep learning model was developed and evaluated using area under the receiver operating characteristic curve (AUROC). Performance was additionally validated on 8003 CXRs from an external site and compared against visual assessment by 15 board-certified radiologists. RESULTS: The model yielded an AUROC of 0.79 (0.76-0.81) for SLVH, 0.80 (0.77-0.84) for DLV, and 0.80 (0.78-0.83) for the composite label, with similar performance on an external data set. The model outperformed all 15 individual radiologists for predicting the composite label and achieved a sensitivity of 71% vs. 66% against the consensus vote across all radiologists at a fixed specificity of 73%. CONCLUSIONS: Deep learning analysis of CXRs can accurately detect the presence of certain structural abnormalities and may be useful in early identification of patients with LV hypertrophy and dilation. As a resource to promote further innovation, 71 589 CXRs with adjoining echocardiographic labels have been made publicly available.
Assuntos
Aprendizado Profundo , Hipertrofia Ventricular Esquerda , Radiografia Torácica , Humanos , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Radiografia Torácica/métodos , Feminino , Masculino , Pessoa de Meia-Idade , Ecocardiografia/métodos , Idoso , Insuficiência Cardíaca/diagnóstico por imagem , Ventrículos do Coração/diagnóstico por imagem , Curva ROCRESUMO
BACKGROUND: For patients with asymptomatic, severe aortic stenosis (AS) and preserved left ventricular ejection fraction, current guidelines recommend clinical surveillance every 6 to 12 months. To date, no randomized trials have examined whether an early intervention with transcatheter aortic valve replacement (TAVR) will improve outcomes among these patients. STUDY DESIGN AND OBJECTIVES: EARLY TAVR is a prospective, randomized, controlled, and multicenter trial, with an event-based design. Asymptomatic severe AS patients (n = 900) are randomized 1:1 to either clinical surveillance or TAVR with the Edwards SAPIEN 3/SAPIEN 3 Ultra transcatheter heart valve. Patients are stratified by whether they are able to perform a treadmill stress test. The primary end point is death, stroke, or unplanned cardiovascular hospitalization. Patients who are asymptomatic but have a positive stress test will be followed in a registry and undergo aortic valve replacement as per current guidelines. CONCLUSIONS: EARLY TAVR is the largest randomized trial to date assessing the role of early intervention among patients with asymptomatic severe AS compared to clinical surveillance and the first to study the role of TAVR. TRIAL REGISTRATION NUMBER: NCT03042104.
Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Humanos , Estenose da Valva Aórtica/epidemiologia , Volume Sistólico , Estudos Prospectivos , Fatores de Risco , Resultado do Tratamento , Função Ventricular Esquerda , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Índice de Gravidade de DoençaRESUMO
Coronavirus disease 2019 (COVID-19) is a global pandemic affecting 185 countries and >3 000 000 patients worldwide as of April 28, 2020. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2, which invades cells through the angiotensin-converting enzyme 2 receptor. Among patients with COVID-19, there is a high prevalence of cardiovascular disease, and >7% of patients experience myocardial injury from the infection (22% of critically ill patients). Although angiotensin-converting enzyme 2 serves as the portal for infection, the role of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers requires further investigation. COVID-19 poses a challenge for heart transplantation, affecting donor selection, immunosuppression, and posttransplant management. There are a number of promising therapies under active investigation to treat and prevent COVID-19.
Assuntos
Betacoronavirus , Doenças Cardiovasculares , Infecções por Coronavirus , Pandemias , Peptidil Dipeptidase A , Pneumonia Viral , Antagonistas de Receptores de Angiotensina/uso terapêutico , Enzima de Conversão de Angiotensina 2 , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , COVID-19 , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/enzimologia , Infecções por Coronavirus/complicações , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/enzimologia , Infecções por Coronavirus/terapia , Infecções por Coronavirus/virologia , Humanos , Peptidil Dipeptidase A/metabolismo , Pneumonia Viral/complicações , Pneumonia Viral/enzimologia , Pneumonia Viral/terapia , Pneumonia Viral/virologia , Receptores Virais/antagonistas & inibidores , Receptores Virais/metabolismo , SARS-CoV-2 , Tratamento Farmacológico da COVID-19RESUMO
Critical care cardiology has been impacted by the coronavirus disease-2019 (COVID-19) pandemic. COVID-19 causes severe acute respiratory distress syndrome, acute kidney injury, as well as several cardiovascular complications including myocarditis, venous thromboembolic disease, cardiogenic shock, and cardiac arrest. The cardiac intensive care unit is rapidly evolving as the need for critical care beds increases. Herein, we describe the changes to the cardiac intensive care unit and the evolving role of critical care cardiologists and other clinicians in the care of these complex patients affected by the COVID-19 pandemic. These include practical recommendations regarding structural and organizational changes to facilitate care of patients with COVID-19; staffing and personnel changes; and health and safety of personnel. We draw upon our own experiences at NewYork-Presbyterian Columbia University Irving Medical Center to offer insights into the unique challenges facing critical care clinicians and provide recommendations of how to address these challenges during this unprecedented time.
Assuntos
Cardiologia/tendências , Doenças Cardiovasculares , Infecções por Coronavirus , Cuidados Críticos , Unidades de Terapia Intensiva/organização & administração , Pandemias , Pneumonia Viral , Betacoronavirus , COVID-19 , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/terapia , Doenças Cardiovasculares/virologia , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Cuidados Críticos/métodos , Cuidados Críticos/organização & administração , Cuidados Críticos/tendências , Humanos , Cidade de Nova Iorque , Inovação Organizacional , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , SARS-CoV-2Assuntos
Doenças Cardiovasculares/etiologia , Infecções por Coronavirus/diagnóstico , Insuficiência Cardíaca/etiologia , Pneumonia Viral/diagnóstico , Choque Cardiogênico/etiologia , Síndrome Coronariana Aguda/diagnóstico , Adulto , COVID-19 , Cateterismo Cardíaco , Fármacos Cardiovasculares/uso terapêutico , Doenças Cardiovasculares/diagnóstico , Terapia Combinada , Infecções por Coronavirus/complicações , Infecções por Coronavirus/tratamento farmacológico , Diabetes Mellitus Tipo 2/complicações , Diagnóstico Diferencial , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/terapia , Transplante de Coração , Humanos , Hiperlipidemias/complicações , Hipertensão/complicações , Hipertrofia Ventricular Esquerda/complicações , Imunossupressores/efeitos adversos , Balão Intra-Aórtico , Transplante de Rim , Masculino , Pessoa de Meia-Idade , Pandemias , Pericardite/diagnóstico , Pneumonia Viral/complicações , Pneumonia Viral/tratamento farmacológico , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Respiração Artificial , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/terapia , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/terapiaRESUMO
We sought to delineate further the immunological significance of T lymphocytes infiltrating the valve leaflets in calcific aortic stenosis (CAS) and determine whether there were associated alterations in circulating T cells. Using clonotypic TCR ß-chain length and sequence analysis we confirmed that the repertoire of tricuspid CAS valves contains numerous expanded T cell clones with varying degrees of additional polyclonality, which was greatest in cases with severe calcification. We now report a similar proportion of clonal expansions in the much younger bicuspid valve CAS cases. Peripheral blood flow cytometry revealed elevations in HLA-DR(+) activated CD8 cells and in the CD8(+)CD28(null)CD57(+) memory-effector subset that were significantly greater in both bicuspid and tricuspid CAS cases with more severe valve calcification. Lesser increases of CD4(+)CD28(null) T cells were identified, principally in cases with concurrent atherosclerotic disease. Upon immunostaining the CD8 T cells in all valves were mainly CD28(null), and CD8 T cell percentages were greatest in valves with oligoclonal repertoires. T cell clones identified by their clonotypic sequence as expanded in the valve were also found expanded in the circulating blood CD28(null)CD8(+) T cells and to a lesser degree in the CD8(+)CD28(+) subset, directly supporting the relationship between immunologic events in the blood and the valve. The results suggest that an ongoing systemic adaptive immune response is occurring in cases with bicuspid and tricuspid CAS, involving circulating CD8 T cell activation, clonal expansion, and differentiation to a memory-effector phenotype, with trafficking of T cells in expanded clones between blood and the valve.
Assuntos
Estenose da Valva Aórtica/imunologia , Calcinose/imunologia , Diferenciação Celular/imunologia , Memória Imunológica , Ativação Linfocitária/imunologia , Valva Mitral/imunologia , Subpopulações de Linfócitos T/imunologia , Valva Tricúspide/imunologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/imunologia , Estenose da Valva Aórtica/metabolismo , Estenose da Valva Aórtica/patologia , Linfócitos T CD4-Positivos/imunologia , Linfócitos T CD4-Positivos/patologia , Linfócitos T CD8-Positivos/imunologia , Linfócitos T CD8-Positivos/patologia , Calcinose/metabolismo , Calcinose/patologia , Diferenciação Celular/genética , Movimento Celular/genética , Movimento Celular/imunologia , Células Clonais , Genes Codificadores da Cadeia beta de Receptores de Linfócitos T/imunologia , Humanos , Memória Imunológica/genética , Imunofenotipagem , Ativação Linfocitária/genética , Pessoa de Meia-Idade , Valva Mitral/metabolismo , Valva Mitral/patologia , Dados de Sequência Molecular , Subpopulações de Linfócitos T/metabolismo , Subpopulações de Linfócitos T/patologia , Valva Tricúspide/metabolismo , Valva Tricúspide/patologiaRESUMO
Poliomyelitis was pandemic in the United States and much of the world in the first half of the 20th century. The uses of polio vaccines have essentially eradicated the disease in the United States today. But poliovirus infection survivors who had experienced a paralytic attack can see a return of some symptoms, which is a syndrome called postpolio syndrome (PPS). The anesthetist must preoperatively assess reported amounts of patient physical activity and patient age, which can indicate the amount of muscle degeneration that may have already occurred. Patients with PPS demonstrate altered respiratory function, cold intolerance, a risk for aspiration, and experience chronic pain in muscles and joints. Patients with PPS display an increased sensitivity to some anesthetic agents such as long-acting narcotics and potent inhaled anesthetic gases with a high blood-gas partition coefficient, along with report of increased fatigue, weakness, and somnolence after anesthesia. Anesthesia care must center on the preservation of muscle function postoperatively. The anesthetist should consider the use of short-acting anesthetic agents, increased doses of analgesics, the use of warming devices, and careful attention to patient positioning. Prolonged postoperative care and hospital admission after surgery are possible.
Assuntos
Anestesia/efeitos adversos , Anestesiologia/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Síndrome Pós-Poliomielite/enfermagem , Síndrome Pós-Poliomielite/fisiopatologia , Humanos , Guias de Prática Clínica como Assunto , Estados UnidosRESUMO
Imagine performing an oral endotracheal intubation with the tongue totally absent from your line of sight of the laryngeal anatomy, including the glottis. The addition of the Angle's Classification of Malocclusion, a tool some may call archaic, should be added alongside airway assessment tools that dental surgeons and nurse anesthesiologists commonly use, such as the Mallampati Classification (or Mallampati Score), Thyromental Distance (TMD), Neck Range of Motion, Size of the Tongue, and Interincisor Distance, also called Intermaxillary Distance.
Assuntos
Laringoscopia , Laringe , Humanos , Intubação Intratraqueal , Enfermeiros AnestesistasRESUMO
Exercise stress testing is routinely performed to evaluate suspected coronary artery disease in older adults. However, the available data to predict and compare relative exercise capacity in the general population were developed using predominantly younger, healthy cohorts with few or no women. This study aimed to describe the exercise capacity of patients older than 75 years who underwent a clinically indicated Bruce protocol exercise stress test. This was a retrospective, cross-sectional study of 2,041 consecutive patients older than 75 years who performed a Bruce protocol exercise stress echocardiogram that was terminated because of maximal effort without ischemia at Columbia University Medical Center between April 10, 2009, and July 30, 2020. The analytic sample included 2,041 exercise stress tests in 786 women (median [interquartile range] age 79 [77 to 81] years) and 1,255 men (median [interquartile range] age 79 [77 to 82] years). Cardiovascular risk factors and clinical coronary disease were common and more prevalent in men than women. The median exercise time for men aged 76 to 80 years was 7:22 (minutes:seconds) and for women was 6:00 and significantly decreased in both genders as age increased (p <0.001). The mean (SD) METs achieved for women and men were 6.5 (1.6) and 7.7 (1.7), respectively. Most women (85%) and men (95%) completed the first stage, whereas only 32% of women and 64% of men completed the second stage. It was uncommon for women (3%) or men (15%) to complete the third stage. Fewer than 1% of patients completed the fourth stage, and none completed the fifth stage. At all ages, women had a lower exercise capacity than men. These data allow physicians to compare the exercise capacity of older patients who underwent a Bruce protocol exercise stress test more accurately to a representative sample of similarly aged adults.
Assuntos
Ecocardiografia sob Estresse/métodos , Teste de Esforço/métodos , Tolerância ao Exercício/fisiologia , Equivalente Metabólico , Isquemia Miocárdica/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Isquemia Miocárdica/fisiopatologia , Fatores SexuaisRESUMO
BACKGROUND: Valvular heart disease is an important contributor to cardiovascular morbidity and mortality and remains underdiagnosed. Deep learning analysis of electrocardiography (ECG) may be useful in detecting aortic stenosis (AS), aortic regurgitation (AR), and mitral regurgitation (MR). OBJECTIVES: This study aimed to develop ECG deep learning algorithms to identify moderate or severe AS, AR, and MR alone and in combination. METHODS: A total of 77,163 patients undergoing ECG within 1 year before echocardiography from 2005-2021 were identified and split into train (n = 43,165), validation (n = 12,950), and test sets (n = 21,048; 7.8% with any of AS, AR, or MR). Model performance was assessed using area under the receiver-operating characteristic (AU-ROC) and precision-recall curves. Outside validation was conducted on an independent data set. Test accuracy was modeled using different disease prevalence levels to simulate screening efficacy using the deep learning model. RESULTS: The deep learning algorithm model accuracy was as follows: AS (AU-ROC: 0.88), AR (AU-ROC: 0.77), MR (AU-ROC: 0.83), and any of AS, AR, or MR (AU-ROC: 0.84; sensitivity 78%, specificity 73%) with similar accuracy in external validation. In screening program modeling, test characteristics were dependent on underlying prevalence and selected sensitivity levels. At a prevalence of 7.8%, the positive and negative predictive values were 20% and 97.6%, respectively. CONCLUSIONS: Deep learning analysis of the ECG can accurately detect AS, AR, and MR in this multicenter cohort and may serve as the basis for the development of a valvular heart disease screening program.
Assuntos
Insuficiência da Valva Aórtica , Estenose da Valva Aórtica , Aprendizado Profundo , Doenças das Valvas Cardíacas , Insuficiência da Valva Mitral , Insuficiência da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/diagnóstico , Eletrocardiografia , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/epidemiologia , Humanos , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/epidemiologiaRESUMO
There is significant interest in developing transcatheter therapy for valvular heart disease (VHD). Numerous devices have been developed for the percutaneous treatment of pulmonary and aortic stenosis as well as mitral regurgitation. Several of these devices have progressed to randomized clinical trials. These ongoing trials for aortic stenosis and mitral regurgitation will provide important insights into the durability of these therapies as well as the results following standard surgical repair. The field of transcatheter valve therapy is rapidly evolving, and this review aims to summarize the current status of the field.
Assuntos
Estenose da Valva Aórtica/cirurgia , Cateterismo Cardíaco , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Insuficiência da Valva Mitral/cirurgia , Humanos , Desenho de PróteseRESUMO
Importance: Critical illness, a marked inflammatory response, and viruses such as SARS-CoV-2 may prolong corrected QT interval (QTc). Objective: To evaluate baseline QTc interval on 12-lead electrocardiograms (ECGs) and ensuing changes among patients with and without COVID-19. Design, Setting, and Participants: This cohort study included 3050 patients aged 18 years and older who underwent SARS-CoV-2 testing and had ECGs at Columbia University Irving Medical Center from March 1 through May 1, 2020. Patients were analyzed by treatment group over 5 days, as follows: hydroxychloroquine with azithromycin, hydroxychloroquine alone, azithromycin alone, and neither hydroxychloroquine nor azithromycin. ECGs were manually analyzed by electrophysiologists masked to COVID-19 status. Multivariable modeling evaluated clinical associations with QTc prolongation from baseline. Exposures: COVID-19, hydroxychloroquine, azithromycin. Main Outcomes and Measures: Mean QTc prolongation, percentage of patients with QTc of 500 milliseconds or greater. Results: A total of 965 patients had more than 2 ECGs and were included in the study, with 561 (58.1%) men, 198 (26.2%) Black patients, and 191 (19.8%) aged 80 years and older. There were 733 patients (76.0%) with COVID-19 and 232 patients (24.0%) without COVID-19. COVID-19 infection was associated with significant mean QTc prolongation from baseline by both 5-day and 2-day multivariable models (5-day, patients with COVID-19: 20.81 [95% CI, 15.29 to 26.33] milliseconds; P < .001; patients without COVID-19: -2.01 [95% CI, -17.31 to 21.32] milliseconds; P = .93; 2-day, patients with COVID-19: 17.40 [95% CI, 12.65 to 22.16] milliseconds; P < .001; patients without COVID-19: 0.11 [95% CI, -12.60 to 12.81] milliseconds; P = .99). COVID-19 infection was independently associated with a modeled mean 27.32 (95% CI, 4.63-43.21) millisecond increase in QTc at 5 days compared with COVID-19-negative status (mean QTc, with COVID-19: 450.45 [95% CI, 441.6 to 459.3] milliseconds; without COVID-19: 423.13 [95% CI, 403.25 to 443.01] milliseconds; P = .01). More patients with COVID-19 not receiving hydroxychloroquine and azithromycin had QTc of 500 milliseconds or greater compared with patients without COVID-19 (34 of 136 [25.0%] vs 17 of 158 [10.8%], P = .002). Multivariable analysis revealed that age 80 years and older compared with those younger than 50 years (mean difference in QTc, 11.91 [SE, 4.69; 95% CI, 2.73 to 21.09]; P = .01), severe chronic kidney disease compared with no chronic kidney disease (mean difference in QTc, 12.20 [SE, 5.26; 95% CI, 1.89 to 22.51; P = .02]), elevated high-sensitivity troponin levels (mean difference in QTc, 5.05 [SE, 1.19; 95% CI, 2.72 to 7.38]; P < .001), and elevated lactate dehydrogenase levels (mean difference in QTc, 5.31 [SE, 2.68; 95% CI, 0.06 to 10.57]; P = .04) were associated with QTc prolongation. Torsades de pointes occurred in 1 patient (0.1%) with COVID-19. Conclusions and Relevance: In this cohort study, COVID-19 infection was independently associated with significant mean QTc prolongation at days 5 and 2 of hospitalization compared with day 0. More patients with COVID-19 had QTc of 500 milliseconds or greater compared with patients without COVID-19.
Assuntos
Azitromicina , Tratamento Farmacológico da COVID-19 , COVID-19 , Eletrocardiografia , Hidroxicloroquina , Síndrome do QT Longo , Idoso de 80 Anos ou mais , Anti-Infecciosos/administração & dosagem , Anti-Infecciosos/efeitos adversos , Azitromicina/administração & dosagem , Azitromicina/efeitos adversos , COVID-19/diagnóstico , COVID-19/epidemiologia , Teste para COVID-19/métodos , Quimioterapia Combinada/métodos , Quimioterapia Combinada/estatística & dados numéricos , Eletrocardiografia/métodos , Eletrocardiografia/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Hidroxicloroquina/administração & dosagem , Hidroxicloroquina/efeitos adversos , Síndrome do QT Longo/induzido quimicamente , Síndrome do QT Longo/diagnóstico , Síndrome do QT Longo/epidemiologia , Síndrome do QT Longo/virologia , Masculino , Pessoa de Meia-Idade , New York/epidemiologia , Avaliação de Processos e Resultados em Cuidados de Saúde , Fatores de Risco , SARS-CoV-2 , Fatores de TempoRESUMO
The coronavirus disease 2019 (COVID-19) can result in a hyperinflammatory state, leading to acute respiratory distress syndrome (ARDS), myocardial injury, and thrombotic complications, among other sequelae. Statins, which are known to have anti-inflammatory and antithrombotic properties, have been studied in the setting of other viral infections, but their benefit has not been assessed in COVID-19. This is a retrospective analysis of patients admitted with COVID-19 from February 1st through May 12th, 2020 with study period ending on June 11th, 2020. Antecedent statin use was assessed using medication information available in the electronic medical record. We constructed a multivariable logistic regression model to predict the propensity of receiving statins, adjusting for baseline sociodemographic and clinical characteristics, and outpatient medications. The primary endpoint includes in-hospital mortality within 30 days. A total of 2626 patients were admitted during the study period, of whom 951 (36.2%) were antecedent statin users. Among 1296 patients (648 statin users, 648 non-statin users) identified with 1:1 propensity-score matching, statin use is significantly associated with lower odds of the primary endpoint in the propensity-matched cohort (OR 0.47, 95% CI 0.36-0.62, p < 0.001). We conclude that antecedent statin use in patients hospitalized with COVID-19 is associated with lower inpatient mortality.
Assuntos
Tratamento Farmacológico da COVID-19 , COVID-19/mortalidade , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Idoso , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Pontuação de Propensão , Estudos Retrospectivos , SARS-CoV-2/isolamento & purificaçãoRESUMO
Background Cardiovascular involvement in coronavirus disease 2019 (COVID-19) is common and leads to worsened mortality. Diagnostic cardiovascular studies may be helpful for resource appropriation and identifying patients at increased risk for death. Methods and Results We analyzed 887 patients (aged 64±17 years) admitted with COVID-19 from March 1 to April 3, 2020 in New York City with 12 lead electrocardiography within 2 days of diagnosis. Demographics, comorbidities, and laboratory testing, including high sensitivity cardiac troponin T (hs-cTnT), were abstracted. At 30 days follow-up, 556 patients (63%) were living without requiring mechanical ventilation, 123 (14%) were living and required mechanical ventilation, and 203 (23%) had expired. Electrocardiography findings included atrial fibrillation or atrial flutter (AF/AFL) in 46 (5%) and ST-T wave changes in 306 (38%). 27 (59%) patients with AF/AFL expired as compared to 181 (21%) of 841 with other non-life-threatening rhythms (P<0.001). Multivariable analysis incorporating age, comorbidities, AF/AFL, QRS abnormalities, and ST-T wave changes, and initial hs-cTnT ≥20 ng/L showed that increased age (HR 1.04/year), elevated hs-cTnT (HR 4.57), AF/AFL (HR 2.07), and a history of coronary artery disease (HR 1.56) and active cancer (HR 1.87) were associated with increased mortality. Conclusions Myocardial injury with hs-cTnT ≥20 ng/L, in addition to cardiac conduction perturbations, especially AF/AFL, upon hospital admission for COVID-19 infection is associated with markedly increased risk for mortality than either diagnostic abnormality alone.
Assuntos
Fibrilação Atrial/diagnóstico , COVID-19/epidemiologia , Eletrocardiografia , Frequência Cardíaca/fisiologia , Medição de Risco/métodos , SARS-CoV-2 , Troponina T/sangue , Fibrilação Atrial/sangue , Fibrilação Atrial/epidemiologia , Biomarcadores/sangue , COVID-19/sangue , Comorbidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Prognóstico , Estudos Retrospectivos , Fatores de RiscoRESUMO
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the coronavirus disease 2019 (COVID-19) pandemic, which has resulted in global healthcare crises and strained health resources. As the population of patients recovering from COVID-19 grows, it is paramount to establish an understanding of the healthcare issues surrounding them. COVID-19 is now recognized as a multi-organ disease with a broad spectrum of manifestations. Similarly to post-acute viral syndromes described in survivors of other virulent coronavirus epidemics, there are increasing reports of persistent and prolonged effects after acute COVID-19. Patient advocacy groups, many members of which identify themselves as long haulers, have helped contribute to the recognition of post-acute COVID-19, a syndrome characterized by persistent symptoms and/or delayed or long-term complications beyond 4 weeks from the onset of symptoms. Here, we provide a comprehensive review of the current literature on post-acute COVID-19, its pathophysiology and its organ-specific sequelae. Finally, we discuss relevant considerations for the multidisciplinary care of COVID-19 survivors and propose a framework for the identification of those at high risk for post-acute COVID-19 and their coordinated management through dedicated COVID-19 clinics.
Assuntos
COVID-19/complicações , SARS-CoV-2 , Doença Aguda , COVID-19/epidemiologia , COVID-19/etnologia , COVID-19/terapia , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/terapia , Humanos , Defesa do Paciente , Síndrome , Síndrome de Resposta Inflamatória Sistêmica/epidemiologia , Síndrome de Resposta Inflamatória Sistêmica/terapia , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/prevenção & controleRESUMO
Importance: There is a paucity of data detailing cardiac remodeling in female athletes compared with male athletes. The lack of reference cardiac data for elite female basketball players or female athletes of similar size makes it difficult to differentiate athletic remodeling from potential underlying cardiac disorders in this population of athletes. Objective: To assess cardiac structure and function in elite female basketball players. Design, Setting, and Participants: This cross-sectional echocardiographic study included 140 Women's National Basketball Association (WNBA) athletes on active rosters for the 2017 season. The WNBA mandates annual preseason stress echocardiograms for each athlete. The WNBA has partnered with Columbia University to annually perform a review of these studies. Data analysis was performed from June 7, 2017, to October 5, 2017. Main Outcomes and Measures: Echocardiographic variables included left ventricular (LV) dimensions, wall thickness, mass, prevalence of LV hypertrophy, aortic dimensions, right ventricular (RV) dimension, and right and left atrial size. Linear regression was used to assess the associations between cardiac structure and function with body size quantified as body surface area (BSA) in the primary analysis. Results: A total of 140 female athletes (mean [SD] age, 26.8 [3.9] years; 105 [75.0%] African American) participated in the study. Mean (SD) athlete height was 183.4 (9.0) cm, and mean (SD) BSA was 2.02 (0.18) m2. Compared with guideline-defined normal values, LV enlargement was present in 36 athletes (26.0%) and 57 athletes (42.2%) had RV enlargement. There was a linear correlation between LV and RV cavity sizes and BSA extending to the uppermost biometrics (LV cavity size: r, 0.48; RV cavity size: r, 0.32; P < .001 for both). Maximal left ventricular wall thickness (LVWT) ranged from 0.6 to 1.4 cm, with 78 athletes (55.7%) having LVWT of 1.0 cm or greater and only 1 athlete (0.7%) having LVWT greater than 1.3 cm. Twenty-three athletes (16.4%) met the criteria for left ventricular hypertrophy (LVH) (>95 g/m2). Eccentric LVH was present in 16 athletes (69.6%), concentric LVH in 7 athletes (30.4%), and concentric remodeling in 27 athletes (19.3%). Mean aortic root diameter was 3.1 cm (95% CI, 3.0-3.2). Only 2 athletes (1.4%) had guideline-defined aortic enlargement compared with a range of 18% to 42% for left and right ventricular and atrial enlargement. Conclusions and Relevance: In this study, increased cardiac dimensions were frequently observed in WNBA athletes. Both BSA and physiologic remodeling affected cardiac morphologic findings. This study may provide a framework to define the range of athletic cardiac remodeling exhibited by elite female basketball players.
Assuntos
Atletas , Basquetebol , Ecocardiografia/métodos , Átrios do Coração/diagnóstico por imagem , Hipertrofia Ventricular Esquerda/diagnóstico , Remodelação Ventricular/fisiologia , Adulto , Estudos Transversais , Eletrocardiografia , Feminino , Humanos , Hipertrofia Ventricular Esquerda/epidemiologia , Hipertrofia Ventricular Esquerda/fisiopatologia , Incidência , Estados Unidos/epidemiologia , Adulto JovemRESUMO
The novel coronavirus disease 2019, otherwise known as COVID-19, is a global pandemic with primary respiratory manifestations in those who are symptomatic. It has spread to >187 countries with a rapidly growing number of affected patients. Underlying cardiovascular disease is associated with more severe manifestations of COVID-19 and higher rates of mortality. COVID-19 can have both primary (arrhythmias, myocardial infarction, and myocarditis) and secondary (myocardial injury/biomarker elevation and heart failure) cardiac involvement. In severe cases, profound circulatory failure can result. This review discusses the presentation and management of patients with severe cardiac complications of COVID-19 disease, with an emphasis on a Heart-Lung team approach in patient management. Furthermore, it focuses on the use of and indications for acute mechanical circulatory support in cardiogenic and/or mixed shock.
Assuntos
Síndrome Coronariana Aguda/terapia , Arritmias Cardíacas/terapia , Infecções por Coronavirus/terapia , Insuficiência Cardíaca/terapia , Miocardite/terapia , Pneumonia Viral/terapia , Síndrome Coronariana Aguda/complicações , Antibacterianos/efeitos adversos , Antivirais/uso terapêutico , Arritmias Cardíacas/induzido quimicamente , Arritmias Cardíacas/complicações , Azitromicina/efeitos adversos , Betacoronavirus , COVID-19 , Cardiotônicos/uso terapêutico , Doença Crônica , Infecções por Coronavirus/complicações , Síndrome da Liberação de Citocina/complicações , Síndrome da Liberação de Citocina/terapia , Inibidores Enzimáticos/efeitos adversos , Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca/etiologia , Coração Auxiliar , Humanos , Hidroxicloroquina/efeitos adversos , Balão Intra-Aórtico , Infarto do Miocárdio/complicações , Infarto do Miocárdio/terapia , Miocardite/complicações , Pandemias , Intervenção Coronária Percutânea , Pneumonia Viral/complicações , SARS-CoV-2 , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , TromboemboliaRESUMO
The coronavirus disease 2019 crisis is a global pandemic of a novel infectious disease with far-ranging public health implications. With regard to cardiac electrophysiology (EP) services, we discuss the "real-world" challenges and solutions that have been essential for efficient and successful (1) ramping down of standard clinical practice patterns and (2) pivoting of workflow processes to meet the demands of this pandemic. The aims of these recommendations are to outline: (1) essential practical steps to approaching procedures, as well as outpatient and inpatient care of EP patients, with relevant examples, (2) successful strategies to minimize exposure risk to patients and clinical staff while also balancing resource utilization, (3) challenges related to redeployment and restructuring of clinical and support staff, and (4) considerations regarding continued collaboration with clinical and administrative colleagues to implement these changes. While process changes will vary across practices and hospital systems, we believe that these experiences from 4 different EP sections in a large New York City hospital network currently based in the global epicenter of the coronavirus disease 2019 pandemic will prove useful for other EP practices adapting their own practices in preparation for local surges.
Assuntos
Assistência Ambulatorial/tendências , Eletrofisiologia Cardíaca , Infecções por Coronavirus , Reestruturação Hospitalar , Controle de Infecções , Pandemias , Administração dos Cuidados ao Paciente , Pneumonia Viral , Telemedicina/tendências , Betacoronavirus/isolamento & purificação , COVID-19 , Eletrofisiologia Cardíaca/métodos , Eletrofisiologia Cardíaca/organização & administração , Eletrofisiologia Cardíaca/tendências , Gestão de Mudança , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Procedimentos Clínicos/tendências , Reestruturação Hospitalar/métodos , Reestruturação Hospitalar/organização & administração , Hospitalização/tendências , Hospitais Urbanos/organização & administração , Humanos , Controle de Infecções/métodos , Controle de Infecções/organização & administração , Cidade de Nova Iorque , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/organização & administração , Administração dos Cuidados ao Paciente/tendências , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , SARS-CoV-2RESUMO
Patients with structural heart disease are at increased risk of adverse outcomes from the coronavirus disease-2019 (COVID-19) due to advanced age and comorbidity. In the midst of a global pandemic of a novel infectious disease, reality-based considerations comprise an important starting point for formulating clinical management pathways. The aims of these "crisis-driven" recommendations are: 1) to ensure appropriate and timely treatment of structural heart disease patients; 2) to minimize the risk of COVID-19 exposure to patients and health care workers; and 3) to limit resource utilization under conditions of constraint. Although the degree of disruption to usual practice will vary across the United States and elsewhere, we hope that early experiences from a heart team operating in the current global epicenter of COVID-19 may prove useful for others adapting their practice in advance of local surges of COVID-19.
Assuntos
Infecções por Coronavirus , Procedimentos Clínicos , Cardiopatias , Controle de Infecções/métodos , Pandemias , Pneumonia Viral , Betacoronavirus/isolamento & purificação , COVID-19 , Comorbidade , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/terapia , Procedimentos Clínicos/organização & administração , Procedimentos Clínicos/tendências , Cardiopatias/epidemiologia , Cardiopatias/cirurgia , Humanos , Inovação Organizacional , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Pneumonia Viral/terapia , SARS-CoV-2RESUMO
Although COVID-19 is most well known for causing substantial respiratory pathology, it can also result in several extrapulmonary manifestations. These conditions include thrombotic complications, myocardial dysfunction and arrhythmia, acute coronary syndromes, acute kidney injury, gastrointestinal symptoms, hepatocellular injury, hyperglycemia and ketosis, neurologic illnesses, ocular symptoms, and dermatologic complications. Given that ACE2, the entry receptor for the causative coronavirus SARS-CoV-2, is expressed in multiple extrapulmonary tissues, direct viral tissue damage is a plausible mechanism of injury. In addition, endothelial damage and thromboinflammation, dysregulation of immune responses, and maladaptation of ACE2-related pathways might all contribute to these extrapulmonary manifestations of COVID-19. Here we review the extrapulmonary organ-specific pathophysiology, presentations and management considerations for patients with COVID-19 to aid clinicians and scientists in recognizing and monitoring the spectrum of manifestations, and in developing research priorities and therapeutic strategies for all organ systems involved.