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Nukaga S, Fujiwara-Tani R, Mori T, Kawahara I, Nishida R, Miyagawa Y, Goto K, Ohmori H, Fujii K, Sasaki T, Nakashima C, Luo Y, Mori S, Kishi S, Ogata R, Kuniyasu H. SARS-CoV-2-Derived RNA Fragment Induces Myocardial Dysfunction via siRNA-like Suppression of Mitochondrial ATP Synthase. Int J Mol Sci 2025; 26:5392. [PMID: 40508201 PMCID: PMC12156209 DOI: 10.3390/ijms26115392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2025] [Revised: 05/31/2025] [Accepted: 06/02/2025] [Indexed: 06/16/2025] Open
Abstract
Myocardial injury is a critical determinant of prognosis in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection; however, its underlying mechanisms remain incompletely understood. In this study, we examined the effects of SARS-CoV-2-derived RNA fragments on human cardiomyocytes. We identified a 19-nucleotide sequence within the viral genome that shares complete sequence homology with the human F1F0 ATP synthase subunit alpha gene (ATP5A). This sequence was found to associate with Argonaute 2 (AGO2) and downregulate ATP5A expression via a mechanism analogous to RNA interference. Consequently, oxidative phosphorylation was suppressed in cardiomyocytes, leading to impaired myocardial maturation and the emergence of heart failure-like phenotypes. Notably, exosome-mimetic liposomal delivery of this RNA fragment to cardiomyocytes reproduced the ATP5A-suppressive effect. These findings suggest that SARS-CoV-2-derived RNA fragments may contribute to myocardial injury through the siRNA-like modulation of mitochondrial gene expression. Further validation in animal models and patient-derived materials is warranted.
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Grants
- 25K14462 Ministry of Education, Culture, Sports, Science and Technology
- 25K14487 Ministry of Education, Culture, Sports, Science and Technology
- 24K20535 Ministry of Education, Culture, Sports, Science and Technology
- 24K14281 Ministry of Education, Culture, Sports, Science and Technology
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Affiliation(s)
- Shota Nukaga
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
- Division of Rehabilitation, Hanna Central Hospital, Ikoma 630-0243, Japan
| | - Rina Fujiwara-Tani
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
| | - Takuya Mori
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
- Department of Medical Ethics and Genetics, Kyoto University, Kyoto 606-8501, Japan
| | - Isao Kawahara
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
- Division of Rehabilitation, Hanna Central Hospital, Ikoma 630-0243, Japan
| | - Ryoichi Nishida
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
| | - Yoshihiro Miyagawa
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
| | - Kei Goto
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
| | - Hitoshi Ohmori
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
| | - Kiyomu Fujii
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
| | - Takamitsu Sasaki
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
| | - Chie Nakashima
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
| | - Yi Luo
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
| | - Shiori Mori
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
- Department of Cancer Biology, Institute of Biomedical Science, Kansai Medical University, Osaka 573-1010, Japan
| | - Shingo Kishi
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
- Department of Pathological Diagnosis, Nozaki Tokushukai Hospital, Daito 574-0074, Japan
| | - Ruiko Ogata
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
| | - Hiroki Kuniyasu
- Department of Molecular Pathology, Nara Medical University School of Medicine, Kashihara 634-8521, Japan
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Markousis-Mavrogenis G, Vartela V, Pepe A, Sierra-Galan L, Androulakis E, Perazzolo A, Christidi A, Belegrinos A, Giannakopoulou A, Bonou M, Vrettou AR, Lazarioti F, Skantzos V, Quaia E, Mohiaddin R, Mavrogeni SI. Cardiovascular Magnetic Resonance Reveals Cardiac Inflammation and Fibrosis in Symptomatic Patients with Post-COVID-19 Syndrome: Findings from the INSPIRE-CMR Multicenter Study. J Clin Med 2024; 13:6919. [PMID: 39598063 PMCID: PMC11594310 DOI: 10.3390/jcm13226919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2024] [Revised: 11/07/2024] [Accepted: 11/12/2024] [Indexed: 11/29/2024] Open
Abstract
Introduction. Post-coronavirus disease-2019 (COVID-19) patients may develop cardiac symptoms. We hypothesized that cardiovascular magnetic resonance (CMR) can assess the background of post-COVID-19 cardiac symptoms using multi-parametric evaluation. We aimed to conduct an investigation of symptomatic patients with post-COVID-19 syndrome using CMR (INSPIRE-CMR). Methods. INSIPRE-CMR is a retrospective multicenter study including 174 patients from five centers referred for CMR due to cardiac symptoms. CMR was performed using 3.0 T/1.5 T system (24%/76%, respectively). Myocardial inflammation was determined by the updated Lake Louise criteria. Results. Further, 174 patients with median age of 40 years (IQR: 26-54), 72 (41%) were women, and 17 (9.7%) had a history of autoimmune disease, muscular dystrophy, or cancer. In total, 149 (86%) patients were late gadolinium enhanced (LGE)-positive with a non-ischemic pattern, and of those evaluated with the updated Lake Louise criteria, 141/145 (97%) had ≥1 pathologic T1 index. Based on the T2-criterion, 62/173 (36%) patients had ≥1 pathologic T2 index. Collectively, 48/145 (33%) patients had both positive T1- and T2-criterion. A positive T2-criterion or a combination of a positive T1- and T2-criterion were significantly more common amongst patients with severe COVID-19 [45 (31%) vs. 17 (65%), p = 0.001 and 32 (27%) vs. 16 (64%), p < 0.001, respectively]. During the one-year evaluation, available for 65/174 patients, shortness of breath, chest pain, and arrhythmia were identified in 7 (4%), 15 (8.6%), and 43 (24.7%), respectively. CMR evaluation, available in a minority of them, showed mildly reduced LVEF, while nat T1 mapping and EVC remained at levels higher than the normal values of the local MRI units. Conclusions. The majority of post-COVID-19 patients with cardiac symptoms presented non-ischemic LGE and abnormalities in T1 and T2-based indices. Multi-parametric CMR reveals important information on post-COVID-19 patients, supporting its role in short/long-term evaluation.
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Affiliation(s)
- George Markousis-Mavrogenis
- University Research Institute of Maternal and Child Health and Precision Medicine and UNESCO Chair in Adolescent Health Care, Medical School, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, 11527 Athens, Greece;
- Olympic Diagnostic Center, 18537 Piraeus, Greece; (F.L.); (V.S.)
| | | | - Alessia Pepe
- Department of Radiology, Medical Faculty, University of Padua, 35127 Padua, Italy; (A.P.); (A.P.); (E.Q.)
| | | | - Emmanouil Androulakis
- Royal Brompton Hospital, Imaging Centre, Guy’s and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK; (E.A.); (R.M.)
| | - Anna Perazzolo
- Department of Radiology, Medical Faculty, University of Padua, 35127 Padua, Italy; (A.P.); (A.P.); (E.Q.)
| | | | - Antonios Belegrinos
- Faculty of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | | | | | | | - Fotini Lazarioti
- Olympic Diagnostic Center, 18537 Piraeus, Greece; (F.L.); (V.S.)
| | | | - Emilio Quaia
- Department of Radiology, Medical Faculty, University of Padua, 35127 Padua, Italy; (A.P.); (A.P.); (E.Q.)
| | - Raad Mohiaddin
- Royal Brompton Hospital, Imaging Centre, Guy’s and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK; (E.A.); (R.M.)
- National Heart and Lung Institute, Imperial College London, London SW7 2AZ, UK
| | - Sophie I. Mavrogeni
- University Research Institute of Maternal and Child Health and Precision Medicine and UNESCO Chair in Adolescent Health Care, Medical School, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, 11527 Athens, Greece;
- Olympic Diagnostic Center, 18537 Piraeus, Greece; (F.L.); (V.S.)
- Onassis Cardiac Surgery Center, 11527 Athens, Greece;
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3
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Magalhães TA, Carneiro ACDC, Moreira VDM, Trad HS, Lopes MMU, Cerci RJ, Nacif MS, Schvartzman PR, Chagas ACP, Costa IBSDS, Schmidt A, Shiozaki AA, Montenegro ST, Piegas LS, Zapparoli M, Nicolau JC, Fernandes F, Hadlich MS, Ghorayeb N, Mesquita ET, Gonçalves LFG, Ramires FJA, Fernandes JDL, Schwartzmann PV, Rassi S, Torreão JA, Mateos JCP, Beck-da-Silva L, Silva MC, Liberato G, Oliveira GMMD, Feitosa Filho GS, Carvalho HDSMD, Markman Filho B, Rocha RPDS, Azevedo Filho CFD, Taratsoutchi F, Coelho-Filho OR, Kalil Filho R, Hajjar LA, Ishikawa WY, Melo CA, Jatene IB, Albuquerque ASD, Rimkus CDM, Silva PSDD, Vieira TDR, Jatene FB, Azevedo GSAAD, Santos RD, Monte GU, Ramires JAF, Bittencourt MS, Avezum A, Silva LSD, Abizaid A, Gottlieb I, Precoma DB, Szarf G, Sousa ACS, Pinto IMF, Medeiros FDM, Caramelli B, Parga Filho JR, Santos TSGD, Prazeres CEED, Lopes MACQ, Avila LFRD, Scanavacca MI, Gowdak LHW, Barberato SH, Nomura CH, Rochitte CE. Cardiovascular Computed Tomography and Magnetic Resonance Imaging Guideline of the Brazilian Society of Cardiology and the Brazilian College of Radiology - 2024. Arq Bras Cardiol 2024; 121:e20240608. [PMID: 39475988 DOI: 10.36660/abc.20240608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2025] Open
Affiliation(s)
- Tiago Augusto Magalhães
- Complexo Hospital de Clínicas da Universidade Federal do Paraná (CHC-UFPR), Curitiba, PR - Brasil
- Hospital do Coração (HCOR), São Paulo, SP - Brasil
- Hospital Sírio Libanês, SP, São Paulo, SP - Brasil
| | | | - Valéria de Melo Moreira
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | - Marly Maria Uellendahl Lopes
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
- DASA - Diagnósticos da América S/A, São Paulo, SP - Brasil
| | | | - Marcelo Souto Nacif
- Universidade Federal Fluminense, Niterói, RJ - Brasil
- Hospital Universitário Antonio Pedro, Niterói, RJ - Brasil
| | | | - Antônio Carlos Palandrini Chagas
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
- Faculdade de Medicina do ABC, Santo André, SP - Brasil
| | | | - André Schmidt
- Universidade de São Paulo (USP), Ribeirão Preto, SP - Brasil
| | - Afonso Akio Shiozaki
- ND Núcleo Diagnóstico, Maringá, PR - Brasil
- Ômega Diagnóstico, Maringá, PR - Brasil
- Hospital Paraná, Maringá, PR - Brasil
| | | | | | - Marcelo Zapparoli
- Quanta Diagnóstico por Imagem, Curitiba, PR - Brasil
- DAPI, Curitiba, PR - Brasil
| | - José Carlos Nicolau
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - Fabio Fernandes
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - Marcelo Souza Hadlich
- Fleury Medicina e Saúde, Rio de Janeiro, RJ - Brasil
- Rede D'Or RJ, Rio de Janeiro, RJ - Brasil
- Unimed, Rio de Janeiro, RJ - Brasil
- Instituto Nacional de Cardiologia (INC), Rio de Janeiro, RJ - Brasil
| | - Nabil Ghorayeb
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
- Inspirali Educação, São Paulo, SP - Brasil
- Anhanguera Educacional, São Paulo, SP - Brasil
| | | | - Luiz Flávio Galvão Gonçalves
- Hospital São Lucas, Rede D'Or SE, Aracaju, SE - Brasil
- Hospital Universitário da Universidade Federal de Sergipe, Aracaju, SE - Brasil
- Clínica Climedi, Aracaju, SE - Brasil
| | - Felix José Alvarez Ramires
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | - Pedro Vellosa Schwartzmann
- Hospital Unimed Ribeirão Preto, Ribeirão Preto, SP - Brasil
- Centro Avançado de Pesquisa, Ensino e Diagnóstico (CAPED), Ribeirão Preto, SP - Brasil
| | | | | | - José Carlos Pachón Mateos
- Hospital do Coração (HCOR), São Paulo, SP - Brasil
- Hospital Sírio Libanês, SP, São Paulo, SP - Brasil
| | - Luiz Beck-da-Silva
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | | | - Gabriela Liberato
- Hospital Sírio Libanês, SP, São Paulo, SP - Brasil
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | | | - Hilka Dos Santos Moraes de Carvalho
- PROCAPE - Universidade de Pernambuco, Recife, PE - Brasil
- Hospital das Clínicas de Pernambuco da Universidade Federal de Pernambuco (UFPE), Recife, PE - Brasil
- Real Hospital Português de Pernambuco, Recife, PE - Brasil
| | - Brivaldo Markman Filho
- Hospital das Clínicas de Pernambuco da Universidade Federal de Pernambuco (UFPE), Recife, PE - Brasil
| | | | | | - Flávio Taratsoutchi
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | - Roberto Kalil Filho
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | - Walther Yoshiharu Ishikawa
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - Cíntia Acosta Melo
- Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP - Brasil
- Hospital Infantil Sabará, São Paulo, SP - Brasil
| | | | | | - Carolina de Medeiros Rimkus
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
- Instituto D'Or de Pesquisa e Ensino (IDOR), São Paulo SP - Brasil
| | - Paulo Savoia Dias da Silva
- Fleury Medicina e Saúde, Rio de Janeiro, RJ - Brasil
- University of Iowa Hospitals and Clinics, Iowa City - EUA
| | - Thiago Dieb Ristum Vieira
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - Fabio Biscegli Jatene
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - Guilherme Sant Anna Antunes de Azevedo
- ECOMAX, Blumenau, SC - Brasil
- Hospital Unimed Blumenau, Blumenau, SC - Brasil
- Hospital São José de Jaraguá do Sul, Blumenau, SC - Brasil
- Cliniimagem Criciúma, Blumenau, SC - Brasil
| | - Raul D Santos
- Hospital Sírio Libanês, SP, São Paulo, SP - Brasil
- Universidade de São Paulo (USP), Ribeirão Preto, SP - Brasil
| | | | - José Antonio Franchini Ramires
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | - Alvaro Avezum
- Hospital Alemão Oswaldo Cruz, São Paulo, SP - Brasil
| | | | | | - Ilan Gottlieb
- Fonte Imagem Medicina Diagnostica, Rio de Janeiro, RJ - Brasil
| | | | - Gilberto Szarf
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | - Antônio Carlos Sobral Sousa
- Universidade Federal de Sergipe, Aracaju, SE - Brasil
- Hospital São Lucas, Aracaju, SE - Brasil
- Rede D'Or de Aracaju, Aracaju, SE - Brasil
| | | | | | - Bruno Caramelli
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - José Rodrigues Parga Filho
- Hospital Sírio Libanês, SP, São Paulo, SP - Brasil
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | | | | | | | | | - Mauricio Ibrahim Scanavacca
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
| | - Luis Henrique Wolff Gowdak
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
- Universidade de São Paulo (USP), Ribeirão Preto, SP - Brasil
| | - Silvio Henrique Barberato
- Quanta Diagnóstico por Imagem, Curitiba, PR - Brasil
- Cardioeco, Centro de Diagnóstico Cardiovascular, Curitiba, PR - Brasil
| | | | - Carlos Eduardo Rochitte
- Hospital do Coração (HCOR), São Paulo, SP - Brasil
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo SP - Brasil
- DASA - Diagnósticos da América S/A, São Paulo, SP - Brasil
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Kole C, Stefanou Ε, Karvelas N, Schizas D, Toutouzas KP. Acute and Post-Acute COVID-19 Cardiovascular Complications: A Comprehensive Review. Cardiovasc Drugs Ther 2024; 38:1017-1032. [PMID: 37209261 PMCID: PMC10199303 DOI: 10.1007/s10557-023-07465-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE OF REVIEW The risk of cardiovascular complications due to SARS-CoV-2 are significantly increased within the first 6 months of the infection. Patients with COVID-19 have an increased risk of death, and there is evidence that many may experience a wide range of post-acute cardiovascular complications. Our work aims to provide an update on current clinical aspects of diagnosis and treatment of cardiovascular manifestations during acute and long-term COVID-19. RECENT FINDINGS SARS-CoV-2 has been shown to be associated with increased incidence of cardiovascular complications such as myocardial injury, heart failure, and dysrhythmias, as well as coagulation abnormalities not only during the acute phase but also beyond the first 30 days of the infection, associated with high mortality and poor outcomes. Cardiovascular complications during long-COVID-19 were found regardless of comorbidities such as age, hypertension, and diabetes; nevertheless, these populations remain at high risk for the worst outcomes during post-acute COVID-19. Emphasis should be given to the management of these patients. Treatment with low-dose oral propranolol, a beta blocker, for heart rate management may be considered, since it was found to significantly attenuate tachycardia and improve symptoms in postural tachycardia syndrome, while for patients on ACE inhibitors or angiotensin-receptor blockers (ARBs), under no circumstances should these medications be withdrawn. In addition, in patients at high risk after hospitalization due to COVID-19, thromboprophylaxis with rivaroxaban 10 mg/day for 35 days improved clinical outcomes compared with no extended thromboprophylaxis. In this work we provide a comprehensive review on acute and post-acute COVID-19 cardiovascular complications, symptomatology, and pathophysiology mechanisms. We also discuss therapeutic strategies for these patients during acute and long-term care and highlight populations at risk. Our findings suggest that older patients with risk factors such as hypertension, diabetes, and medical history of vascular disease have worse outcomes during acute SARS-CoV-2 infection and are more likely to develop cardiovascular complications during long-COVID-19.
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Affiliation(s)
- Christo Kole
- Cardiology Department, Sismanoglio General Hospital of Attica, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Εleni Stefanou
- Artificial Kidney Unit, General Hospital of Messinia, Kalamata, Greece
| | - Nikolaos Karvelas
- Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Dall’Ara G, Compagnone M, Carletti R, Piciucchi S, Gardini E, Galvani M. Case Report: Asymptomatic SARS-COV2 infection triggering recurrent Takotsubo syndrome. Front Cardiovasc Med 2024; 11:1418316. [PMID: 38854654 PMCID: PMC11157011 DOI: 10.3389/fcvm.2024.1418316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/15/2024] [Indexed: 06/11/2024] Open
Abstract
Takotsubo syndrome (TTS) is a rare disease mimicking acute coronary syndrome, often triggered by physical or emotional stress, and characterized by transient left ventricular dysfunction. Recurrences are described in about 5% of cases and may have different clinical and imaging patterns. In the present report, SARS-COV-2 infection, even in the absence of symptoms and overt emotional stress, seems correlated with recurrence of TTS, due to the absence of other recognized triggers. The hypothesis is that in predisposed patients, events like catecholamine-induced myocyte injury, direct viral damage, cytokine storm, immune-mediated damage, and procoagulant state, all possibly induced by the infection, may elicit endothelial dysfunction as substrate for TTS onset.
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Affiliation(s)
- Gianni Dall’Ara
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Forlì Campus, Forlì, Italy
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | | | | | - Sara Piciucchi
- Department of Radiology, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Elisa Gardini
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Marcello Galvani
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Forlì Campus, Forlì, Italy
- Cardiology Unit, Morgagni-Pierantoni Hospital, Forlì, Italy
- Cardiovascular Research Unit, Myriam Zito Sacco Heart Foundation, Forlì, Italy
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6
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Bilehjani E, Fakhari S, Farzin H, Tajlil A, Nader ND. Diagnosis and treatment of cardiovascular manifestations of COVID-19: a narrative review. Acta Cardiol 2024; 79:267-273. [PMID: 37606350 DOI: 10.1080/00015385.2023.2246200] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 08/03/2023] [Indexed: 08/23/2023]
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was the main pathogen in the COVID-19 pandemic. This viral infection has been associated with several respiratory and non-respiratory complications contributing to a higher mortality rate, especially in patients with underlying heart diseases worldwide. Once considered a respiratory tract disease, it is now well-known that COVID-19 patients may experience a wide range of cardiac manifestations. Because of its remarkable direct and indirect effects on the cardiovascular system, herein, we examined the published literature that studied the hypothetical mechanisms of injury, manifestations, and diagnostic modalities, including changes in molecular biomarkers with a predictive value in the prognostication of the disease, as well as emerging evidence regarding the long-term cardiac complications of the disease.
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Affiliation(s)
- Eissa Bilehjani
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Solmaz Fakhari
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Haleh Farzin
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Arezou Tajlil
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Nader D Nader
- Departments of Anesthesiology and Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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7
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Kawanaka H, Ogano M, Hibako K, Tanabe J. Takotsubo Cardiomyopathy Presenting with QT Prolongation and Torsade de Pointes in a Patient with Coronavirus Disease 2019. J NIPPON MED SCH 2024; 91:124-128. [PMID: 36823121 DOI: 10.1272/jnms.jnms.2023_90-607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Coronavirus disease 2019 (COVID-19) is associated with cardiovascular complications; however, Takotsubo cardiomyopathy (TCM) with QT prolongation and Torsade de pointes has been reported only rarely. We present a case of TCM after QT prolongation and Torsade de pointes. A 58-year-old woman was admitted because of COVID-19-related pneumonia. Seven days after admission, she developed sudden loss of consciousness without any indication of cardiovascular disease. A monitoring electrocardiogram indicated Torsade de pointes and a prolonged QT interval. Emergency cardiac catheterization revealed TCM. She was treated with favipiravir and steroids, followed by rehabilitation, and her condition improved. To detect asymptomatic TCM, routine electrocardiography screening should be considered for patients with COVID-19.
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Affiliation(s)
| | - Michio Ogano
- Department of Cardiovascular Medicine, Shizuoka Medical Center
| | - Keita Hibako
- Department of Emergency Medicine, Shizuoka Medical Center
| | - Jun Tanabe
- Department of Cardiovascular Medicine, Shizuoka Medical Center
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8
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Sivasubramanian BP, Ravikumar DB, Vyas B, Panchal V, Puli S, Kiernan G, Venkata VS. Role of POCUS in the Management of New-onset Tachyarrhythmia in the Setting of SARS-CoV-2: A Case Report. J Community Hosp Intern Med Perspect 2023; 13:50-53. [PMID: 38596561 PMCID: PMC11000831 DOI: 10.55729/2000-9666.1261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/05/2023] [Accepted: 08/10/2023] [Indexed: 04/11/2024] Open
Abstract
Introduction SARS-CoV-2 infection is associated with myocardial inflammation, new onset cardiomyopathy, and arrhythmias. Here, we describe the utilization of POCUS and management of concurrent new onset atrial tachycardia and heart failure with reduced ejection fraction (HfrEF) in a patient with SARS-CoV-2 infection. Presentation An 80-year-old female with multiple medical problems presented with sudden onset of shortness of breath and cough. She tested positive for SARS-CoV-2. Initially, she was hypoxic on room air and her heart rhythm was sinus tachycardia. CT angiogram of the chest showed consolidation, pleural effusion, and absence of pulmonary embolism. Because of persistent tachycardia, repeat EKGs and POCUS were performed. Subsequent EKGs showed intermittent atrial tachycardia and sinus tachycardia. Initially, home beta blockers were continued on admission, and additional dosages were considered for rate control, but Cardiac POCUS revealed HfrEF and was subsequently confirmed by comprehensive cardiac echocardiogram, consistent with SARS-CoV-2 infection-related cardiomyopathy. Beta blockers were discontinued, and treatment with amiodarone and furosemide showed improvement in symptoms. The patient was discharged with oral amiodarone and supplemental oxygen. Additionally, once the patient's hemodynamics improved, oral carvedilol was also started as part of GDMT for HfrEF. Follow-up echocardiogram 4 months later showed recovery of systolic EF to 60%. Conclusion It is essential to consider new onset HFrEF in the evaluation and management of new onset tachyarrhythmias since IV fluids and AV nodal blocking agents can be harmful in decompensated HFrEF. With the advent of POCUS, HFrEF can be quickly identified, and therapy can be tailored to that diagnosis.
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Affiliation(s)
- Barath P. Sivasubramanian
- Department of Infectious Diseases, University of Texas Health Science Centre, San Antonio, TX, 78229,
USA
| | - Diviya B. Ravikumar
- Department of Internal Medicine, ESIC Medical College and PGIMSR, Chennai, Tamil Nadu,
India
| | - Bhavya Vyas
- Department of Medicine, Smt. N.H.L. Municipal Medical College and SVPISMR, Ahmedabad, Gujarat,
India
| | - Viraj Panchal
- Department of Medicine, Smt. N.H.L. Municipal Medical College and SVPISMR, Ahmedabad, Gujarat,
India
| | - Srikanth Puli
- Hospital Medicine Division, Cheshire Medical Center,
USA
| | - Gerard Kiernan
- Hospital Medicine Division, Cheshire Medical Center,
USA
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9
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Fan Y, Guan B, Xu J, Zhang H, Yi L, Yang Z. Role of toll-like receptor-mediated pyroptosis in sepsis-induced cardiomyopathy. Biomed Pharmacother 2023; 167:115493. [PMID: 37734261 DOI: 10.1016/j.biopha.2023.115493] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/08/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023] Open
Abstract
Sepsis, a life-threatening dysregulated status of the host response to infection, can cause multiorgan dysfunction and mortality. Sepsis places a heavy burden on the cardiovascular system due to the pathological imbalance of hyperinflammation and immune suppression. Myocardial injury and cardiac dysfunction caused by the aberrant host responses to pathogens can lead to cardiomyopathy, one of the most critical complications of sepsis. However, many questions about the specific mechanisms and characteristics of this complication remain to be answered. The causes of sepsis-induced cardiac dysfunction include abnormal cardiac perfusion, myocardial inhibitory substances, autonomic dysfunction, mitochondrial dysfunction, and calcium homeostasis dysregulation. The fight between the host and pathogens acts as the trigger for sepsis-induced cardiomyopathy. Pyroptosis, a form of programmed cell death, plays a critical role in the progress of sepsis. Toll-like receptors (TLRs) act as pattern recognition receptors and participate in innate immune pathways that recognize damage-associated molecular patterns as well as pathogen-associated molecular patterns to mediate pyroptosis. Notably, pyroptosis is tightly associated with cardiac dysfunction in sepsis and septic shock. In line with these observations, induction of TLR-mediated pyroptosis may be a promising therapeutic approach to treat sepsis-induced cardiomyopathy. This review focuses on the potential roles of TLR-mediated pyroptosis in sepsis-induced cardiomyopathy, to shed light on this promising therapeutic approach, thus helping to prevent and control septic shock caused by cardiovascular disorders and improve the prognosis of sepsis patients.
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Affiliation(s)
- Yixuan Fan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Intensive Care Unit, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Baoyi Guan
- Department of Internal Medicine-Cardiovascular, The First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Jianxing Xu
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Intensive Care Unit, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - He Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China
| | - Liang Yi
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Intensive Care Unit, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
| | - Zhixu Yang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China; Intensive Care Unit, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China.
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10
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Alonzo A, Di Fusco SA, Castello L, Matteucci A, Spinelli A, Marino G, Aquilani S, Imperoli G, Colivicchi F. Tako-Tsubo syndrome in patients with COVID-19: a single-center retrospective case series. Monaldi Arch Chest Dis 2023; 94. [PMID: 37675931 DOI: 10.4081/monaldi.2023.2675] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/02/2023] [Indexed: 09/08/2023] Open
Abstract
Growing evidence shows that COVID-19 is associated with an increase in Tako-Tsubo syndrome (TTS) incidence. We collected data from patients hospitalized in our multidisciplinary COVID-19 department who had a diagnosis of TTS during the second and third waves of the pandemic in Italy. We reported four cases of TTS associated with COVID-19. Except for COVID-19, no patient had any classical TTS triggers. The mean age was 72 years (67-81) and all patients had COVID-19-related interstitial pneumonia confirmed by computed tomography. Typical apical ballooning and transitory reduction in left ventricle (LV) systolic function with a complete recovery before discharge were observed in all patients. The mean LV ejection fraction at TTS onset was 42% (40-48%). The electrocardiogram showed ST-segment elevation in two cases, while an evolution with negative T waves and corrected QT prolongation was observed in all patients. Three patients underwent coronary angiography. Two patients had Alzheimer's disease. The time interval from hospital admission to TTS onset was 4 (2-6) days, and the time interval from COVID-19 symptom onset to TTS diagnosis was 10 (8-12) days. COVID-19 may be a trigger for TTS, though TTS pathophysiology in COVID-19 patients remains unclear, likely due to its multifactorial nature.
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Affiliation(s)
- Alessandro Alonzo
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, Rome.
| | | | - Lorenzo Castello
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, Rome.
| | - Andrea Matteucci
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, Rome.
| | - Antonella Spinelli
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, Rome.
| | - Gaetano Marino
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, Rome.
| | - Stefano Aquilani
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, Rome.
| | - Giuseppe Imperoli
- Medicine Unit, Emergency Department, San Filippo Neri Hospital, Rome.
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Division, San Filippo Neri Hospital, Rome.
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11
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Yugar-Toledo JC, Yugar LBT, Sedenho-Prado LG, Schreiber R, Moreno H. Pathophysiological effects of SARS-CoV-2 infection on the cardiovascular system and its clinical manifestations-a mini review. Front Cardiovasc Med 2023; 10:1162837. [PMID: 37260945 PMCID: PMC10229057 DOI: 10.3389/fcvm.2023.1162837] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/18/2023] [Indexed: 06/02/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 may have a mild presentation, with few symptoms, or progress to a severe condition, characterized by generalized inflammation, systemic microvascular involvement, coagulopathy, and pulmonary and cardiovascular complications. Men present with more severe symptoms than women, especially men who are older and who present with comorbidities such as hypertension, diabetes mellitus, and a history of atherosclerotic diseases. Owing to its association with endothelial dysfunction, inflammation, thrombosis, and microvascular obstruction, SARS-CoV-2 infection can cause lesions in several organs, including the myocardium and the coronary arterial bed, which can result in clinical manifestations involving the cardiovascular system. In this mini review, we summarize the effects of SARS-CoV-2 infection on the cardiovascular system in both children and adults and characterize the various clinical manifestations associated with this disease.
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Affiliation(s)
| | | | | | - Roberto Schreiber
- Department of Internal Medicine, School of Medical Sciences, State University of Campinas (UNICAMP), São Paulo, Brazil
| | - Heitor Moreno
- Department of Internal Medicine, School of Medical Sciences, State University of Campinas (UNICAMP), São Paulo, Brazil
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12
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Holby SN, Richardson TL, Laws JL, McLaren TA, Soslow JH, Baker MT, Dendy JM, Clark DE, Hughes SG. Multimodality Cardiac Imaging in COVID. Circ Res 2023; 132:1387-1404. [PMID: 37167354 PMCID: PMC10171309 DOI: 10.1161/circresaha.122.321882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Infection with SARS-CoV-2, the virus that causes COVID, is associated with numerous potential secondary complications. Global efforts have been dedicated to understanding the myriad potential cardiovascular sequelae which may occur during acute infection, convalescence, or recovery. Because patients often present with nonspecific symptoms and laboratory findings, cardiac imaging has emerged as an important tool for the discrimination of pulmonary and cardiovascular complications of this disease. The clinician investigating a potential COVID-related complication must account not only for the relative utility of various cardiac imaging modalities but also for the risk of infectious exposure to staff and other patients. Extraordinary clinical and scholarly efforts have brought the international medical community closer to a consensus on the appropriate indications for diagnostic cardiac imaging during this protracted pandemic. In this review, we summarize the existing literature and reference major societal guidelines to provide an overview of the indications and utility of echocardiography, nuclear imaging, cardiac computed tomography, and cardiac magnetic resonance imaging for the diagnosis of cardiovascular complications of COVID.
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Affiliation(s)
- S Neil Holby
- Cardiovascular Medicine Fellowship, Division of Cardiology, Department of Internal Medicine (S.N.H., T.L.R., J.L.L.), Vanderbilt University Medical Center
| | - Tadarro Lee Richardson
- Cardiovascular Medicine Fellowship, Division of Cardiology, Department of Internal Medicine (S.N.H., T.L.R., J.L.L.), Vanderbilt University Medical Center
| | - J Lukas Laws
- Cardiovascular Medicine Fellowship, Division of Cardiology, Department of Internal Medicine (S.N.H., T.L.R., J.L.L.), Vanderbilt University Medical Center
| | - Thomas A McLaren
- Division of Cardiology, Department of Internal Medicine, Department of Radiology & Radiological Sciences (T.A.M., S.G.H.), Vanderbilt University Medical Center
| | - Jonathan H Soslow
- Thomas P. Graham Jr Division of Pediatric Cardiology, Department of Pediatrics (J.H.S.), Vanderbilt University Medical Center
| | - Michael T Baker
- Division of Cardiology, Department of Internal Medicine (M.T.B., J.M.D.), Vanderbilt University Medical Center
| | - Jeffrey M Dendy
- Division of Cardiology, Department of Internal Medicine (M.T.B., J.M.D.), Vanderbilt University Medical Center
| | - Daniel E Clark
- Division of Cardiology, Department of Internal Medicine, Stanford University School of Medicine (D.E.C.)
| | - Sean G Hughes
- Division of Cardiology, Department of Internal Medicine, Department of Radiology & Radiological Sciences (T.A.M., S.G.H.), Vanderbilt University Medical Center
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13
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Ludwikowska KM, Moksud N, Tracewski P, Sokolski M, Szenborn L. Cardiac Involvement in Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) in Poland. Biomedicines 2023; 11:biomedicines11051251. [PMID: 37238922 DOI: 10.3390/biomedicines11051251] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/13/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is an immune-mediated complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Cardiovascular system is commonly involved. Acute heart failure (AHF) is the most severe complication of MIS-C, leading to cardiogenic shock. The aim of the study was to characterise the course of MIS-C with a focus on cardiovascular involvement, based on echocardiographic (echo) evaluation, in 498 children (median age 8.3 years, 63% boys) hospitalised in 50 cities in Poland. Among them, 456 (91.5%) had cardiovascular system involvement: 190 (48.2%) of patients had (most commonly atrioventricular) valvular insufficiency, 155 (41.0%) had contractility abnormalities and 132 (35.6%) had decreased left ventricular ejection fraction (LVEF < 55%). Most of these abnormalities improved within a few days. Analysis of the results obtained from two echo descriptions (a median of 5 days apart) revealed a >10% increase in LVEF even in children with primarily normal LVEF. Lower levels of lymphocytes, platelets and sodium and higher levels of inflammatory markers on admission were significantly more common among older children with contractility dysfunction, while younger children developed coronary artery abnormality (CAA) more often. The incidence of ventricular dysfunction might be underestimated. The majority of children with AHF improved significantly within a few days. CAAs were relatively rare. Children with impaired contractility as well as other cardiac abnormalities differed significantly from children without such conditions. Due to the exploratory nature of this study, these findings should be confirmed in further studies.
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Affiliation(s)
- Kamila M Ludwikowska
- Department of Pediatric Infectious Diseases, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland
| | - Nafeesa Moksud
- Laboratory of Genetics and Epigenetics of Human Diseases, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Rudolfa Weigla 12, 53-114 Wrocław, Poland
| | - Paweł Tracewski
- Department of Pediatric Cardiology, Regional Specialist Hospital in Wroclaw, Research and Development Center, Kamieńskiego 73a, 51-124 Wrocław, Poland
| | - Mateusz Sokolski
- Institute of Heart Diseases, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Leszek Szenborn
- Department of Pediatric Infectious Diseases, Wroclaw Medical University, Ludwika Pasteura 1, 50-367 Wrocław, Poland
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14
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De Michieli L, Jaffe AS, Sandoval Y. Use and Prognostic Implications of Cardiac Troponin in COVID-19. Heart Fail Clin 2023; 19:163-176. [PMID: 36863808 PMCID: PMC9973555 DOI: 10.1016/j.hfc.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Myocardial injury is common in patients with COVID-19 and is associated with an adverse prognosis. Cardiac troponin (cTn) is used to detect myocardial injury and assist with risk stratification in this population. SARS-CoV-2 infection can play a role in the pathogenesis of acute myocardial injury due to both direct and indirect damage to the cardiovascular system. Despite the initial concerns about an increased incidence of acute myocardial infarction (MI), most cTn increases are related to chronic myocardial injury due to comorbidities and/or acute nonischemic myocardial injury. This review will discuss the latest findings on this topic.
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Affiliation(s)
- Laura De Michieli
- Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA,Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, Padova 35128, Italy
| | - Allan S. Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA,Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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15
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Abstract
PURPOSE OF REVIEW Cardiac consequences occur in both acute COVID-19 and post-acute sequelae of COVID-19 (PASC). Here, we highlight the current understanding about COVID-19 cardiac effects, based upon clinical, imaging, autopsy, and molecular studies. RECENT FINDINGS COVID-19 cardiac effects are heterogeneous. Multiple, concurrent cardiac histopathologic findings have been detected on autopsies of COVID-19 non-survivors. Microthrombi and cardiomyocyte necrosis are commonly detected. Macrophages often infiltrate the heart at high density but without fulfilling histologic criteria for myocarditis. The high prevalences of microthrombi and inflammatory infiltrates in fatal COVID-19 raise the concern that recovered COVID-19 patients may have similar but subclinical cardiac pathology. Molecular studies suggest that SARS-CoV-2 infection of cardiac pericytes, dysregulated immunothrombosis, and pro-inflammatory and anti-fibrinolytic responses underlie COVID-19 cardiac pathology. The extent and nature by which mild COVID-19 affects the heart is unknown. Imaging and epidemiologic studies of recovered COVID-19 patients suggest that even mild illness confers increased risks of cardiac inflammation, cardiovascular disorders, and cardiovascular death. The mechanistic details of COVID-19 cardiac pathophysiology remain under active investigation. The ongoing evolution of SARS-CoV-2 variants and vast numbers of recovered COVID-19 patients portend a burgeoning global cardiovascular disease burden. Our ability to prevent and treat cardiovascular disease in the future will likely depend on comprehensive understanding of COVID-19 cardiac pathophysiologic phenotypes.
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Affiliation(s)
- Lorenzo R. Sewanan
- Department of Medicine, Columbia University Irving Medical Center, New York, NY USA
| | - Kevin J. Clerkin
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Irving Medical Center, New York, NY USA
| | | | - Emily J. Tsai
- Center for Advanced Cardiac Care, Division of Cardiology, Columbia University Irving Medical Center, New York, NY USA
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16
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Endogenous Catecholamine Release in COVID-19 Related Acute Respiratory Distress Syndrome: Link between Enhanced Sympathetic Stimulation, Cardiac Dysfunction and Outcome. J Clin Med 2023; 12:jcm12041557. [PMID: 36836097 PMCID: PMC9965663 DOI: 10.3390/jcm12041557] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/09/2023] [Accepted: 02/09/2023] [Indexed: 02/18/2023] Open
Abstract
The aim of this study was to measure the serum levels of catecholamines in patients admitted to intensive care unit (ICU) with COVID-19-related acute respiratory distress syndrome (ARDS) and describe their relation with clinical, inflammatory and echocardiographic parameters. Serum levels of endogenous catecholamines (norepinephrine, epinephrine and dopamine) were measured at ICU admission. We enrolled 71 patients consecutively admitted to ICU due to moderate to severe ARDS. 11 patients (15.5%) died during the admission in ICU. Serum levels of endogenous catecholamines were significantly elevated. Norepinephrine levels were higher in those with RV and LV systolic dysfunction, higher CRP, and higher IL-6. Patients with higher mortality rate were those with norepinephrine values ≥ 3124 ng/mL, CRP ≥ 17.2 mg/dL and IL-6 ≥ 102 pg/mL. Univariable analysis by Cox proportional hazards regression modelling showed that norepinephrine, IL-6 and CRP had the highest risk of acute mortality. Multivariable analysis showed that only norepinephrine and IL-6 retained in the model. Marked increase of serum catecholamine levels is present during acute phase of critically ill COVID-19 and it is associated with inflammatory and clinical parameters.
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17
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Alblaihed L, Brady WJ, Al-Salamah T, Mattu A. Dysrhythmias associated with COVID-19: Review and management considerations. Am J Emerg Med 2023; 64:161-168. [PMID: 36563500 PMCID: PMC9721478 DOI: 10.1016/j.ajem.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/21/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), is known to affect the cardiovascular system. Cardiac manifestations in COVID-19 can be due to direct damage to the myocardium and conduction system as well as by the disease's effect on the various organ systems. These manifestations include acute coronary syndrome, ST- segment elevations, cardiomyopathy, and dysrhythmias. Some of these dysrhythmias can be detrimental to the patient. Therefore, it is important for the emergency physician to be aware of the different arrhythmias associated with COVID-19 and how to manage them. This narrative review discusses the pathophysiology underlying the various arrhythmias associated with COVID-19 and their management considerations.
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Affiliation(s)
- Leen Alblaihed
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, United States of America,Corresponding author
| | - William J. Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, United States of America
| | - Tareq Al-Salamah
- Department of Emergency Medicine, College of Medicine, King Saud University, PO Box 7805, Riyadh 11472, Saudi Arabia
| | - Amal Mattu
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, United States of America
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18
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Abstract
The pandemic of COVID-19 in worldwide causes recent millions of morbidity and mortality in all countries and is the most important challenge in the world in recent years. Coronavirus is a single-stranded RNA virus and infection with COVID-19 leads to acute respiratory distress syndrome, lung inflammation, cytokine storm, and death. The other complications include endothelial dysfunction, activation of coagulation, thromboembolic events, and vascular disease. Cardiovascular complications such as myocardial and stroke ischemia, pulmonary thromboembolism, systemic arterial, and deep vein thrombosis were reported. In this review, we presented immuno-pathological mechanisms and the effects of COVID-19 on the cardiovascular system, heart, vessels, coagulation system, and molecular glance of immuno-inflammation to the COVID-19's pathology on the cardiovascular system.
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Affiliation(s)
- Entezar Mehrabi Nasab
- Department of Cardiology, School of Medicine, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Cardiology, School of Medicine, Valiasr Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Hassan Aghajani
- Department of Cardiology, School of Medicine, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Hassanzadeh Makoei
- Department of Cardiology, School of Medicine, Ayatollah Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Seyyed Shamsadin Athari
- Department of Immunology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
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19
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Davis MG, Bobba A, Majeed H, Bilal MI, Nasrullah A, Ratmeyer GM, Chourasia P, Gangu K, Farooq A, Avula SR, Sheikh AB. COVID-19 With Stress Cardiomyopathy Mortality and Outcomes Among Patients Hospitalized in the United States: A Propensity Matched Analysis Using the National Inpatient Sample Database. Curr Probl Cardiol 2023; 48:101607. [PMID: 36690311 PMCID: PMC9859766 DOI: 10.1016/j.cpcardiol.2023.101607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
Takotsubo syndrome (stress cardiomyopathy) has become a well-known complication of COVID-19 infections, with limited large-scale studies evaluating outcomes. We used the National Inpatient Sample (NIS) database to compare COVID-19 patients with and without stress cardiomyopathy. A total of 1,659,040 patients were included in the study: COVID-19 with stress cardiomyopathy (n = 1665, 0.1%) and COVID-19 without stress cardiomyopathy (n = 1657, 375, and 99.9%). The primary outcome was in-hospital mortality, with secondary analysis with propensity matching performed to confirm results from traditional multivariate analysis. COVID-19 patients with stress cardiomyopathy had significantly increased in-hospital mortality compared to COVID-19 patients without stress cardiomyopathy (32.8% vs 14.6%, adjusted OR [aOR]: 2.3 [95% CI, 1.2-4.5], P = 0.01) along with significantly increased mechanical ventilation and vasopressor support, hospitalization charge, acute kidney injury requiring hemodialysis, cardiogenic shock, and cardiac arrest. These results emphasize the need for more research to reduce worse outcomes with COVID-19-related stress cardiomyopathy patients.
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Affiliation(s)
- Monique G Davis
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Aniesh Bobba
- Department of Medicine, John H Stronger Hospital, Cook County, Chicago, IL
| | - Harris Majeed
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Muhammad I Bilal
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA
| | - Adeel Nasrullah
- Division of Pulmonology and Critical Care, Allegheny Health Network, Pittsburgh, PA
| | - Glenn M Ratmeyer
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Prabal Chourasia
- Department of Hospital Medicine, Mary Washington Hospital, Fredericksburg, VA.
| | - Karthik Gangu
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS
| | - Asif Farooq
- Department of Family and Community Medicine, Texas Tech Health Sciences Center, Lubbock, TX
| | - Sindhu R Avula
- Department of Interventional Cardiology, Division of Cardiology, University of Kansas, St Francis Campus, Kansas City, KS
| | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
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20
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Titus A, Sattar Y, Patel N, Taha A, Sandhyavenu H, Gonuguntla K, Thyagaturu H, Almas T, Balla S. In-Hospital Outcomes of Takotsubo Cardiomyopathy During the COVID-19 Pandemic: Propensity Matched National Cohort. Curr Probl Cardiol 2023; 48:101598. [PMID: 36681214 DOI: 10.1016/j.cpcardiol.2023.101598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 01/12/2023] [Indexed: 01/20/2023]
Abstract
Takotsubo Cardiomyopathy (TTS) is an acute reversible left ventricular dysfunction with regional ballooning secondary to various physical or psychological triggers, including COVID-19. The impact of TTS on outcomes in COVID-19 patients is not well studied. The Nationwide in-patient sample database from 2019 to 2020 was utilized to identify TTS patients with and without COVID-19. Clinical Modification (ICD-10-CM) codes U07.1 and I51.81 were used as disease identifiers for COVID-19 and TTS, respectively. Multivariate logistic regression was performed to report adjusted odds ratios (aOR) and propensity score match (PSM) was done to compare outcomes among TTS patients with and without COVID. The primary outcome was in-hospital mortality. A total of 83,215 TTS patients for the period 2019-2020 were included in our study, of which 1665 (2%) had COVID-19. COVID-19 with TTS group had higher adjusted odds of in-hospital mortality (aOR 7.23, PSM 32.7% vs 10.16%, p = <0.001), cardiogenic shock; (aOR 2.32, PSM 16.7% vs 9.5%, P < 0.001) and acute kidney injury; (aOR 2.30, PSM 47.5% vs 33.1%, P< 0.001) compared to TTS without COVID-19. TTS hospitalizations with COVID-19 were associated with longer lengths of stay (12 ± 12 vs 7 ± 9 days) and higher total cost ($47,702 ± $67,940 vs $26,957 ± $44,286) compared to TTS without COVID. TTS with COVID-19 group had a higher proportion of males compared to TTS without COVID-19 group (37.8% vs 18.5%). TTS with COVID-19 group had a greater proportion of non-white race. The proportion of Blacks, Hispanics, and Asian/Pacific Islander was higher in the COVID-19 TTS group compared to TTS without COVID-19 group (12.9% vs 8.4%, 20.4% vs 6.5%, 5 vs 2.2%, respectively). TTS in the setting of COVID-19 illness has worse outcomes in terms of in-hospital mortality, cardiogenic shock, and acute kidney injury. Male sex and non-white race were more likely to be affected by TTS in the setting of COVID-19. The out-of-hospital morbidity and mortality in patients who suffered TTS during COVID-19 illness need further study. Studies are needed to provide mechanistic insights into the interaction between COVID-19 and TTS.
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Affiliation(s)
- Anoop Titus
- Department of Medicine, Saint Vincent Hospital, Worcester, MA
| | - Yasar Sattar
- Department of Cardiology, West Virginia University, Morgantown, WV
| | - Neel Patel
- Department of Medicine, New York Medical College/ Landmark Medical Center, Woonsocket, RI
| | - Amro Taha
- Department of Medicine, Weiss Memorial Hospital, Chicago, IL
| | | | | | | | | | - Sudarshan Balla
- Department of Cardiology, West Virginia University, Morgantown, WV.
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21
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Majeed H, Gangu K, Shekhar R, Sagheer S, Garg I, Shuja H, Bobba A, Chourasia P, Avula SR, Sheikh AB. Impact of COVID-19 on Patients Hospitalized with ST-Segment Elevation Myocardial Infarction in the United States during the Early Pandemic: An Analysis of Outcomes, Care Delivery, and Racial Disparities in Mortality. Infect Dis Rep 2023; 15:55-65. [PMID: 36648860 PMCID: PMC9844427 DOI: 10.3390/idr15010006] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/18/2022] [Accepted: 12/30/2022] [Indexed: 01/11/2023] Open
Abstract
The COVID-19 pandemic has impacted healthcare delivery to patients with ST-segment elevation myocardial infarction (STEMI). The aim of our retrospective study was to determine the effect of COVID-19 on inpatient STEMI outcomes and to investigate changes in cardiac care delivery during 2020. We utilized the National Inpatient Sample database to examine inpatient mortality and cardiac procedures among STEMI patients with and without COVID-19. In our study, STEMI patients with COVID-19 had higher inpatient mortality (47.4% vs. 11.2%, aOR: 3.8, 95% CI: 3.2−4.6, p < 0.001), increased length of stay (9.0 days vs. 4.3 days, p < 0.001) and higher cost of hospitalization (USD 172,518 vs. USD 131,841, p = 0.004) when compared to STEMI patients without COVID-19. STEMI patients with COVID-19 also received significantly less invasive cardiac procedures (coronary angiograms: 30.4% vs. 50.8%, p < 0.001; PCI: 32.9% vs. 70.1%, p < 0.001; CABG: 0.9% vs. 4.1%, p < 0.001) and were more likely to receive systemic thrombolytic therapy (4.2% vs. 1.1%, p < 0.001) when compared to STEMI patients without COVID-19. Our findings are the result of complications of SARS-CoV2 infection as well as alterations in healthcare delivery due to the burden of the COVID-19 pandemic.
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Affiliation(s)
- Harris Majeed
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Karthik Gangu
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS 66103, USA
| | - Rahul Shekhar
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Shazib Sagheer
- Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Hina Shuja
- Department of Medicine, Karachi Medical and Dental College, Karachi 74700, Pakistan
| | - Aniesh Bobba
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL 60612, USA
| | - Prabal Chourasia
- Division of Hospital Medicine, Mary Washington Hospital, Fredericksburg, VA 22401, USA
| | - Sindhu Reddy Avula
- Department of Interventional Cardiology, Division of Cardiology, University of Kansas Health System St. Francis Campus, Kansas City, KS 66606, USA
| | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
- Correspondence:
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22
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Rivera-Torres J, Girón N, San José E. COVID-19: A Comprehensive Review on Cardiovascular Alterations, Immunity, and Therapeutics in Older Adults. J Clin Med 2023; 12:488. [PMID: 36675416 PMCID: PMC9865642 DOI: 10.3390/jcm12020488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 01/11/2023] Open
Abstract
Here, we present a review focusing on three relevant issues related to COVID-19 and its impact in older adults (60 years and older). SARS-CoV-2 infection starts in the respiratory system, but the development of systemic diseases accompanied by severe clinical manifestations has also been reported, with cardiovascular and immune system dysfunction being the major ones. Additionally, the presence of comorbidities and aging represent major risk factors for the severity and poor prognosis of the disease. Since aging-associated decline has been largely related to immune and cardiovascular alterations, we sought to investigate the consequences and the underlying mechanisms of these pathologies to understand the severity of the illness in this population. Understanding the effects of COVID-19 on both systems should translate into comprehensive and improved medical care for elderly COVID-19 patients, preventing cardiovascular as well as immunological alterations in this population. Approved therapies that contribute to the improvement of symptoms and a reduction in mortality, as well as new therapies in development, constitute an approach to managing these disorders. Among them, we describe antivirals, cytokine antagonists, cytokine signaling pathway inhibitors, and vaccines.
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Affiliation(s)
- José Rivera-Torres
- Department of Health Sciences, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
| | - Natalia Girón
- Department of Health Sciences, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
| | - Esther San José
- Department of Health Sciences, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
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23
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José SG, Carrizales-Sepúlveda EF, Vera-Pineda R, Morales-Rendón EJ, de Jesús Ortiz-Corona J, Flores-Ramírez R. Takotsubo Cardiomyopathy and COVID-19: A Case Report and Literature Review. Curr Cardiol Rev 2023; 19:e180822207660. [PMID: 35984028 PMCID: PMC10201897 DOI: 10.2174/1573403x18666220818155039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/03/2022] [Accepted: 06/10/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Takotsubo cardiomyopathy is characterized by transient regional ventricular abnormalities in the absence of coronary artery disease and is reported as a complication of COVID-19. CASE PRESENTATION It can have a diverse clinical presentation, occasionally resembling an acute coronary syndrome, and progress to acute heart failure and cardiogenic shock, adversely affecting patients' prognosis. A high index of suspicion and a thorough diagnostic approach supported by ancillary studies like echocardiography and coronary angiography is key for an accurate diagnosis and correct medical treatment. Herein, we report a patient with severe COVID-19 who developed Takotsubo cardiomyopathy. CONCLUSION We also present a detailed literature review regarding the relationship between COVID-19 and Takotsubo cardiomyopathy.
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Affiliation(s)
- Solís Gabriel José
- Cardiology Service, Hospital Universitario, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | | | - Raymundo Vera-Pineda
- Cardiology Service, Hospital Universitario, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Eliu Jefte Morales-Rendón
- Cardiology Service, Hospital Universitario, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
- Division of Interventional Cardiology, Cardiology Service, Hospital Universitario, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - José de Jesús Ortiz-Corona
- Cardiology Service, Hospital Universitario, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
- Division of Interventional Cardiology, Cardiology Service, Hospital Universitario, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
| | - Ramiro Flores-Ramírez
- Cardiology Service, Hospital Universitario, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
- Echocardiography Laboratory, Cardiology Service, Hospital Universitario, Universidad Autónoma de Nuevo León, Monterrey, Nuevo León, México
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24
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Majeed H, Gangu K, Sagheer S, Garg I, Khan U, Shuja H, Bobba A, Chourasia P, Shekhar R, Avula SR, Sheikh AB. COVID-19 and NSTEMI Outcomes among Hospitalized Patients in the United States and Racial Disparities in Mortality: Insight from National Inpatient Sample Database. Vaccines (Basel) 2022; 10:2024. [PMID: 36560434 PMCID: PMC9780864 DOI: 10.3390/vaccines10122024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/23/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
The COVID-19 pandemic has impacted healthcare delivery to patients with non-ST-segment elevation myocardial infraction (NSTEMI). The aim of our retrospective study is to determine the effect of COVID-19 on inpatient NSTEMI outcomes and to investigate whether changes in cardiac care contributed to the observed outcomes. After multivariate adjustment, we found that NSTEMI patients with COVID-19 had a higher rate of inpatient mortality (37.3% vs. 7.3%, adjusted odds ratio: 4.96, 95% CI: 4.6−5.4, p < 0.001), increased length of stay (9.9 days vs. 5.4 days, adjusted LOS: 3.6 days longer, p < 0.001), and a higher cost of hospitalization (150,000 USD vs. 110,000 USD, inflation-adjusted cost of hospitalization: 36,000 USD higher, p < 0.001) in comparison to NSTEMI patients without COVID-19, despite a lower burden of pre-existing cardiac comorbidity. NSTEMI patients with COVID-19 also received less invasive cardiac procedures (coronary angiography: 8.7% vs. 50.3%, p < 0.001; PCI: 4.8% vs. 29%, p < 0.001; and CABG: 0.7% vs. 6.2%, p < 0.001). In our study, we observed increased mortality and in-hospital complications to be a combined effect of COVID-19 infection and myocardial inflammation as a result of cytokine storm, prothrombic state, oxygen supply/demand imbalance and alterations in healthcare delivery from January to December 2020.
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Affiliation(s)
- Harris Majeed
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Karthik Gangu
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS 66103, USA
| | - Shazib Sagheer
- Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Umair Khan
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Hina Shuja
- Department of Medicine, Karachi Medical and Dental College, Karachi 74700, Pakistan
| | - Aniesh Bobba
- Department of Medicine, John H. Stronger Hospital, Cook County, Chicago, IL 60612, USA
| | - Prabal Chourasia
- Division of Hospital Medicine, Mary Washington Hospital, Fredericksburg, VA 22401, USA
| | - Rahul Shekhar
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
| | - Sindhu Reddy Avula
- Department of Interventional Cardiology, Division of Cardiology, University of Kansas, St. Francis Campus, Kansas City, KS 66606, USA
| | - Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM 87106, USA
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25
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Pruzansky AJ, Slade JJ, Stephenson M, Pursnani S. A Review of Cardiovascular Complications among Pregnant Patients with COVID-19. Rev Cardiovasc Med 2022; 23:383. [PMID: 39076200 PMCID: PMC11269075 DOI: 10.31083/j.rcm2311383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/15/2022] [Accepted: 08/25/2022] [Indexed: 07/31/2024] Open
Abstract
Cardiovascular complications of severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection are well-described in the general population but remain limited among pregnant patients. This review summarizes data from case reports, case series, and observational studies of cardiovascular manifestations of corona virus disease 2019 (COVID-19) in pregnant patients and provides recommendations to the cardiovascular clinician regarding management considerations in this vulnerable population. Pregna is an immunocompromised state in which cardiovascular demands are increased. Cardiovascular complications of COVID-19 that have been described in pregnancy include myocardial injury, cardiomyopathy, thromboembolism, pre-eclampsia and arrhythmia. Physiologic and cardiovascular changes in pregnancy predispose pregnant patients with COVID-19 to more severe illness than the general population. Black or Hispanic race, obesity, diabetes, hypertension and lung disease are risk factors for more severe infection, maternal death and adverse perinatal outcomes. Pregnant patients with severe COVID-19 disease compared with non-pregnant age-matched women with COVID infection are more likely to be admitted to the intensive care unit (ICU), receive mechanical ventilation and require advanced mechanical circulatory support. Cardiovascular complications of COVID-19 in pregnant patients requires further attention, particularly given the anticipated increase in birth volume and ongoing nature of COVID-19 pandemic with novel variants. Clinicians should have a lower threshold for cardiac testing and multidisciplinary management in pregnant women with severe COVID-19 disease. Given the persistence of COVID-19 within our communities, diagnostic laboratory and imaging testing for high-risk pregnant patients hospitalized with COVID-19 infection should be routine. We strongly urge the implementation of a cardio-obstetric multidisciplinary team in individually managing these high-risk patients in an effort to improve maternal and fetal outcomes.
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Affiliation(s)
- Alix J. Pruzansky
- Department of Cardiology, Kaiser Permanente, Santa Clara, CA 95051, USA
| | - Justin J. Slade
- Department of Cardiology, Kaiser Permanente, San Francisco, CA 94115, USA
| | - Megan Stephenson
- Department of Maternal Fetal Medicine, Kaiser Permanente, Santa Clara, CA 95051, USA
| | - Seema Pursnani
- Department of Cardiology, Kaiser Permanente, Santa Clara, CA 95051, USA
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26
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Shechter A, Yelin D, Margalit I, Abitbol M, Morelli O, Hamdan A, Vaturi M, Eisen A, Sagie A, Kornowski R, Shapira Y. Assessment of Adult Patients with Long COVID Manifestations Suspected as Cardiovascular: A Single-Center Experience. J Clin Med 2022; 11:jcm11206123. [PMID: 36294444 PMCID: PMC9605399 DOI: 10.3390/jcm11206123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/06/2022] [Accepted: 10/17/2022] [Indexed: 12/15/2022] Open
Abstract
Background: Persistent symptoms affect a subset of coronavirus disease 2019 (COVID-19) survivors. Some of these may be cardiovascular (CV)-related. Objective: To assess the burden of objective CV morbidity among, and to explore the short-term course experienced by, COVID-19 patients with post-infectious symptomatology suspected as CV. Methods: This was a single-center, retrospective analysis of consecutive adult patients with new-onset symptoms believed to be CV following recovery from COVID-19, who had been assessed at a dedicated ‘Cardio’-COVID clinic between June 2020 and June 2021. All participants were followed for 1 year for symptomatic course and the occurrence of new CV diagnoses and major adverse cardiovascular events (MACE). Results: A total of 96 patients (median age 54 (IQR, 44–64) years, 52 (54%) females) were included in the final analysis. Initial visits occurred within a median of 142 days after the diagnosis of acute COVID. Nearly all (99%) patients experienced a symptomatic acute illness, which was graded as severe in 26 (27%) cases according to the National Institutes of Health (NIH) criteria. Long-COVID symptoms included mainly dyspnea and fatigue. While the initial work-up was mostly normal, 45% of the 11 cardiac magnetic resonance studies performed revealed pathologies. New CV diagnoses were made in nine (9%) patients and mainly included myocarditis that later resolved. An abnormal spirometry was the only variable associated with these. No MACE were recorded. Fifty-two (54%) participants felt that their symptoms improved. No association was found between CV morbidity and symptomatic course. Conclusions: In our experience, long-COVID symptoms of presumed CV origin signified actual CV disease in a minority of patients who, irrespective of the final diagnosis, faced a fair 1-year prognosis.
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Affiliation(s)
- Alon Shechter
- Department of Cardiology, Rabin Medical Center, Petach Tikva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6910203, Israel
- Correspondence: ; Tel.: +972-3-9377107; Fax: +972-3-9249850
| | - Dana Yelin
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6910203, Israel
- Long-COVID Clinic, Rabin Medical Center, Petach Tikva 4941492, Israel
| | - Ili Margalit
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6910203, Israel
- Long-COVID Clinic, Rabin Medical Center, Petach Tikva 4941492, Israel
| | - Merry Abitbol
- Department of Cardiology, Rabin Medical Center, Petach Tikva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6910203, Israel
| | - Olga Morelli
- Department of Cardiology, Rabin Medical Center, Petach Tikva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6910203, Israel
| | - Ashraf Hamdan
- Department of Cardiology, Rabin Medical Center, Petach Tikva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6910203, Israel
| | - Mordehay Vaturi
- Department of Cardiology, Rabin Medical Center, Petach Tikva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6910203, Israel
| | - Alon Eisen
- Department of Cardiology, Rabin Medical Center, Petach Tikva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6910203, Israel
| | - Alex Sagie
- Department of Cardiology, Rabin Medical Center, Petach Tikva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6910203, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petach Tikva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6910203, Israel
| | - Yaron Shapira
- Department of Cardiology, Rabin Medical Center, Petach Tikva 4941492, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6910203, Israel
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27
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Okuyama J, Izumi SI, Funakoshi S, Seto S, Sasaki H, Ito K, Imamura F, Willgerodt M, Fukuda Y. Supporting adolescents' mental health during COVID-19 by utilising lessons from the aftermath of the Great East Japan Earthquake. HUMANITIES & SOCIAL SCIENCES COMMUNICATIONS 2022; 9:332. [PMID: 36187842 PMCID: PMC9510442 DOI: 10.1057/s41599-022-01330-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/31/2022] [Indexed: 06/16/2023]
Abstract
Historical data can determine how adolescents recover from difficult situations such as the Coronavirus disease 2019 (COVID-19) pandemic. This study analysed 3 years of data obtained from high-school students who had been affected by the 2011 Great East Japan Earthquake and consequently evidenced the importance of increasing resilience among affected adolescents. This involved identifying factors contributing to resilience through a model that assessed for each tsunami disaster. This model was determined by assessing the correlation between survivors' resilience scores and their measured psychological and lifestyle scores. This approach showed that, in all tsunami damage models, resilience was most affected by the depressed emotions. Thus, our approach suggests that interventions for improving the depressed mood may improve resilience in adolescents during the COVID-19 pandemic.
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Affiliation(s)
- Junko Okuyama
- Designated National University, Core Research Cluster of Disaster Science, Tohoku University, Sendai, Japan
- Department of Rehabilitation, Tohoku University, Sendai, Japan
| | - Shin-Ichi Izumi
- Department of Rehabilitation, Tohoku University, Sendai, Japan
| | | | - Shuji Seto
- International Research Institute of Disaster Science, Tohoku University, Sendai, Japan
| | - Hiroyuki Sasaki
- International Research Institute of Disaster Science, Tohoku University, Sendai, Japan
| | - Kiyoshi Ito
- International Research Institute of Disaster Science, Tohoku University, Sendai, Japan
| | - Fumihiko Imamura
- Designated National University, Core Research Cluster of Disaster Science, Tohoku University, Sendai, Japan
- International Research Institute of Disaster Science, Tohoku University, Sendai, Japan
| | - Mayumi Willgerodt
- Department of Child, Family, and Population Health Nursing at the University of Washington, Seattle, USA
| | - Yu Fukuda
- Notre Dame Seishin University, Okayama, Japan
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28
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Abstract
Cases of severe heart damage in patients presenting with multisystem inflammatory syndrome in children are one of the most intriguing phenomena during the coronavirus disease of 2019 pandemic. The pathophysiology of myocardial changes in the course of this syndrome has not been fully understood yet. We present a case of a child with multisystem inflammatory syndrome in children and with cardiac changes corresponding to Takotsubo syndrome.
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29
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Barberato SH, Bruneto EG, Reis GS, de Oliveira PRF, Possamai AF, Silvestre O, Silva MMF. Abnormal Echocardiographic Findings in Hospitalized Patients with Covid-19: A Systematic Review and Meta-analysis. Arq Bras Cardiol 2022; 119:267-279. [PMID: 35830075 PMCID: PMC9363071 DOI: 10.36660/abc.20210485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 10/12/2021] [Accepted: 12/08/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (Covid-19) can lead to severe respiratory distress and acute cardiac injury, but it is unclear how often it can cause cardiac dysfunction. OBJECTIVE In this systematic review, we aimed to summarize the main echocardiographic findings in patients with Covid-19. METHODS We systematically searched in PUBMED, EMBASE, LILACS and Cochrane databases, in addition MedRxiv and Scielo preprints from inception to July 21st, 2021. Studies reporting echocardiographic data in patients with Covid-19 were included. Demographic characteristics, previous cardiovascular disease (CVD), and echocardiographic findings were extracted. We performed a meta-analysis of proportions to estimate the main echocardiographic findings. The level of significance was p < 0.05. RESULTS From 11,233 studies, 38 fulfilled inclusion criteria and were included in the meta-analysis. The estimated proportions of left ventricular (LV) systolic dysfunction were 25% (95%CI: 19, 31; I293%), abnormal global longitudinal strain 34% (95% CI 23, 45; I290%), righ ventricular (RV) systolic dysfunction 17% (95%CI 13, 21; I290%), pericardial effusion 17% (95%CI: 9, 26; I297%), and pulmonary hypertension 23% (95%CI: 15, 33, I2 96%). LV systolic dysfunction was directly associated with study-specific prevalence of previous abnormal echocardiogram (p<0.001). The proportion of patients in mechanical ventilation, indicating severity of disease, did not explain the heterogeneity in the proportions of LV dysfunction (p=0.37). CONCLUSION Among hospitalized patients with Covid-19, LV dysfunction has been reported in one quarter, with smaller proportions of right ventricular dysfunction, pericardial effusion and pulmonary hypertension. However, there was a higher proportion of LV dysfunction among studies reporting the presence of prior heart disease, which suggests that cardiac dysfunction was mostly pre-existing.
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Affiliation(s)
- Silvio Henrique Barberato
- Centro de Diagnóstico CardiovascularCuritibaPRBrasilCardioEco Centro de Diagnóstico Cardiovascular, Curitiba, PR – Brasil
- Quanta Diagnóstico, EcocardiografiaCuritibaPRBrasilQuanta Diagnóstico, Ecocardiografia,Curitiba, PR – Brasil
| | - Eduardo G. Bruneto
- Universidade Federal do AcreRio BrancoACBrasilUniversidade Federal do Acre, Rio Branco, AC – Brasil
| | - Gabriel S. Reis
- Universidade Federal do ParanáCuritibaPRBrasilUniversidade Federal do Paraná, Curitiba, PR – Brasil
| | - Paula Rauen Franco de Oliveira
- Pontifícia Universidade Católica do ParanáCuritibaPRBrasilPontifícia Universidade Católica do Paraná, Curitiba, PR – Brasil
| | - Alexandre F. Possamai
- Pontifícia Universidade Católica do ParanáCuritibaPRBrasilPontifícia Universidade Católica do Paraná, Curitiba, PR – Brasil
| | - Odilson Silvestre
- Universidade Federal do AcreRio BrancoACBrasilUniversidade Federal do Acre, Rio Branco, AC – Brasil
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30
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Arroyo-Rodríguez C, Victoria-Nandayapa JR, López-Aceves M, Machain-Leyva CZ, Soto-Gaxiola AH, Pérez-Méndez FM, Navarro-Ruiz JE, García-Gámez GE, Jacobo-López S, Victoria-Nandayapa V. Takotsubo syndrome in COVID-19: a case series study. Echocardiography 2022; 39:920-934. [PMID: 35733395 PMCID: PMC9349628 DOI: 10.1111/echo.15398] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 05/01/2022] [Accepted: 05/22/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Takotsubo syndrome is a clinical syndrome characterized by an acute and transient left ventricular systolic dysfunction related to an emotional or physical stressful event. CASE PRESENTATION During the Covid-19 pandemic, five cases of Takotsubo syndrome in hospitalized, mechanically ventilated patients due critical SARS-CoV-2 infection have been identified at our institution. Here we present the electrocardiographic, echocardiographic and angiographic characteristics of this case series. All cases were initially suspected by echocardiography performed due an abnormal electrocardiogram, troponin elevation or clinical deterioration. CONCLUSION A high index of suspicion should be sought to identify Takotsubo syndrome and other cardiac complications associated with SARS-CoV-2 infection.
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Affiliation(s)
- Cuitláhuac Arroyo-Rodríguez
- Cardiology Department, Hospital San José Hermosillo, Sonora, Mexico.,Departamento de Medicina y Ciencias de la Salud, Universidad de Sonora, Hermosillo, Sonora, Mexico
| | | | | | - Cyntia Zulema Machain-Leyva
- Division of Cardiology, National Medical Center of the Instituto Mexicano del Seguro Social at Ciudad Obregón, Sonora, Mexico
| | | | | | | | | | - Sergio Jacobo-López
- Intensive Care Unit Department, Hospital San José Hermosillo, Sonora, Mexico
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Roh JD, Kitchen RR, Guseh JS, McNeill JN, Aid M, Martinot AJ, Yu A, Platt C, Rhee J, Weber B, Trager LE, Hastings MH, Ducat S, Xia P, Castro C, Singh A, Atlason B, Churchill TW, Di Carli MF, Ellinor PT, Barouch DH, Ho JE, Rosenzweig A. Plasma Proteomics of COVID-19-Associated Cardiovascular Complications: Implications for Pathophysiology and Therapeutics. JACC Basic Transl Sci 2022; 7:425-441. [PMID: 35530264 PMCID: PMC9067411 DOI: 10.1016/j.jacbts.2022.01.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/12/2022] [Accepted: 01/13/2022] [Indexed: 12/30/2022]
Abstract
To gain insights into the mechanisms driving cardiovascular complications in COVID-19, we performed a case-control plasma proteomics study in COVID-19 patients. Our results identify the senescence-associated secretory phenotype, a marker of biological aging, as the dominant process associated with disease severity and cardiac involvement. FSTL3, an indicator of senescence-promoting Activin/TGFβ signaling, and ADAMTS13, the von Willebrand Factor-cleaving protease whose loss-of-function causes microvascular thrombosis, were among the proteins most strongly associated with myocardial stress and injury. Findings were validated in a larger COVID-19 patient cohort and the hamster COVID-19 model, providing new insights into the pathophysiology of COVID-19 cardiovascular complications with therapeutic implications.
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Affiliation(s)
- Jason D. Roh
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert R. Kitchen
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - J. Sawalla Guseh
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jenna N. McNeill
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Malika Aid
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Amanda J. Martinot
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Biomedical Sciences, Section of Pathology, Tufts University Cummings School of Veterinary Medicine, North Grafton, Massachusetts, USA
| | - Andy Yu
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Colin Platt
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James Rhee
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brittany Weber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lena E. Trager
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret H. Hastings
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sarah Ducat
- Department of Biomedical Sciences, Section of Pathology, Tufts University Cummings School of Veterinary Medicine, North Grafton, Massachusetts, USA
| | - Peng Xia
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Claire Castro
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Abhilasha Singh
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bjarni Atlason
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy W. Churchill
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcelo F. Di Carli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Patrick T. Ellinor
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Dan H. Barouch
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, Massachusetts, USA
| | - Jennifer E. Ho
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony Rosenzweig
- Corrigan Minehan Heart Center, Division of Cardiology, Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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32
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Moady G, Rubinstein G, Mobarki L, Atar S. Takotsubo Syndrome in the Emergency Room - Diagnostic Challenges and Suggested Algorithm. Rev Cardiovasc Med 2022; 23:131. [PMID: 39076227 PMCID: PMC11273971 DOI: 10.31083/j.rcm2304131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 07/31/2024] Open
Abstract
Takotsubo syndrome is an important condition to consider among patients with acute chest pain in the emergency room. It often mimics acute coronary syndrome since chest pain and ECG changes are key features in both conditions. The hallmark of takotsubo syndrome is transient left ventricular dysfunction (characterized by apical ballooning) followed by complete echocardiographic recovery in most cases. Although most patients exhibit a benign course, lethal complications may occur. The use of hand-held point-of-care focused cardiac ultrasound may be helpful for early identification of takotsubo syndrome and distinguishing it from acute coronary syndrome and other cardiovascular emergencies. Emergency room physicians should be familiar with typical and atypical presentations of takotsubo syndrome and its key electrocardiographic changes. The approach in the emergency room should be based on a combination the clinical presentation, ECG, and handheld echocardiography device findings, rather than a single electrocardiographic algorithm.
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Affiliation(s)
- Gassan Moady
- Department of Cardiology, Galilee Medical Center, 2210001 Nahariya, Israel
- Azrieli Faculty of Medicine, Bar Ilan University, 1311502 Safed, Israel
| | - Gal Rubinstein
- Department of Cardiology, Galilee Medical Center, 2210001 Nahariya, Israel
| | - Loai Mobarki
- Department of Cardiology, Galilee Medical Center, 2210001 Nahariya, Israel
| | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, 2210001 Nahariya, Israel
- Azrieli Faculty of Medicine, Bar Ilan University, 1311502 Safed, Israel
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33
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Pillarisetti J, Cheema MS, Haloot J, Panday M, Badin A, Mehta A, Anderson AS, Prasad A. Cardiac Complications of COVID-19: Incidence and Outcomes. Indian Heart J 2022; 74:170-177. [PMID: 35490848 PMCID: PMC9050189 DOI: 10.1016/j.ihj.2022.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 04/10/2022] [Accepted: 04/26/2022] [Indexed: 01/08/2023] Open
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34
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Rallidis LS, Iordanidis D, Kosmas N, Varounis C, Filippatos G. Rising trends in Takostubo syndrome during the COVID-19 pandemic: a single center experience. Hellenic J Cardiol 2022; 65:49-50. [PMID: 35337968 PMCID: PMC8942435 DOI: 10.1016/j.hjc.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/26/2022] [Accepted: 03/16/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Loukianos S Rallidis
- Second Department of Cardiology, National & Kapodistrian University of Athens, School of Medicine, University General Hospital ATTIKON, National & Kapodistrian University of Athens.
| | - Dimitrios Iordanidis
- Second Department of Cardiology, National & Kapodistrian University of Athens, School of Medicine, University General Hospital ATTIKON, National & Kapodistrian University of Athens
| | - Nikolaos Kosmas
- Second Department of Cardiology, National & Kapodistrian University of Athens, School of Medicine, University General Hospital ATTIKON, National & Kapodistrian University of Athens
| | - Christos Varounis
- Second Department of Cardiology, National & Kapodistrian University of Athens, School of Medicine, University General Hospital ATTIKON, National & Kapodistrian University of Athens
| | - Gerasimos Filippatos
- Second Department of Cardiology, National & Kapodistrian University of Athens, School of Medicine, University General Hospital ATTIKON, National & Kapodistrian University of Athens
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35
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Sustained Impairment in Cardiopulmonary Exercise Capacity Testing in Patients after COVID-19: A Single Center Experience. Can Respir J 2022; 2022:2466789. [PMID: 35242250 PMCID: PMC8886771 DOI: 10.1155/2022/2466789] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 01/28/2022] [Indexed: 12/11/2022] Open
Abstract
Background Following COVID-19, patients often present with ongoing symptoms comparable to chronic fatigue and subjective deterioration of exercise capacity (EC), which has been recently described as postacute COVID-19 syndrome. Objective To objectify the reduced EC after COVID-19 and to evaluate for pathologic limitations. Methods Thirty patients with subjective limitation of EC performed cardiopulmonary exercise testing (CPET). If objectively limited in EC or deteriorated in oxygen pulse, we offered cardiac stress magnetic resonance imaging (MRI) and a follow-up CPET. Results Eighteen male and 12 female patients were included. Limited relative EC was detected in 11/30 (36.7%) patients. Limitation correlated with reduced body weight-indexed peak oxygen (O2) uptake (peakV̇O2/kg) (mean 74.7 (±7.1) % vs. 103.6 (±14.9) %, p < 0.001). Reduced peakV̇O2/kg was found in 18/30 (60.0%) patients with limited EC. Patients with reduced EC widely presented an impaired maximum O2 pulse (75.7% (±5.6) vs. 106.8% (±13.9), p < 0.001). Abnormal gas exchange was absent in all limited EC patients. Moreover, no patient showed signs of reduced pulmonary perfusion. Using cardiac MRI, diminished biventricular ejection fraction was ruled out in 16 patients as a possible cause for reduced O2 pulse. Despite noncontrolled training exercises, follow-up CPET did not reveal any exercise improvements. Conclusions Deterioration of EC was not associated with ventilatory or pulmonary vascular limitation. Exercise limitation was related to both reduced O2 pulse and peakV̇O2/kg, which, however, did not correlate with the initial severity of COVID-19. We hypothesize that impaired microcirculation or limited peripheral O2 utilization might be causative for prolonged deterioration of EC following acute COVID-19 infection.
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36
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Eftekharzadeh P, Patel A, Sokolova E, Rodas A, Ahmed S. Takotsubo Cardiomyopathy: A COVID-19 Complication. Cureus 2022; 14:e22803. [PMID: 35399473 PMCID: PMC8980236 DOI: 10.7759/cureus.22803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 01/17/2023] Open
Abstract
COVID-19 started as an unknown viral illness and has been a challenging pandemic to overcome. The virus has been associated with multiple organ involvement, including the heart. Takotsubo cardiomyopathy (TSCM), a stress cardiomyopathy, is an uncommon complication in patients diagnosed with COVID-19. The pathogenesis is historically a result of stress onto the body that leads to a catecholamine surge. However, COVID-19 may cause direct damage to the cardiac myocytes via spike protein and angiotensin-converting enzyme 2 (ACE2) receptors which can further exacerbate the stressful insult on the patient and lower the threshold for developing TSCM. In this case report, we discuss a 94-year-old female who presented with signs and symptoms of acute coronary syndrome but, upon cardiac catheterization, was found to have basal hypercontraction with apical ballooning, consistent with TSCM.
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37
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Li P, Wang Y, Liang J, Zuo X, Li Q, Sherif AA, Zhang J, Xu Y, Huang Z, Dong M, Teng C, Pan S, Dixon RAF, Wei X, Wu L, Jin C, Cai P, Dai Q, Ma J, Liu Q. Takotsubo syndrome and respiratory diseases: a systematic review. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac009. [PMID: 35919117 PMCID: PMC9242042 DOI: 10.1093/ehjopen/oeac009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/02/2022] [Accepted: 02/23/2022] [Indexed: 06/15/2023]
Abstract
Takotsubo syndrome (TTS) is a rare cardiovascular condition characterized by reversible ventricular dysfunction and a presentation resembling that of acute myocardial infarction. An increasing number of studies has shown the association of respiratory diseases with TTS. Here, we comprehensively reviewed the literature and examined the available evidence for this association. After searching PubMed, EMBASE, and Cochrane Library databases, two investigators independently reviewed 3117 studies published through May 2021. Of these studies, 99 met the inclusion criteria (n = 108 patients). In patients with coexisting respiratory disease and TTS, the most common TTS symptom was dyspnoea (70.48%), followed by chest pain (24.76%) and syncope (2.86%). The most common type of TTS was apical, accounting for 81.13% of cases, followed by the midventricular (8.49%), basal (8.49%), and biventricular (1.89%) types. Among the TTS cases, 39.82% were associated with obstructive lung disease and 38.89% were associated with pneumonia. Coronavirus disease 2019 (COVID-19), which has been increasingly reported in patients with TTS, was identified in 29 of 42 (69.05%) patients with pneumonia. The overall mortality rate for patients admitted for respiratory disease complicated by TTS was 12.50%. Obstructive lung disease and pneumonia are the most frequently identified respiratory triggers of TTS. Medications and invasive procedures utilized in managing respiratory diseases may also contribute to the development of TTS. Furthermore, the diagnosis of TTS triggered by these conditions can be challenging due to its atypical presentation. Future prospective studies are needed to establish appropriate guidelines for managing respiratory disease with concurrent TTS.
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Affiliation(s)
- Pengyang Li
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Yanxuan Wang
- Xinxiang Medical University, Xinxiang, Henan, China
| | - Jing Liang
- Xinxiang Medical University, Xinxiang, Henan, China
| | - Xinyu Zuo
- Xinxiang Medical University, Xinxiang, Henan, China
| | - Qiuyue Li
- Xinxiang Medical University, Xinxiang, Henan, China
| | - Akil Adrian Sherif
- Department of Medicine, Divison of Cardiology, Saint Vincent Hospital, Worcester, MA, USA
| | - Jingyi Zhang
- Xinxiang Medical University, Xinxiang, Henan, China
| | - Yidan Xu
- Xinxiang Medical University, Xinxiang, Henan, China
| | - Zirui Huang
- Xinxiang Medical University, Xinxiang, Henan, China
| | - Man Dong
- The Third Affiliated Hospital of Xinxiang Medical University, Xinxiang, Henan, China
| | - Catherine Teng
- Division of Cardiology, Department of Medicine, University of Texas at San Antonio, San Antonio, TX, USA
| | - Su Pan
- Wafic Said Molecular Cardiology Research Laboratory, Texas Heart Institute, 6770 Bertner Avenue, MC 2-255, Houston, TX 77030, USA
| | - Richard A F Dixon
- Wafic Said Molecular Cardiology Research Laboratory, Texas Heart Institute, 6770 Bertner Avenue, MC 2-255, Houston, TX 77030, USA
| | - Xin Wei
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Lingling Wu
- Division of Cardiovascular Disease, University of Alabama at Birmingham Hospital, Birmingham, AL, USA
| | - Chengyue Jin
- Department of Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Peng Cai
- Department of Mathematical Sciences, Worcester Polytechnic Institute, Worcester, MA, USA
| | - Qiying Dai
- Department of Medicine, Divison of Cardiology, Saint Vincent Hospital, Worcester, MA, USA
| | - Jianjun Ma
- Xinxiang Medical University, Xinxiang, Henan, China
| | - Qi Liu
- Wafic Said Molecular Cardiology Research Laboratory, Texas Heart Institute, 6770 Bertner Avenue, MC 2-255, Houston, TX 77030, USA
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Al-Kindi S, Zidar DA. COVID-lateral damage: cardiovascular manifestations of SARS-CoV-2 infection. Transl Res 2022; 241:25-40. [PMID: 34780967 PMCID: PMC8588575 DOI: 10.1016/j.trsl.2021.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 02/07/2023]
Abstract
Early in the pandemic, concern that cardiovascular effects would accompany COVID-19 was fueled by lessons from the first SARS epidemic, knowledge that the SARS-COV2 entry receptor (Angiotensin-converting enzyme 2, ACE2) is highly expressed in the heart, early reports of myocarditis, and first-hand accounts by physicians caring for those with severe COVID-19. Over 18 months, our understanding of the cardiovascular manifestations has expanded greatly, leaving more new questions than those conclusively answered. Cardiac involvement is common (∼20%) but not uniformly observed in those who require treatment in a hospitalized setting. Cardiac MRI studies raise the possibility of manifestations in those with minimal symptoms. Some appear to experience protracted cardiovascular symptoms as part of a larger syndrome of post-acute sequelae of COVID-19. Instances of vaccine induced thrombosis and myocarditis are exceedingly rare but illustrate the need to monitor the cardiovascular safety of interventions that induce inflammation. Here, we will summarize the current understanding of potential cardiovascular manifestations of SARS-COV2. To provide proper context, paradigms of cardiovascular injury due to other inflammatory processes will also be discussed. Ongoing research and a deeper understanding COVID-19 may ultimately reveal new insight into the mechanistic underpinnings of cardiovascular disease. Thus, in this time of unprecedented suffering and risk to global health, there exists the opportunity that well conducted translational research of SARS-COV2 may provide health dividends that outlast the current pandemic.
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Key Words
- ace2, angiotensin-converting enzyme 2
- pasc, post-acute sequelae of covid-19
- cvd, cardiovascular disease
- tnf, tumor necrosis factor
- pamp, pathogen associated molecular patterns
- damps, damage associated molecular patterns
- car-t, chimeric antigen receptor therapy
- dvt, deep venous thrombosis
- tf, tissue factor
- psgl, p-selectin glycoprotein ligand
- nets, neutrophil extracellular traps
- lv, left ventricular
- crp, c-reactive protein
- lge, late gadolinium enhancement
- cbv, coxsackie virus b
- b19v, parvovirus b12
- car, coxsackievirus and adenovirus receptor
- ns1, nonstructural protein 1
- ec, endothelial cells
- scrnaseq, single cell rna sequencing
- embx, endomyocardial biopsy
- tte, transthoracic echocardiograms
- rv, right ventricular
- gls, global longitudinal strain
- hscrp, high sensitivity c-reative protein
- vitt, vaccine-induced immune thrombotic thrombocytopenia
- dtap, diphtheria, tetanus, and polio
- vaers, vaccine adverse event reporting system
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Affiliation(s)
- Sadeer Al-Kindi
- Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio
| | - David A Zidar
- Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio; Louis Stokes VA Medical Center, Cleveland, Ohio.
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Nwaedozie S, Rezkalla SH. ST Segment Elevation Myocardial Infarction in the COVID-19 Era: Appraisal of the Evidence. Clin Med Res 2022; 20:52-60. [PMID: 35086855 PMCID: PMC9390854 DOI: 10.3121/cmr.2021.1707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/10/2021] [Indexed: 11/18/2022]
Abstract
The COVID-19 pandemic continues to present a public health challenge and has had a significant impact on the presentation, time-dependent management, and clinical outcomes of ST elevation myocardial infarction (STEMI). Patients with COVID-19 and pre-disposing cardiovascular risk factors like hypertension, hyperlipidemia, and diabetes mellitus are at a higher risk of developing STEMI, and global trends have highlighted delayed management of STEMI, which may contribute to worse clinical outcomes. Prolonged time to intervention has also resulted in an increased rate of no reflow, which is an independent risk factor for worse outcomes in these patients. Timely primary percutaneous coronary intervention (PCI) remains standard of care for STEMI and can be attained within the recommended 90 minutes timeline from hospital presentation. A coordinated, safe, standardized, algorithmic approach among emergency medical services, emergency departments, and cardiac catheterization laboratory is needed to ensure optimal patient outcome during and after the COVID-19 pandemic. The focus of this case report is to highlight the challenges of PCI for ST elevation myocardial infarction in the COVID-19 era.
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Affiliation(s)
- Somto Nwaedozie
- Department of Internal Medicine, Marshfield Clinic, Marshfield, Wisconsin USA
| | - Shereif H Rezkalla
- Department of Cardiology, Marshfield Clinic, Marshfield, Wisconsin USA
- Adjunct Professor of Medicine, University of Wisconsin, Madison, Wisconsin, USA
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40
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Maitz T, Parfianowicz D, Vojtek A, Rajeswaran Y, Vyas AV, Gupta R. COVID-19 Cardiovascular Connection: A Review of Cardiac Manifestations in COVID-19 Infection and Treatment Modalities. Curr Probl Cardiol 2022:101186. [PMID: 35351486 PMCID: PMC8957382 DOI: 10.1016/j.cpcardiol.2022.101186] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/22/2022] [Indexed: 01/08/2023]
Abstract
The coronavirus pandemic has crippled healthcare system since its outbreak in 2020, and has led to over 2.6 million deaths worldwide. Clinical manifestations of COVID-19 range from asymptomatic carrier to severe pneumonia, to life-threatening acute respiratory distress syndrome (ARDS). The early efforts of the pandemic surrounded treating the pulmonary component of COVID-19, however, there has been robust data surrounding the cardiac complications associated with the virus. This is suspected to be from a marked inflammatory response as well as direct viral injury. Arrhythmias, acute myocardial injury, myocarditis, cardiomyopathy, thrombosis, and myocardial fibrosis are some of the observed cardiac complications. There have been high morbidity and mortality rates in those affected by cardiac conditions associated with COVID-19. Additionally, there have been documented cases of patients presenting with typical cardiac symptoms who are subsequently discovered to have COVID-19 infection. In those who test positive for COVID-19, clinical awareness of the significant cardiac components of the virus is pertinent to prevent morbidity and mortality. Unfortunately, treatment and preventative measures developed for COVID-19 have been shown to be also be associated with cardiac complications. This is a comprehensive review of the cardiac complications and manifestations of COVID-19 infection in addition to those associated with both treatment and vaccination.
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Affiliation(s)
- Theresa Maitz
- Department of Medicine, Lehigh Valley Health Network, Allentown, PA
| | | | - Ashley Vojtek
- Department of Medicine, Lehigh Valley Health Network, Allentown, PA
| | | | - Apurva V Vyas
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA.
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41
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Affiliation(s)
- Laura De Michieli
- Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA; Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, Padova 35128, Italy
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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42
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Del Prete A, Conway F, Della Rocca DG, Biondi-Zoccai G, De Felice F, Musto C, Picichè M, Martuscelli E, Natale A, Versaci F. COVID-19, Acute Myocardial Injury, and Infarction. Card Electrophysiol Clin 2022; 14:29-39. [PMID: 35221083 PMCID: PMC8556597 DOI: 10.1016/j.ccep.2021.10.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Severe acute respiratory syndrome coronavirus-2 can affect the cardiovascular system yielding a wide range of complications, including acute myocardial injury. The myocardium can be damaged by direct viral invasion or indirect mechanisms, sustained by systemic inflammation, immune-mediated response, and dysregulation of the renin-angiotensin system. Myocardial injury affects about one-quarter of patients with COVID-19, can manifest even in the absence of previous cardiovascular disease, and is associated to higher mortality rates and long-term sequelae. This review describes the pathophysiological mechanisms of myocardial injury and infarction and discusses the main clinical outcomes and diagnostic challenges associated with myocardial damage during COVID-19.
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Affiliation(s)
- Armando Del Prete
- Division of Cardiology, Santa Maria Goretti Hospital, Via Guido Reni 1, 04100 Latina, Italy; Department of Systems Medicine, University of Rome "Tor Vergata", Via Montpellier 1, 00133 Rome, Italy.
| | - Francesca Conway
- London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, United Kingdom
| | - Domenico G Della Rocca
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 000 N Interstate Hwy 35 Suite 720, Austin, TX 78705, USA
| | - Giuseppe Biondi-Zoccai
- Division of Cardiology, Santa Maria Goretti Hospital, Via Guido Reni 1, 04100 Latina, Italy; Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Corso della Repubblica 79, 04100 Latina, Italy; Mediterranea Cardiocentro, Via Ponte di Tappia 82, 80133 Naples, Italy
| | - Francesco De Felice
- Division of Cardiology, San Camillo Hospital, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Carmine Musto
- Division of Cardiology, San Camillo Hospital, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Marco Picichè
- Department of Cardiac Surgery, San Bortolo Hospital, Viale Ferdinando Rodolfi 37, 36100 Vicenza, Italy
| | - Eugenio Martuscelli
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Via Montpellier 1, 00133 Rome, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 000 N Interstate Hwy 35 Suite 720, Austin, TX 78705, USA; Interventional Electrophysiology, Scripps Clinic, 9898 Genesee Ave Fl 3, La Jolla, CA 92037, USA; Metro Health Medical Center, Case Western Reserve University School of Medicine, 9501 Euclid Ave, Cleveland, OH 44106, USA
| | - Francesco Versaci
- Division of Cardiology, Santa Maria Goretti Hospital, Via Guido Reni 1, 04100 Latina, Italy
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Zmaili M, Alzubi J, Alkhayyat M, Cohen J, Alkharabsheh S, Rana M, Alvarez PA, Mansoor E, Xu B. Takotsubo cardiomyopathy in orthotopic liver transplant recipients: A cohort study using multi-center pooled electronic health record data. World J Hepatol 2022; 14:400-410. [PMID: 35317180 PMCID: PMC8891665 DOI: 10.4254/wjh.v14.i2.400] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/08/2021] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Takotsubo cardiomyopathy (TCM), or stress-induced cardiomyopathy, is associated with adverse prognosis. Limited data suggest that TCM occurring in orthotopic liver transplant (OLT) recipients is associated with elevated peri-operative risk. AIM To characterize the predictors of TCM in OLT recipients, using a large, multi-center pooled electronic health database. METHODS A multi-institutional database (Explorys Inc, Cleveland, OH, USA), an aggregate of de-identified electronic health record data from 26 United States healthcare systems was surveyed. A cohort of patients with a Systematized Nomenclature of Medicine-Clinical Terms of "liver transplant" between 09/2015 and 09/2020 was identified. Subsequently, individuals who developed a new diagnosis of TCM following OLT were identified. Furthermore, the risk associations with TCM among this patient population were characterized using linear regression. RESULTS Between 09/2015 and 09/2020, of 37718540 patients in the database, 38740 (0.10%) had a history of OLT (60.6% had an age between 18-65 years, 58.1% female). A new diagnosis of TCM was identified in 0.3% of OLT recipients (45.5% had an age between 18-65 years, 72.7% female), compared to 0.04% in non-OLT patients [odds ratio (OR): 7.98, 95% confidence intervals: 6.62-9.63, (P < 0.0001)]. OLT recipients who developed TCM, compared to those who did not, were more likely to be greater than 65 years of age, Caucasian, and female (P < 0.05). There was also a significant association with cardiac arrhythmias, especially ventricular arrhythmias (P < 0.0001). CONCLUSION TCM was significantly more likely to occur in LT recipients vs non-recipients. Older age, Caucasian ethnicity, female gender, and presence of arrhythmias were significantly associated with TCM in LT recipients.
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Affiliation(s)
- Mohammad Zmaili
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Jafar Alzubi
- Department of Medicine, Division of Cardiology, Einstein Medical Center, Philadelphia, PA 19141, United States
| | - Motasem Alkhayyat
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Joshua Cohen
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Saqer Alkharabsheh
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Mariam Rana
- Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Paulino A Alvarez
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Emad Mansoor
- Department of Gastroenterology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH 44106, United States
| | - Bo Xu
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, United States.
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Moady G, Atar S. Stress-Induced Cardiomyopathy—Considerations for Diagnosis and Management during the COVID-19 Pandemic. Medicina (B Aires) 2022; 58:medicina58020192. [PMID: 35208516 PMCID: PMC8875249 DOI: 10.3390/medicina58020192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 12/12/2022] Open
Abstract
The novel coronavirus disease 2019 (COVID-19) is associated with several cardiovascular manifestations including myocardial injury, myocarditis, arrhythmia, and pulmonary embolism. Rare cases of stress-induced cardiomyopathy, or takotsubo syndrome have also been reported during the acute infection, and secondary to stress following lockdown and self-isolation. Diagnosis in the setting of the acute infection is challenging since conventional imaging modalities such as transthoracic echocardiography and coronary angiography should be restricted to minimize physician-patient contact until the patients is tested negative for COVID-19. The use of point of care hand-held ultrasound is appropriate for this purpose. The overall course of the disease seems to be similar to takotsubo in the general population. Physicians should be familiar with the clinical presentation, possible complications, and management of takotsubo during COVID-19 outbreak. Here, we review the special considerations in the diagnosis and management of takotsubo syndrome during the current pandemic.
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Affiliation(s)
- Gassan Moady
- Department of Cardiology, Galilee Medical Center, Nahariya 2221006, Israel;
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 5290002, Israel
- Correspondence: ; Tel.: +972-4-9107273
| | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Nahariya 2221006, Israel;
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 5290002, Israel
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Kimura M, Hashiguchi S, Tanaka K, Hagiwara M, Takahashi K, Miyaji Y, Joki H, Doi H, Koga M, Takeuchi H, Tanaka F. Case Report: Takotsubo Cardiomyopathy in Bickerstaff Brainstem Encephalitis Triggered by COVID-19. Front Neurol 2022; 12:822247. [PMID: 35002947 PMCID: PMC8741194 DOI: 10.3389/fneur.2021.822247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 12/08/2021] [Indexed: 12/28/2022] Open
Abstract
Takotsubo cardiomyopathy (TCM) is a stress-induced cardiomyopathy triggered by critical illness including severe neurological disorders. However, an association between TCM and Bickerstaff brainstem encephalitis (BBE) has rarely been described. During the current coronavirus disease 2019 (COVID-19) pandemic, growing evidence indicates that COVID-19 often leads to various neurological disorders, but there are few reports of an association between COVID-19 and BBE. Here we report a case of TCM associated with BBE triggered by COVID-19, which subsided with immunotherapy for BBE. Both transthoracic echocardiography and electrocardiography led to early and accurate diagnosis of TCM. Sustained hemodynamic instability due to TCM was immediately lessened with immunotherapy whereas additional plasmapheresis and immunotherapy were required to treat BBE. This case indicates that BBE might follow COVID-19 and TCM should be considered when hemodynamic status remains unstable in a patient with BBE.
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Affiliation(s)
- Mizuki Kimura
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shunta Hashiguchi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kenichi Tanaka
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Manato Hagiwara
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Keita Takahashi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yosuke Miyaji
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hideto Joki
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hiroshi Doi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Michiaki Koga
- Department of Neurology and Clinical Neuroscience, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Hideyuki Takeuchi
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Fumiaki Tanaka
- Department of Neurology and Stroke Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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46
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Techasatian W, Nishimura Y, Nagamine T, Ha G, Huang R, Shah P, Yeo J, Kanitsoraphan C. Characteristics of Takotsubo cardiomyopathy in patients with COVID-19: Systematic scoping review. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 13:100092. [PMID: 35128499 PMCID: PMC8802667 DOI: 10.1016/j.ahjo.2022.100092] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 01/01/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND COVID-19 has recently been associated with the development of Takotsubo cardiomyopathy (TCM). This scoping review aims to summarize the existing evidence regarding TCM in COVID-19 and offer future direction for study. METHODS Following the PRISMA Extension for Scoping Reviews, MEDLINE and EMBASE were searched for all peer-reviewed articles with relevant keywords including "Takotsubo", "Stress-induced cardiomyopathy" and "COVID-19" from their inception to September 25, 2021. RESULTS A total of 40 articles with 52 cases were included. Patients with TCM and COVID-19 showed only slight female predominance (59.6%), median age of 68.5 years, and were mostly of the apical subtype (88.6%). All-cause mortality was 36.5%. The median LVEF was 30%. Compared to those without TCM, those with TCM in COVID-19 had more critical illness, higher mortality, lower LVEF, and higher cardiac and inflammatory biomarkers. Notably, the diagnostic criteria of TCM were considerably different between case reports and observational studies. CONCLUSION This scoping review identifies that TCM in COVID-19 may have distinct features that distinguish this condition from TCM without COVID-19. Future studies are warranted to help describe risk factors, determine the utility of inflammatory biomarkers and serum catecholamine levels, and establish disease-specific diagnostic criteria.
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Affiliation(s)
- Witina Techasatian
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Todd Nagamine
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Gavin Ha
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Ricky Huang
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Parthav Shah
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Jihun Yeo
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Chanavuth Kanitsoraphan
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
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47
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Cardiovascular Disease in the COVID-19 Era: Myocardial Injury and Thrombosis. PRACTICAL CARDIOLOGY 2022. [PMCID: PMC7893250 DOI: 10.1016/b978-0-323-80915-3.00044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
COVID-19 is now appreciated as a pandemic, presenting with a wide range of symptoms, mostly respiratory, yet involving other organs massively. Myocardial injury is a crucial complication with significant negative impact on prognosis. Despite all the investigations, exact pathophysiologic mechanisms remain unclear, and so do the appropriate treatments. Thrombosis has been increasingly observed since the first reports, with venous thromboembolism being the major concern. The strategy of thrombosis prophylaxis, though known to be helpful to the clinical scenario, is still a subject of debate.
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48
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Lin IC, Wu CW, Lin YJ, Lo MH, Hsieh KS, Chan JYH, Wu KLH. Milrinone effects on cardiac mitochondria, hemodynamics, and death in catecholamine-infused rats. Pediatr Res 2022; 92:1309-1315. [PMID: 35121850 PMCID: PMC8814569 DOI: 10.1038/s41390-022-01964-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 01/12/2022] [Accepted: 01/16/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Catecholamine-storm is considered the major cause of enterovirus 71-associated cardiopulmonary death. To elucidate the effect of milrinone on cardiac mitochondria and death, a rat model of catecholamine-induced heart failure was investigated. METHODS Young male Spray-Dawley rats received a continuous intravenous infusion of norepinephrine then followed by co-treatment with and without milrinone or esmolol. Vital signs were monitored and echocardiography was performed at indicated time points. At the end of experiments, hearts were extracted to study mitochondrial function, biogenesis, and DNA copy numbers. RESULTS Hypernorepinephrinemia induced persistent tachycardia, hypertension, and high mortality and significantly impaired the activities of the electron transport chain and suppressed mitochondrial DNA copy number, mitochondrial transcription factor A and peroxisome proliferator-activated receptor-gamma coactivator 1-α. Norepinephrine-induced hypertension could be significantly suppressed by milrinone and esmolol. Milrinone improved but esmolol deteriorated the survival rate. The left ventricle was significantly enlarged shortly after norepinephrine infusion but later gradually reduced in size by milrinone. The impairment and suppression of mitochondrial function could be significantly reversed by milrinone but not by esmolol. CONCLUSIONS Milrinone may protect the heart via maintaining mitochondrial function from hypernorepinephrinemia. This study warrants the importance of milrinone and the preservation of mitochondrial function in the treatment of catecholamine-induced death. IMPACT Milrinone may protect the heart from hypernorepinephrinemia-induced death via maintaining myocardial mitochondrial activity, function, and copy number. Maintenance of cardiac mitochondrial function may be a potential therapeutic strategy in such catecholamine-induced heart failure.
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Affiliation(s)
- I-Chun Lin
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Chih-Wei Wu
- grid.413804.aInstitute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ying-Jui Lin
- grid.145695.a0000 0004 1798 0922Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mao-Hung Lo
- grid.145695.a0000 0004 1798 0922Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kai-Sheng Hsieh
- grid.412896.00000 0000 9337 0481Department of Pediatrics, Shuang Ho Hospital—Taipei Medical University, New Taipei City, Taiwan
| | - Julie Y. H. Chan
- grid.413804.aInstitute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Kay L. H. Wu
- grid.413804.aInstitute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan ,grid.469082.10000 0004 0634 2650Department of Senior Citizen Services, National Tainan Institute of Nursing, Tainan, Taiwan
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49
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Khaloo P, Shaqdan A, Ledesma PA, Uzomah UA, Jennifer Galvin, Ptaszek LM, Ruskin JN. Distinct etiologies of high-sensitivity troponin T elevation predict different mortality risks for patients hospitalized with COVID-19. Int J Cardiol 2021; 351:118-125. [PMID: 34952038 PMCID: PMC8690225 DOI: 10.1016/j.ijcard.2021.12.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/24/2021] [Accepted: 12/17/2021] [Indexed: 12/15/2022]
Abstract
Background Cardiovascular events in the context of COVID-19 infection increase the risk of negative patient outcomes, but large cohort studies describing this association are limited. The purpose of the current study was to investigate the potential associations between cardiovascular events and mortality in patients hospitalized due to COVID-19. Methods A retrospective chart review was performed in 2450 patients hospitalized for confirmed COVID-19 infection within a single hospital network between March 15 and June 15, 2020. Logistic regression analysis was used to identify predictors of mortality. Results In the study population, 57% of patients had elevated high sensitivity troponin (hs-TnT) levels. Acute heart failure occurred in 23% of patients and arrhythmias were observed in 8% of patients. Of the 1401 patients with elevated hs-TnT levels, a primary cardiac etiology (e.g., myocardial infarction) was identified in 653 (47%) patients. In the remaining 748 (53%) patients, there was evidence of a primary non-cardiac etiology for hs-TnT elevation such as renal failure (n = 304) and critical illness (n = 286). Elevated hs-TnT was associated with increased risk of mortality. A significantly higher mortality rate was observed for hs-TnT elevation associated with a primary cardiac etiology (OR 4.6, 95% CI: 2.7–7.6; P < 0.001) than a primary non-cardiac etiology (OR 2.7, 95% CI: 1.6–4.5; P < 0.001). Conclusions Elevated hs-TnT in the context of COVID-19 infection is associated with a significantly increased mortality risk. Hs-TnT elevation in the context of a primary cardiac etiology confers a nearly 2-fold higher mortality risk than hs-TnT elevation due to a primary non-cardiac etiology.
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Affiliation(s)
- Pegah Khaloo
- Cardiac Arrhythmia Service, MGH Heart Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America
| | - Ayman Shaqdan
- Cardiac Arrhythmia Service, MGH Heart Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America
| | - Pablo A Ledesma
- Cardiac Arrhythmia Service, MGH Heart Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America
| | - Uwajachukwumma A Uzomah
- Cardiac Arrhythmia Service, MGH Heart Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America
| | - Jennifer Galvin
- Cardiac Arrhythmia Service, MGH Heart Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America
| | - Leon M Ptaszek
- Cardiac Arrhythmia Service, MGH Heart Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America
| | - Jeremy N Ruskin
- Cardiac Arrhythmia Service, MGH Heart Center, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States of America.
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50
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Possari RY, Andrade-Gomes HJ, Mello VC, Galdeano EA, Aguiar-Filho LF, Bittencourt MS, Ponte EV, Bertoche LR, Caio LRS, Rodrigues JD, Alcantara FB, Freitas MAC, Sarinho JCGC, Cervigne NK, Rodrigues WM, Aprahamian I. Association of coronary calcification with prognosis of Covid-19 patients without known heart disease. Braz J Med Biol Res 2021; 54:e11681. [PMID: 34878066 PMCID: PMC8647900 DOI: 10.1590/1414-431x2021e11681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/14/2021] [Indexed: 11/21/2022] Open
Abstract
Risk factors that determine the severity of Covid-19 have not been fully elucidated. The aim of this study was to evaluate the role of coronary artery calcification (CAC) as a risk factor for death or mechanical ventilation (MV) of patients without known heart disease infected with Covid-19. We analyzed 283 consecutive in-patients with acute respiratory symptoms with chest computed tomography (chest-CT), without previous heart disease, and criteria for Covid-19 (RT-PCR positive and/or typical clinical and chest-CT findings). CAC was classified by the number of coronary segments affected as absent (0), mild (1-3), and severe calcification (more than 3). The association between CAC, CAC severity, and death or MV due to severe respiratory failure was assessed by logistic regression. The mean age was 58.7±15.7 years and 54.1% were men. Patients with CAC were older, more likely to have hypertension, and less likely to be obese. CAC was present in 75 patients (26.5%), of which 42 had a mild calcification and 33 had severe calcification, and was associated with death (OR=2.35, 95%CI: 1.01-5.48) or MV (OR=2.72, 95%CI: 1.20-6.20) adjusted for multiple confounders, with significant and increased odds ratio for the severe form of CAC (death: OR=3.70, 95%CI: 1.20-11.42; MV: OR=3.30, 95%CI: 1.09-9.95). We concluded that CAC was an independent risk factor for death or MV in Covid-19 patients without previous heart disease, particularly for those with severe calcification. CAC can be easily visualized on common chest-CT, widely used in evaluation of moderate to severe Covid-19.
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Affiliation(s)
- R Y Possari
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - H J Andrade-Gomes
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil.,Imagem Cardíaca, Prevent Senior, São Paulo, SP, Brasil.,Imagem Cardíaca, United Health Group, São Paulo, SP, Brasil
| | - V C Mello
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - E A Galdeano
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil.,Departamento de Medicina Interna, Hospital de Caridade São Vicente de Paulo, Jundiaí, SP, Brasil
| | - L F Aguiar-Filho
- Imagem Cardíaca, Prevent Senior, São Paulo, SP, Brasil.,Imagem Cardíaca, United Health Group, São Paulo, SP, Brasil.,Instituto Dante Pazzanese de Cardiologia, São Paulo, SP, Brasil
| | - M S Bittencourt
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, SP, Brasil.,Laboratório DASA, São Paulo, SP, Brasil.,University of Pittsburgh Medical Center and University of Pittsburgh, Pittsburgh, PA, USA
| | - E V Ponte
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - L R Bertoche
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - L R S Caio
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - J D Rodrigues
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - F B Alcantara
- Departamento de Regulação da Saúde, Prefeitura de Jundiaí, Jundiaí, SP, Brasil
| | - M A C Freitas
- Departamento de Medicina Interna, Hospital de Caridade São Vicente de Paulo, Jundiaí, SP, Brasil
| | - J C G C Sarinho
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil.,Departamento de Medicina Interna, Hospital de Caridade São Vicente de Paulo, Jundiaí, SP, Brasil
| | - N K Cervigne
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil
| | - W M Rodrigues
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil.,Departamento de Medicina Interna, Hospital de Caridade São Vicente de Paulo, Jundiaí, SP, Brasil
| | - I Aprahamian
- Departamento de Medicina Interna, Faculdade de Medicina de Jundiaí, Jundiaí, SP, Brasil.,Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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