COVID-19 for the Cardiologist: Basic Virology, Epidemiology, Cardiac Manifestations, and Potential Therapeutic Strategies

Cardiac SARS-CoV-2 Infection, Involvement of Cytokines in Postmortem Immunohistochemical Study

In the context of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, significant attention was given to pulmonary manifestations. However, cardiac involvement is increasingly recognized as a critical factor influencing the prognosis, leading to myocardial damage, heart failure, acute coronary syndromes, potentially lethal arrhythmic events, and sudden cardiac death. Despite these findings, there is a lack of studies detailing the necroscopic, macroscopic, and microscopic cardiac changes associated with SARS-CoV-2. This study aimed to investigate the presence of SARS-CoV-2 viral proteins in cardiac tissue using immunohistochemical techniques to assess viral tropism. The analysis of cardiac tissue samples from deceased subjects, in different stages of conservation, confirmed to be positive for SARS-CoV-2 via reverse transcriptase-polymerase chain reaction (RT-PCR), showed immunopositivity for the SARS-CoV-2-NP viral antigen in 33% of cases. Notably, the presence of leukocyte infiltrates sufficient for diagnosing lymphocytic myocarditis was not observed. The central proinflammatory cytokines involved in the pathogenetic mechanism of coronavirus disease 19 (COVID-19) were researched using the immunohistochemical method. A significant increase in cytokine expression was detected, indicating myocardial involvement and dysfunction during SARS-CoV-2 infection. These findings suggest that the immunohistochemical detection of SARS-CoV-2 viral antigens and inflammatory cytokine expression in cardiac tissue could be crucial for a proper forensic assessment of the cause of death, even in sudden cardiac death.

Incidence of Secondary Sclerosing Cholangitis in Hospitalized Long COVID-19 Patients: A Retrospective Single Center Study

BACKGROUND

SARS-CoV-2 infection and associated COVID-19 disease can lead to critical illness with a risk of developing a multiple organ failure. Subsequently, this may lead to various pathological sequelae, such as secondary sclerosing cholangitis after surviving COVID-19 (SSC-COVID).

OBJECTIVE

The aim is to retrospectively analyze a cohort of hospitalized patients with first-wave (February 2020-June 2020) SARS-CoV-2 infection and persisting unclear cholangiopathy to determine the incidence of SSC-COVID and its risk factors.

RESULTS

A total of 249 patients were hospitalized at the university hospital in Tübingen, Germany, with SARS-CoV-2 infection during the first wave of the pandemic. Of these, 35.3% (88/249) required intensive care treatment; 16.5% (41/249) of them died due to the complications of COVID-19; 30.8% (64/208) of surviving patients could be followed up und were retrospectively analyzed at our center. The incidence of confirmed SSC-COVID was 7.8% (5/64). All SSC-COVID patients had an ICU stay >20 days, for invasive ventilation, positioning treatment, vasopressor treatment, but possible risk factors for SSC were not significant due to the small number of patients.

CONCLUSIONS

SSC-COVID is an emerging disease in post-COVID patients with a high incidence in our single-center cohort. SSC-COVID should be considered as a differential diagnosis, if unclear cholangiopathy or cholestasis persists after SARS-CoV-2 infection.

Role of epinephrine in attenuating cytokine storm, decreasing ferritin, and inhibiting ferroptosis in SARS-CoV-2

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus responsible for coronavirus disease 2019. It presents one of the most threatening pandemics in the history of humanity. The mortality and morbidity represent an unprecedented challenge to the modern medical era. SARS-CoV-2 results in acute respiratory distress syndrome, high concentrations of proinflammatory mediators, cytokine storm (CS) due to massive release of cytokines, hypercoagulation, and hemoglobin disintegration. Dysregulation of iron homeostasis, iron overload as indicated by high ferritin level, and ferroptosis are major factors in the pathogenesis of the disease. We report a case of SARS-CoV-2 in which the use of epinephrine (Epi) resulted in an unexpected attenuation of CS, decreasing ferritin level and inhibiting ferroptosis.

CASE PRESENTATION

A 64-year-old male patient with a history of multiple medical comorbidities had been diagnosed with SARS-CoV-2. Further evaluation showed marked increase in inflammatory markers, severe hyperferritinemia, and lymphopenia in laboratory blood tests. The characteristic score of CS was strongly positive, and in addition to regular treatment, the patient received Epi due to development of acute generalized skin rash, severe itching, and edema of lips and tongue. Epi may have successfully terminated not only the acute cutaneous condition, but also have attenuated CS, decreased ferritin level, and other inflammatory markers in addition to complete patient's recovery.

CONCLUSION

Epinephrine may attenuate CS and inhibit ferroptosis which is an iron-dependent, non-apoptotic mode of cell death. Epi interacts with ferric and/or ferrous iron and built a stable complex that impedes activation of beta-adrenergic receptors. Epi may cause marked decrease of ferritin and other inflammatory markers. Epi may be used to decrease iron overload which is associated with many medical diseases like type 2 diabetes mellitus and cardiometabolic diseases such as coronary heart disease and cerebrovascular disease. As a new clinical indication extensive studies are required for further assessment and possible therapeutic uses.

The COVID-19 in athletes (COVA) study: a national study on cardio-pulmonary involvement of SARS-CoV-2 infection among elite athletes

Background

COVID-19 can cause cardiopulmonary involvement. Physical activity and cardiac complications can worsen prognosis, while pulmonary complications can reduce performance.

Aims

To determine the prevalence and clinical implications of SARS-CoV-2 cardiopulmonary involvement in elite athletes.

Methods

An observational study between 1 July 2020 and 30 June 2021 with the assessment of coronary biomarkers, electrocardiogram, echocardiography, Holter-monitoring, spirometry, and chest X-ray in Danish elite athletes showed that PCR-tested positive for SARS-CoV-2. The cohort consisted of male football players screened weekly (cohort I) and elite athletes on an international level only tested if they had symptoms, were near-contact, or participated in international competitions (cohort II). All athletes were categorized into two groups based on symptoms and duration of COVID-19: Group 1 had no cardiopulmonary symptoms and duration ≤7 days, and; Group 2 had cardiopulmonary symptoms or disease duration >7 days.

Results

In total 121 athletes who tested positive for SARS-CoV-2 were investigated. Cardiac involvement was identified in 2/121 (2%) and pulmonary involvement in 15/121 (12%) participants. In group 1, 87 (72%), no athletes presented with signs of cardiac involvement, and 8 (7%) were diagnosed with radiological COVID-19-related findings or obstructive lung function. In group 2, 34 (28%), two had myocarditis (6%), and 8 (24%) were diagnosed with radiological COVID-19-related findings or obstructive lung function.

Conclusions

These clinically-driven data show no signs of cardiac involvement among athletes who tested positive for SARS-CoV-2 infection without cardiopulmonary symptoms and duration <7 days. Athletes with cardiopulmonary symptoms or prolonged duration of COVID-19 display, exercise-limiting cardiopulmonary involvement.

Hepatobiliary long-term consequences of COVID-19: dramatically increased rate of secondary sclerosing cholangitis in critically ill COVID-19 patients

BACKGROUND

Increasing evidence suggests that secondary sclerosing cholangitis (SSC), which can lead to cirrhosis or liver failure, may be a hepatobiliary long-term complication of COVID-19. The aim of this study was to estimate the frequency and outcome of this COVID-19 sequela and to identify possible risk factors.

METHODS

This observational study, conducted at University Hospital Charité Berlin and Unfallkrankenhaus Berlin, Germany, involved hospitalized patients with COVID-19 pneumonia, including 1082 ventilated COVID-19 patients. We compared COVID-19 patients who developed SSC with a COVID-19 control group by univariate and multivariate analyses.

RESULTS

SSC occurrence after COVID-19 was observed exclusively in critically ill patients with invasive ventilation, albeit with extreme clustering among them. One in every 43 invasively ventilated COVID-19 patients developed this complication. Risk factors preceding the development of secondary sclerosing cholangitis in critically ill COVID-19 patients (SSC-CIP) were signs of systemic reduced blood oxygen supply (e.g., low PaO2/FiO2, ischemic organ infarctions), multi-organ failure (high SOFA score) at admission, high fibrinogen levels and intravenous ketamine use. Multivariate analysis confirmed fibrinogen and increased plasma lactate dehydrogenase as independent risk factors associated with cholangiopathy onset. The 1-year transplant-free survival rate of COVID-19-associated SSC-CIP was 40%.

CONCLUSIONS

COVID-19 causes SSC-CIP in a substantial proportion of critically ill patients. SSC-CIP most likely develops due to severe tissue hypoxia and fibrinogen-associated circulatory disturbances. A significant increase of patients with SSC-CIP is to be expected in the post-COVID era.

[Asymptomatic SARS-CoV-2 Infection and "in situ split" Liver Resection with Fatal Outcome - A Case Report]

We report the perioperative course of a 47-year-old patient who underwent a two-stage liver resection for bilobar metastatic colorectal carcinoma. The respiratory asymptomatic patient was tested positive for SARS-CoV-2 by PCR detection one day before the second surgical procedure. Postoperatively, the patient suffered cardiovascular arrest on postoperative day 8 and died despite immediately initiated resuscitative measures. With an initial clinical suspicion of vascular liver failure, postmortem pathologic examination revealed the underlying cause of death to be COVID-19-related myocarditis with acute right heart failure. Individual multidisciplinary risk assessment should be considered very critically when deviating from the "7-week rule" because the benefit is difficult to objectify, even in oncologic patients.

Long-term Health-Related Quality of Life and Outcomes after Hospitalization for COVID-19 in Brazil: Post-COVID Brazil 1 Study Protocol

BACKGROUND

The long-term impact of hospitalization for COVID-19 on patients' physical, mental, and cognitive health still needs further assessment.

OBJECTIVES

This study aims to evaluate factors associated with quality of life and cardiovascular and non-cardiovascular outcomes 12 months after hospitalization for COVID-19.

METHODS

This prospective multicenter study intends to enroll 611 patients hospitalized due to COVID-19 (NCT05165979). Centralized telephone interviews are scheduled to occur at three, six, nine, and 12 months after hospital discharge. The primary endpoint is defined as the health-related quality-of-life utility score assessed by the EuroQol-5D-3L (EQ-5D-3L) questionnaire at 12 months. Secondary endpoints are defined as the EQ-5D-3L at three, six and nine months, return to work or education, persistent symptoms, new disabilities in instrumental activities of daily living, cognitive impairment, anxiety, depression, and post-traumatic stress symptoms, major cardiovascular events, rehospitalization, as well as all-cause mortality at 3, 6, 9, and 12 months after SARS-CoV-2 infection. A p-value <0.05 will be assumed as statistically significant for all analyses.

RESULTS

The primary endpoint will be presented as the frequency of the EQ-5D-3L score 12 months after COVID-19 hospitalization. A sub-analysis to identify possible associations of independent variables with study outcomes will be presented.

CONCLUSIONS

This study will determine the impact of COVID-19 on the quality of life and cardiovascular and non-cardiovascular outcomes of hospitalized patients 12 months after discharge providing insights to the public health system in Brazil.

Health-Related Quality of Life and Long-Term Outcomes after Mildly Symptomatic COVID-19: The Post-COVID Brazil Study 2 Protocol

BACKGROUND

The long-term effects of mild COVID-19 on physical, cognitive, and mental health are not yet well understood.

OBJECTIVE

The purpose of this paper is to describe the protocol for the ongoing "Post-COVID Brazil" study 2, which aims to evaluate the factors associated with health-related quality of life and long-term cardiovascular and non-cardiovascular outcomes one year after a mild episode of symptomatic COVID-19.

METHODS

The "Post-COVID Brazil" study 2 is a prospective multicenter study that plans to enroll 1047 patients (NCT05197647). Centralized, structured telephone interviews are conducted at 1, 3, 6, 9, and 12 months after COVID-19 diagnosis. The primary outcome is the health-related quality-of-life utility score, assessed using the EuroQol-5D-3L (EQ-5D-3L) questionnaire at 12 months. Secondary endpoints include the EQ-5D-3L at 3, 6, and 9 months, as well as all-cause mortality, major cardiovascular events, hospitalization, return to work or education, persistent symptoms, new disabilities in instrumental activities of daily living, cognitive impairment, anxiety, depression, and post-traumatic stress symptoms at 3, 6, 9, and 12 months after SARS-CoV-2 infection. A p-value < 0.05 will be considered statistically significant for all analyses.

RESULTS

The primary endpoint will be presented as the overall frequency of the EQ-5D-3L domains 12 months after SARS-CoV-2 infection. Main analysis will explore the association of independent variables with the study outcomes.

CONCLUSION

The "Post-COVID Brazil" study 2 aims to clarify the impact of long COVID on the quality of life and cardiovascular and non-cardiovascular outcomes of Brazilian patients who have had mild COVID-19.

Nano-based techniques: A revolutionary approach to prevent covid-19 and enhancing human awareness

In every century of history, there are many new diseases emerged, which are not even cured by many developed countries. Today, despite of scientific development, new deadly pandemic diseases are caused by microorganisms. Hygiene is considered to be one of the best methods of avoiding such communicable diseases, especially viral diseases. Illness caused by SARS-CoV-2 was termed COVID-19 by the WHO, the acronym derived from "coronavirus disease 2019. The globe is living in the worst epidemic era, with the highest infection and mortality rate owing to COVID-19 reaching 6.89% (data up to March 2023). In recent years, nano biotechnology has become a promising and visible field of nanotechnology. Interestingly, nanotechnology is being used to cure many ailments and it has revolutionized many aspects of our lives. Several COVID-19 diagnostic approaches based on nanomaterial have been developed. The various metal NPs, it is highly anticipated that could be viable and economical alternatives for treating drug resistant in many deadly pandemic diseases in near future. This review focuses on an overview of nanotechnology's increasing involvement in the diagnosis, prevention, and therapy of COVID-19, also this review provides readers with an awareness and knowledge of importance of hygiene.

Serum Total Antioxidant Capacity (TAC) and TAC/Lymphocyte Ratio as Promising Predictive Markers in COVID-19

SARS-CoV-2 infection might cause a critical disease, and patients' follow-up is based on multiple parameters. Oxidative stress is one of the key factors in the pathogenesis of COVID-19 suggesting that its level could be a prognostic marker. Therefore, we elucidated the predictive value of the serum non-enzymatic total antioxidant capacity (TAC) and that of the newly introduced TAC/lymphocyte ratio in COVID-19. We included 61 COVID-19 (n = 27 ward, n = 34 intensive care unit, ICU) patients and 29 controls in our study. Serum TAC on admission was measured by an enhanced chemiluminescence (ECL) microplate assay previously validated by our research group. TAC levels were higher (p < 0.01) in ICU (median: 407.88 µmol/L) than in ward patients (315.44 µmol/L) and controls (296.60 µmol/L). Besides the classical parameters, both the TAC/lymphocyte ratio and TAC had significant predictive values regarding the severity (AUC-ROC for the TAC/lymphocyte ratio: 0.811; for TAC: 0.728) and acute kidney injury (AUC-ROC for the TAC/lymphocyte ratio: 0.747; for TAC: 0.733) in COVID-19. Moreover, the TAC/lymphocyte ratio had significant predictive value regarding mortality (AUC-ROC: 0.752). Serum TAC and the TAC/lymphocyte ratio might offer valuable information regarding the severity of COVID-19. TAC measured by our ECL microplate assay serves as a promising marker for the prediction of systemic inflammatory diseases.

Seasonal correlation of meteorological parameters and PM2.5 with the COVID-19 confirmed cases and deaths in Baghdad, Iraq

The COVID-19 pandemic was a serious global health emergency in 2020 and 2021. This study analyzed the seasonal association of weekly averages of meteorological parameters, such as wind speed, solar radiation, temperature, relative humidity, and air pollutant PM2.5, with confirmed COVID-19 cases and deaths in Baghdad, Iraq, a major megacity of the Middle East, for the period June 2020 to August 2021. Spearman and Kendall correlation coefficients were used to investigate the association. The results showed that wind speed, air temperature, and solar radiation have positive and strong correlations with the confirmed cases and deaths in the cold season (autumn and winter 2020-2021). The total COVID-19 cases negatively correlated with relative humidity but were not significant in all seasons. Besides, PM2.5 strongly correlated with COVID-19 confirmed cases for the summer of 2020. The death distribution by age group showed the highest deaths for those aged 60-69. The highest number of deaths was 41% in the summer of 2020. The study provided useful information about the COVID-19 health emergency and meteorological parameters, which can be used for future health disaster planning, adopting prevention strategies and providing healthcare procedures to protect against future infraction transmission.

Role of meteorological parameters with the spread of Covid-19 in Pakistan: application of autoregressive distributed lag approach

This research focuses on the impacts of different meteorological parameters (temperature, humidity, rainfall, and evapotranspiration) on the transmission of Covid-19 in the administrative regions and provinces of Pakistan, i.e., Azad Jammu and Kashmir, Gilgit Baltistan, Khyber Pakhtunkhwa, Islamabad, Punjab, Sindh, and Balochistan from June 10, 2020, to August 31, 2021. This study analyzes the relation between Covid-19-confirmed cases and the meteorological parameters with the help of the autoregressive distributed lag model. In this research, additional tools (t-statistics, f-statistics, and time series analysis) are used for the motive of examining the linear relationship, the productivity of the model, and for the significant association between dependent and independent variables, lnccc and lnevp, lnhum, lnrain, lntemp, respectively. Values of t-statistics and f-statistics reveal that variables have a connection and individual significance for the model exist. Time series display that the Covid-19 spread increased from June 10, 2020, to August 31, 2021, in Pakistan. Temperature positively influenced the Covid-19-confirmed cases in all provinces of Pakistan in the long run. Evapotranspiration and rainfall influenced positively, while specific humidity influenced negatively on the confirmed Covid-19 cases in Azad Jammu Kashmir, Khyber Pakhtunkhwa, and Punjab. Specific humidity had a positive impact, while evapotranspiration and rainfall had the negative impact on the Covid-19-confirmed cases in Sindh and Balochistan. Evapotranspiration and specific humidity influenced positively, while rainfall influenced the Covid-19-confirmed cases negatively in Gilgit Baltistan. Evapotranspiration influenced positively, while specific humidity and rainfall influenced negatively on the Covid-19-confirmed cases in Islamabad.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13762-023-04997-4.

Impact of the Angiotensin-Converting Enzyme (ACE) Inhibitors on the Course of the Acute Respiratory Distress Syndrome (ARDS) Developed During COVID-19 and Other Severe Respiratory Infections Under Hyperferritinemia Conditions: A Cohort Study

Background

Angiotensin-converting enzyme 2 (ACE2) is not only the entry route of SARS-CoV-2 infection but also triggers a major mechanism of COVID-19 aggravation by promoting a hyperinflammatory state, leading to lung injury, hematological and immunological dysregulation. The impact of ACE2 inhibitors on the course of COVID-19 is still unclear. The effect of ACE2 inhibitors on the course of acute respiratory distress syndrome (ARDS) during COVID-19 and other severe respiratory infections in conditions of hyperferritinemia (HF) was investigated.

Methods

A cohort study of critically ill patients with COVID-19 and other respiratory diseases (widespread infection, pneumonia) who underwent treatment in The Critical Care Unit of the First University Clinic (Tbilisi, Georgia) during the 2020-2021 years was conducted. The impact of the ACE2 inhibitors on the course of the ARDS developed during COVID-19 and other severe respiratory infections in conditions of different severity of HF was evaluated.

Results

In COVID-19-infected (I) and uninfected (II) patients with ARDS, ACE2 inhibitors reduce the levels of Ang II, C reactive protein (CRP) and D-dimer (I: from 1508.07  ±  26.68 to 48.51  ±  24.35, from 233.92  ±  13.02 to 198.12  ±  11.88, from 7.88  ±  0.47 to 6.28  ±  0.43; II: from 1000.14  ±  149.49 to 46.23  ±  88.21, 226.48  ±  13.81 to 183.52  ±  17.32, from 6.39  ±  0.58 to 5.48  ±  0.69) at moderate HF and Ang II, CRP levels (I: from 1845.89  ±  89.37 to 49.64  ±  51.05, from 209.28  ±  14.41 to 175.37  ±  9.84; II: from 1753.29  ±  65.95 to 49.76  ±  55.74, 287.10  ±  20.50 to 214.71  ±  17.32) at severe HF, reduce interleukin-6 (IL-6) expression at moderate HF (I: from 1977.23  ±  354.66 to 899.36  ±  323.76) and cause reduction of pCO2 index at severe HF (I: from 69.80  ±  3.22 to 60.44  ±  2.20) in COVID-19-infected patients.

Conclusion

Study results show that the ACE2 inhibitors play an important role in the regulation of inflammatory processes in both COVID-19-infected and uninfected patients with ARDS. ACE2 inhibitors decrease immunological disorders, inflammation, and lung alveoli dysfunction, especially in COVID-19-infected patients.

The controversial effect of smoking and nicotine in SARS-CoV-2 infection

The effects of nicotine and cigarette smoke in many diseases, notably COVID-19 infection, are being debated more frequently. The current basic data for COVID-19 is increasing and indicating the higher risk of COVID-19 infections in smokers due to the overexpression of corresponding host receptors to viral entry. However, current multi-national epidemiological reports indicate a lower incidence of COVID-19 disease in smokers. Current data indicates that smokers are more susceptible to some diseases and more protective of some other. Interestingly, nicotine is also reported to play a dual role, being both inflammatory and anti-inflammatory. In the present study, we tried to investigate the effect of pure nicotine on various cells involved in COVID-19 infection. We followed an organ-based systematic approach to decipher the effect of nicotine in damaged organs corresponding to COVID-19 pathogenesis (12 related diseases). Considering that the effects of nicotine and cigarette smoke are different from each other, it is necessary to be careful in generalizing the effects of nicotine and cigarette to each other in the conducted researches. The generalization and the undifferentiation of nicotine from smoke is a significant bias. Moreover, different doses of nicotine stimulate different effects (dose-dependent response). In addition to further assessing the role of nicotine in COVID-19 infection and any other cases, a clever assessment of underlying diseases should also be considered to achieve a guideline for health providers and a personalized approach to treatment.

A SARS-CoV-2: Companion Animal Transmission and Variants Classification

The continuous emergence of novel viruses and their diseases are a threat to global public health as there have been three outbreaks of coronaviruses that are highly pathogenic to humans in the span of the last two decades, severe acute respiratory syndrome (SARS)-CoV in 2002, Middle East respiratory syndrome (MERS)-CoV in 2012, and novel SARS-CoV-2 which emerged in 2019. The unprecedented spread of SARS-CoV-2 worldwide has given rise to multiple SARS-CoV-2 variants that have either altered transmissibility, infectivity, or immune escaping ability, causing diseases in a broad range of animals including human and non-human hosts such as companion, farm, zoo, or wild animals. In this review, we have discussed the recent SARS-CoV-2 outbreak, potential animal reservoirs, and natural infections in companion and farm animals, with a particular focus on SARS-CoV-2 variants. The expeditious development of COVID-19 vaccines and the advancements in antiviral therapeutics have contained the COVID-19 pandemic to some extent; however, extensive research and surveillance concerning viral epidemiology, animal transmission, variants, or seroprevalence in diverse hosts are essential for the future eradication of COVID-19.

The Comparison of Predicting Factors and Outcomes of MINOCA and STEMI Patients in the 5-Year Follow-Up

The long-term outcomes of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) are still not well known. This study aimed to compare the characteristics and outcomes between MINOCA and STEMI patients in a 5-year follow-up. Between 2010 and 2015 we identified 3171 coronary angiography procedures performed due to acute coronary syndrome, from which 153 had a working MINOCA diagnosis, and the final diagnosis of MINOCA was ascribed to 112 (5.8%) patients. Additionally, we matched 166 patients with STEMI and obstructive coronary arteries as the reference group. In MINOCA patients (mean age of 63 years), there were more females (60% vs. 26%, p < 0.001), and patients presented most frequently with NSTEMI (83.9%). Patients with MINOCA had more frequent atrial fibrillation (22% vs. 5.4%, p < 0.001) and higher left ventricular ejection fraction (59 ± 10% vs. 54 ± 10%, p < 0.001) compared to STEMI patients. We observed only a trend for a higher rate of MACE in STEMI patients at 5 years (11.6% vs. 18.7%, HR 1.82, 95% CI 0.91-3.63, p = 0.09). In multivariable Cox regression, only beta-blocker use was a protective factor (a trend observed), with HR 0.33, 95% CI 0.10-1.15, p = 0.082 of future MACE. The outcomes of MINOCA and STEMI patients were comparable in the 5-year follow-up.

Interaction of COVID-19 With Common Cardiovascular Disorders

The onset and widespread dissemination of the severe acute respiratory syndrome coronavirus-2 in late 2019 impacted the world in a way not seen since the 1918 H1N1 pandemic, colloquially known as the Spanish Flu. Much like the Spanish Flu, which was observed to disproportionately impact young adults, it became clear in the early days of the coronavirus disease 2019 (COVID-19) pandemic that certain groups appeared to be at higher risk for severe illness once infected. One such group that immediately came to the forefront and garnered international attention was patients with preexisting cardiovascular disease. Here, we examine the available literature describing the interaction of COVID-19 with a myriad of cardiovascular conditions and diseases, paying particular attention to patients diagnosed with arrythmias, heart failure, and coronary artery disease. We further discuss the association of acute COVID-19 with de novo cardiovascular disease, including myocardial infarction due to coronary thrombosis, myocarditis, and new onset arrhythmias. We will evaluate various biochemical theories to explain these findings, including possible mechanisms of direct myocardial injury caused by the severe acute respiratory syndrome coronavirus-2 virus at the cellular level. Finally, we will discuss the strategies employed by numerous groups and governing bodies within the cardiovascular disease community to address the unprecedented challenges posed to the care of our most vulnerable patients, including heart transplant recipients, end-stage heart failure patients, and patients suffering from acute coronary syndromes, during the early days and height of the COVID-19 pandemic.

An in-depth appraisal of clinico-biochemical and radiological findings of COVID-19 patients during the COVID-19 pandemic in a dedicated COVID Care Hospital in Eastern India and its outcome in relation to the COVAXIN vaccination status: A 2-year study

Introduction

COVID-19 pandemic hit Odisha province from April 2020 to December 2020, then from April 2021 to August 2021 and from February 2022 to April 2022 as the first, second, and third waves, respectively, with the most severe form witnessed during the second wave. Kalinga Institute of Medical Sciences hospital in Odisha was declared a Dedicated COVID Hospital (DCH) during those three waves and witnessed 9485 cases of admissions among which there were 1214 deaths. COVAXIN vaccination of the vulnerable population was launched in February 2021 onwards. This study has been done to know the clinic-biochemical profiles, radiologic findings of COVID-19 admitted patients, the predictors of mortality in the second wave, and clinical outcomes in the three waves in relation to COVAXIN vaccination status.

Material and Methods

This was a serial three-round retrospective study from the electronic medical records using multistage random sampling where we collected and critically analyzed the demographic, and all the relevant possible health data of the cases that consist of 514 cases admitted in three waves. The data from death certificates among the 555 cases in the second wave have been analyzed to conclude predictors of mortality.

Results

Mortality increased with age, male gender, comorbidities, and raised C-reactive protein level. High NL ratio, extent of pulmonary involvement. There was a wide variation in incidence and spectrum of illness starting from 79% incidence of mild symptomatic in the initial and third wave, but remained in the range of 35-65% in the second wave, respectively, and the most noticeable symptomatic illness was that of the upper respiratory tract. In fulminant cases, the mode of presentations was severe pneumonia and acute respiratory distress syndrome. Males were more sufferers than females. Children had better outcomes compared to adults. COVID-associated coagulopathy had a normal platelet count. Subsequently, in 2021 year onwards vaccination of the vulnerable population was launched in a phased manner that changed the dynamics of the disease outcome by better survival chances despite intercurrent COVID infection by induction of herd immunity. On the contrary, there was a higher prevalence of serious illness among non-vaccinated individuals. While the cases continued during the second wave of the pandemic, long COVID became a clinical entity of symptomatic that persisted or recurred among the COVID illness recovered cases after reverse transcriptase polymerase chain reaction results for COVID-19 became negative. The symptoms consisted of fatigue, cough, dyspnea as pulmonary manifestations and extra-pulmonary involvement of the cardiac, renal, and central nervous systems and the pulmonary imaging features consisted of interstitial pneumonia, consolidation, cavity pattern, and prone to microbial infection. These events lead to morbidity and admission. Coinciding with the vaccination of all population of Odisha province with the first dose of the vaccine by around the period of the first quarter of 2022, there was a new variant named Omicron responsible in the third wave, in which the majority of the admitted cases had.mild upper respiratory illness. This was not as lethal as its predecessors due to its lower propensity to invade the lungs and blood vessels.

Conclusion

Immune dysregulation plays a central role in the pathogenesis of the manifestations. Vaccine-induced protection and the induction of herd immunity played a proactive role in the waning of the severity of clinical presentations.

Benefits and Harms of COVID-19 Vaccines in Cardiovascular Disease: A Comprehensive Review

Patients with a history of cardiovascular disease (CVD) who contract coronavirus disease 2019 (COVID-19) tend to have a worse prognosis and more severe cardiovascular side effects. COVID-19 vaccines, which are intended to prevent COVID-19, may also potentially reduce the severity and complications (including cardiovascular sequelae) of COVID-19, especially in patients with a history of CVD. However, there have also been reports of cardiovascular side effects from COVID-19 vaccines of various brands and types. The purpose of this study is to review the benefits and harms of COVID-19 vaccines in relation to CVD. In this thorough review of the most current evidence on the benefits and harms of COVID-19 vaccines, we present information about the characteristics of cardiovascular complications. Most of the evidence focuses on myocarditis or pericarditis, which are most strongly associated with mRNA vaccines and predominantly occur in young males within days of receiving the second dose. Meanwhile, post-vaccination myocardial infarction is more common in older males, and the first dose of adenoviral vector vaccines appears to play a greater role in this complication. This information may guide us in formulating alternative options and implementing targeted surveillance. Gaining more knowledge about the potential benefits and harms of COVID-19 vaccines will improve our ability to make informed decisions and judgments about the balance of these factors.

More than a key-the pathological roles of SARS-CoV-2 spike protein in COVID-19 related cardiac injury

Cardiac injury is common in hospitalized coronavirus disease 2019 (COVID-19) patients and cardiac abnormalities have been observed in a significant number of recovered COVID-19 patients, portending long-term health issues for millions of infected individuals. To better understand how Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2, CoV-2 for short) damages the heart, it is critical to fully comprehend the biology of CoV-2 encoded proteins, each of which may play multiple pathological roles. For example, CoV-2 spike glycoprotein (CoV-2-S) not only engages angiotensin converting enzyme II (ACE2) to mediate virus infection but also directly activates immune responses. In this work, the goal is to review the known pathological roles of CoV-2-S in the cardiovascular system, thereby shedding lights on the pathogenesis of COVID-19 related cardiac injury.

Ionizable drug delivery systems for efficient and selective gene therapy

Gene therapy has shown great potential to treat various diseases by repairing the abnormal gene function. However, a great challenge in bringing the nucleic acid formulations to the market is the safe and effective delivery to the specific tissues and cells. To be excited, the development of ionizable drug delivery systems (IDDSs) has promoted a great breakthrough as evidenced by the approval of the BNT162b2 vaccine for prevention of coronavirus disease 2019 (COVID-19) in 2021. Compared with conventional cationic gene vectors, IDDSs can decrease the toxicity of carriers to cell membranes, and increase cellular uptake and endosomal escape of nucleic acids by their unique pH-responsive structures. Despite the progress, there remain necessary requirements for designing more efficient IDDSs for precise gene therapy. Herein, we systematically classify the IDDSs and summarize the characteristics and advantages of IDDSs in order to explore the underlying design mechanisms. The delivery mechanisms and therapeutic applications of IDDSs are comprehensively reviewed for the delivery of pDNA and four kinds of RNA. In particular, organ selecting considerations and high-throughput screening are highlighted to explore efficiently multifunctional ionizable nanomaterials with superior gene delivery capacity. We anticipate providing references for researchers to rationally design more efficient and accurate targeted gene delivery systems in the future, and indicate ideas for developing next generation gene vectors.

A Rare Single Case of COVID-19-Induced Acute Myocarditis and Encephalopathy Presenting Simultaneously

The ongoing coronavirus disease 2019 (COVID-19) pandemic may result in cardiovascular complications such as myocarditis, while encephalitis is a potentially life-threatening COVID-19-associated central nervous system complication. This case illustrates the possibility of developing severe multisystem symptoms from a COVID-19 infection, despite having received the COVID-19 vaccine within the year. Delay in treatment for myocarditis and encephalopathy can lead to permanent and possibly fatal damage. Our patient, a middle-aged female with a complicated medical history, initially came in without characteristic manifestations of myocarditis such as shortness of breath, chest pain, or arrhythmia, but with an altered mental status. Through further laboratory tests, the patient was diagnosed with myocarditis and encephalopathy, which were resolved within weeks through medical management and physical/occupational therapy. This case presentation describes the first reported case of concomitant COVID-19 myocarditis and encephalitis after receiving a booster dose within the year.

Restenosis of Coronary Arteries in Patients with Coronavirus Infection: Case Series

Introduction

Coronavirus infection is a risk factor for vascular thrombosis. This is of particular importance for patients undergoing myocardial revascularization since this infection can be a trigger for the formation of restenosis in the area of a previously implanted coronary stent. Understanding the risk factors for stent thrombosis and restenosis is of particular importance in individuals at risk for adverse outcomes. The rarity of such situations makes the present study unique.

Objective

Studying the peculiarities of restenosis and thrombosis of the coronary arteries in patients after coronavirus infection.

Methods

The study was performed in the Department of Cardiovascular Surgery of Emergency Hospital, Semey City, in 2021. We have examined the medical records of 10 consecutive patients with restenosis of coronary arteries after coronavirus infection and 10 matched-by-age patients with similar restenosis of coronary arteries who did not have coronavirus infection as a comparison group. To determine statistically significant differences between independent samples, we calculated the Mann-Whitney U test.

Results

The average age of patients was 65.7 years. Only one case was classified as early restenosis (within 8 days of previous revascularization), two cases represented late restenosis, and seven cases were very late restenoses. In 70% of cases, restenosis was localized in the left anterior descending artery, in 30% of cases, it was in the right coronary artery, and in 40% of cases, it was in the left circumflex artery. In comparison with patients who did not have a coronavirus infection, there were statistically significant differences regarding IgG (P < 0.001) and fibrinogen (P=0.019).

Conclusion

Patients with myocardial revascularization in the past have a higher risk of stent restenosis against the background of coronavirus infection due to excessive neointimal hyperplasia, hypercoagulability, increased inflammatory response, and endothelial dysfunction.

Sex and diet, but not exercise, alter cardiovascular ACE2 and TMPRSS2 mRNA levels in aortic banded swine

SARS-COV-2, or COVID-19, is a respiratory virus that enters tissues via the angiotensin-converting enzyme 2 (ACE2) receptor and is primed and activated by transmembrane protease, serine 2 (TMPRSS2). An interesting dichotomy exists regarding the preventative/therapeutic effects of exercise on COVID-19 infection and severity. Although exercise training has been shown to increase ACE2 receptor levels (increasing susceptibility to COVID-19 infection), it also lowers cardiovascular risk factors, systemic inflammation, and preserves normal renin-angiotensin system axis equilibrium, which is considered to outweigh any enhanced risk of infection by decreasing disease severity. The goal of this study was to determine the effects of chronic exercise training, sex, and Western diet on ACE2 and TMPRSS2 mRNA levels in preclinical swine models of heart failure. We hypothesized chronic exercise training and male sex would increase ACE2 and TMPRSS2 mRNA levels. A retrospective analysis was conducted in previously completed studies including: 1) sedentary and exercise-trained aortic banded male, intact Yucatan mini-swine (n = 6 or 7/group); 2) ovariectomized and/or aortic banded female, intact Yucatan mini-swine (n = 5-8/group); and 3) lean control or Western diet-fed aortic banded female, intact Ossabaw swine (n = 4 or 5/group). Left ventricle, right ventricle, and coronary vascular tissue were evaluated using qRT-PCR. A multivariable regression analysis was used to determine differences between exercise training, sex, and Western diet. Chronic exercise training did not alter ACE2 or TMPRSS2 level regardless of intensity. ACE2 mRNA was altered in a tissue-specific manner due to sex and Western diet. TMPRSS2 mRNA was altered in a tissue-dependent manner due to sex, Western diet, and pig species. These results highlight differences in ACE2 and TMPRSS2 mRNA regulation in an experimental setting of preclinical heart failure that may provide insight into the risk of cardiovascular complications of SARS-COV-2 infection.NEW & NOTEWORTHY This retrospective analysis evaluated the impact of exercise, sex, and diet on ACE2 and TMPRSS2 mRNA levels in preclinical swine heart failure models. Unlike normal exercise intensities, exercise training of an intensity tolerable to a patient with heart failure had no influence on ACE2 or TMPRSS2 mRNA. In a tissue-specific manner, ACE2 mRNA levels were altered due to sex and Western diet, whereas TMPRSS2 mRNA levels were sensitive to sex, Western diet, and pig species.

Cardiac Arrhythmias in Post-COVID Syndrome: Prevalence, Pathology, Diagnosis, and Treatment

An increase in post-COVID patients with late sequelae of acute COVID-19 infection is emerging as an ongoing challenge for physicians and healthcare professionals. Since the beginning of the pandemic, it has rapidly become evident that the acute infection is not limited to the respiratory tract but that several organs, including the cardiovascular system, can be affected. Moreover, in a significant proportion of patients (ranging from about 10 to up to 50%) with former COVID-19, cardiopulmonary symptoms such as dyspnea, palpitations, restricted physical capacity, and cardiac arrhythmias can persist weeks and months after the acute SARS-CoV-2 infection. The spectrum of COVID-19-associated arrhythmias is rather wide, most likely due to various pathomechanisms. In this article, the prevalence of cardiac arrhythmias and underlying pathologies are reviewed, including direct myocardial injury and abnormal consequences with an impact on cardiac electric instability. The hyperinflammatory reaction of the host immune system is specifically considered. Moreover, several distinct rhythm disorders occurring in post-COVID patients are discussed with regard to their clinical management.

Outcomes among ST-Elevation Myocardial Infarction (STEMI) patients with cardiogenic shock and COVID-19: A nationwide analysis

Background

There is paucity of data regarding the characteristics and outcomes of patients admitted for ST Elevation Myocardial Infarction (STEMI) complicated by cardiogenic shock (CS) with concomitant Coronavirus Disease 2019 (COVID-19) infection.

Methods

Using the National Inpatient Sample (NIS) Database for the year 2020, we conducted a retrospective cohort study to investigate the outcomes of patients who sustained STEMI-associated cardiogenic shock (STEMI-CS) with concomitant COVID-19 infection looking at its impact on in-hospital mortality and secondarily at the in-hospital procedure and intervention utilization rates as well as hospital length of stay.

Results

We identified a total of 22,775 patients with STEMI-CS, of which 1.71 % (n = 390/22,775) had COVID-19 infection. Using a stepwise survey multivariable logistic regression model that adjusted for patient and hospital level confounders, concomitant COVID-19 infection among STEMI-CS patients was found to be an independent predictor of overall in-hospital mortality compared to those without COVID-19 (adjusted OR 2.10; 95 % confidence interval [CI], 1.30-3.40). STEMI-CS patients with concomitant COVID-19 infection had similar in-hospital utilization rates for percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), extracorporeal membrane oxygenation (ECMO), percutaneous and durable left ventricular device, intra-arterial aortic balloon pump (IABP), renal replacement therapy (RRT), mechanical ventilation, as well as similar hospital lengths of stay.

Conclusion

Concomitant COVID-19 infection was associated with higher in-hospital mortality rates among patients with cardiogenic shock related to STEMI but had similar in-hospital procedure and intervention utilization rates as well as hospital length of stay.

Abnormal echocardiographic findings after COVID-19 infection: a multicenter registry

The Coronavirus Disease 2019 (COVID-19) pandemic has transformed health systems worldwide. There is conflicting data regarding the degree of cardiovascular involvement following infection. A registry was designed to evaluate the prevalence of echocardiographic abnormalities in adults recovered from COVID-19. We prospectively evaluated 595 participants (mean age 45.5 ± 14.9 years; 50.8% female) from 10 institutions in Argentina and Brazil. Median time between infection and evaluation was two months, and 82.5% of participants were not hospitalized for their infection. Echocardiographic studies were conducted with General Electric equipment; 2DE imaging and global longitudinal strain (GLS) of both ventricles were performed. A total of 61.7% of the participants denied relevant cardiovascular history and 41.8% had prolonged symptoms after resolution of COVID-19 infection. Mean left ventricular ejection fraction (LVEF) was 61.0 ± 5.5% overall. In patients without prior comorbidities, 8.2% had some echocardiographic abnormality: 5.7% had reduced GLS, 3.0% had a LVEF below normal range, and 1.1% had wall motion abnormalities. The right ventricle (RV) was dilated in 1.6% of participants, 3.1% had a reduced GLS, and 0.27% had reduced RV function. Mild pericardial effusion was observed in 0.82% of participants. Male patients were more likely to have new echocardiographic abnormalities (OR 2.82, p = 0.002). Time elapsed since infection resolution (p = 0.245), presence of symptoms (p = 0.927), or history of hospitalization during infection (p = 0.671) did not have any correlation with echocardiographic abnormalities. Cardiovascular abnormalities after COVID-19 infection are rare and usually mild, especially following mild infection, being a low GLS of left and right ventricle, the most common ones in our registry. Post COVID cardiac abnormalities may be more frequent among males.

The impact of daily troponin I and D-dimer serum levels on mortality in COVID-19 pneumonia patients

BACKGROUND

Coronavirus disease 2019 (COVID-19) is an infection resulting in very high morbidity and mortality rates globally. Limited data are available on the cardiovascular manifestations in these patients. The aim of this study was to analyse the daily troponin I and D-dimer levels and their impact on the need for intensive care and on mortality rates of COVID-19-infected patients.

METHODS

Two-hundred and five patients who were hospitalised between 20 March and 5 May 2020, with a diagnosis of moderate-to-severe COVID-19 pneumonia, were analysed retrospectively. Serum troponin I and D-dimer levels were recorded for at least 10 days after admission.

RESULTS

The average age was higher in the group of patients who died compared to the group who were discharged (67.79 ± 14.9 vs 56.87 ± 18.15 years, respectively, p < 0.001). The presence of hypertension, diabetes mellitus, previous coronary bypass surgery, heart failure, chronic renal failure and chronic obstructive pulmonary disease statistically significantly affected mortality rates (p = 0.003, 0.004, 0.045, 0.02, 0.003, 0.007, respectively). The first 10 days of measurements of troponin I and D-dimer were associated with intensive care requirements and mortality (p < 0.001). Both troponin I and D-dimer were higher in the group who died compared to the patients requiring intensive care. Troponin I values of ≥ 16.05 pg/ml on the seventh day were related to the need for intensive care [area under the curve (AUC) 0.896, sensitivity 78.6%, specificity 78.3%, p < 0.001). Troponin I values ≥ 30.25 pg/ml on the ninth day were related to mortality (AUC 0.920, sensitivity 89.5%, specificity 89.3%, p < 0.001). D-dimer values ≥ 878 hg/ml on the second day were associated with intensive care need (AUC 0.896, sensitivity 78.6%, specificity 78.3%, p < 0.001). D-dimer values ≥ 1 106 hg/ml on the 10th day were associated with mortality (AUC 0.817, sensitivity 68.4%, specificity 65.2%, p < 0.001). It was observed that hospitalisation periods ≥ 9.5 days were associated with mortality (AUC 0.738, sensitivity 68.4%, specificity 65.9%, p < 0.001).

CONCLUSIONS

We showed that hospitalisations ≥ 9.5 days in duration were related to increased mortality rates. Troponin I and D-dimer follow-up values in the serum were more effective than other inflammatory markers in predicting mortality and the need for intensive care. A high troponin I value should alert the clinician in terms of clinical deterioration.

Biosensors based detection of novel biomarkers associated with COVID-19: Current progress and future promise

The pandemic situation of COVID-19 has caused global alarm in health care, devastating loss of lives, strangled economy, and paralysis of normal livelihood. The high inter-individual transmission rate created havoc in the global community. Although tremendous efforts are pitching in from across the globe to understand this disease, the clinical features seemed to have a wide range including fever, cough, and fatigue are the prominent features. Congestion, rhinorrhea, sore throat, and diarrhea are other less common features observed. The challenge of this disease lies in the difficulty in maneuvering the clinical course causing severe complications. One of the major causative factors for multi-organ failure in patients with severe COVID-19 complications is systemic vasculitis and cytokine-mediated coagulation disorders. Hence, effective markers trailing the disease severity and disease prognosis are urgently required for prompt medical treatment. In this review article, we have emphasized currently identified inflammatory, hematological, immunological, and biochemical biomarkers of COVID-19. We also discussed currently available biosensors for the detection of COVID-19-associated biomarkers & risk factors and the detection methods as well as their performances. These could be effective tools for rapid and more promising diagnoses in the current pandemic situation. Effective biomarkers and their rapid, scalable, & sensitive detection might be beneficial for the prevention of serious complications and the clinical management of the disease.

Inflammatory biomarkers and cardiac injury in COVID-19 patients

Introduction

Cardiac injury has received considerable attention due to the higher risk of morbidity and mortality associated with coronavirus disease. However, in a developing country, there is a scarcity of data on cardiac injury in COVID-19 patients related to inflammatory biomarkers.

Methods

Therefore, the present research retrospectively analyzes data from three territorial hospitals in Pakistan's Punjab province to investigate the potential impact of the cardiac injury on the mortality and severity of COVID-19-infected patients. We evaluated 2,051 patients between January 16 and April 18, 2022, with confirmed COVID-19. The in-hospital mortality recorded for the selected sample size was about 16.28%.

Results

The majority of the participants were identified as male (64%) with a median age of 65 years. Also, fever, fatigue, and dyspnea were reported as common symptoms. An aggregate of 623 patients (30.38%) had a cardiac injury, and when these patients are compared to those without cardiac injury, the participants were significantly older and had more comorbidities with higher leukocyte counts, elevated levels of C-reactive protein, interleukin-6, procalcitonin, myohemoglobin, creatinine kinase-myocardial band, serum creatinine, high-sensitivity troponin-I, N-terminal pro-B-type natriuretic peptide had a significant amount of multiple ground-glass opacity and bilateral pulmonary infiltration in radiographic results. Participants with heart injury required more non-invasive or invasive mechanical respiration than those who did not have a cardiac injury. Individuals with cardiac injury had higher rates of sepsis, acute respiratory distress syndrome (ARDS), d-dimer concentration, and respiratory failure than those without cardiac injury. Patients who had had a cardiac injury died at a higher rate than those who had not suffered cardiac damage. In the multivariable logistic regression analysis, participants with cardiac injury showed greater odds of COVID-19 mortality and were found associated with older age (OR = 1.99, 95% CI = 0.04-3.19), elevated cardiac troponin I (OR = 18.64, 95% CI = 13.16-23.01), the complication of sepsis (OR = 10.39, 95% CI = 7.41-13.39) and ARDS (OR = 6.65, 95% CI = 4.04-8.91).

Conclusion

Cardiac injury is a frequent complication among patients with coronavirus-induced infection in Punjab, Pakistan, and it is significantly linked to a greater risk of in-hospital mortality.

Mid-term subclinical myocardial injury detection in patients who recovered from COVID-19 according to pulmonary lesion severity

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV 2) may cause damage to the cardiovascular system during the acute phase of the infection. However, recent studies reported mid- to long-term subtle cardiac injuries after recovering from acute coronavirus disease 2019 (COVID-19). This study aimed to determine the relationship between the severity of chest computed tomography (CT) lesions and the persistence of subtle myocardial injuries at mid-term follow-up of patients who recovered from COVID-19 infection.

Methods

All patients with COVID-19 were enrolled prospectively in this study. Sensitive troponin T (hsTnT) and chest CT scans were performed on all patients during the acute phase of COVID-19 infection. At the mid-term follow-up, conventional transthoracic echocardiograph and global longitudinal strain (GLS) of the left and right ventricles (LV and RV) were determined and compared between patients with chest CT scan lesions of &lt; 50% (Group 1) and those with severe chest CT scan lesions of greater or equal to 50% (Group 2).

Results

The mean age was 55 ± 14 years. Both LV GLS and RV GLS values were significantly decreased in group 2 (p = 0.013 and p = 0.011, respectively). LV GLS value of more than −18 was noted in 43% of all the patients, and an RV GLS value of more than −20 was observed in 48% of them. The group with severe chest CT scan lesions included more patients with reduced LV GLS and reduced RV GLS than the group with mild chest CT scan lesions [(G1:29 vs. G2:57%, p = 0.002) and (G1:36 vs. G2:60 %, p = 0.009), respectively].

Conclusion

Patients with severe chest CT scan lesions are more likely to develop subclinical myocardial damage. Transthoracic echocardiography (TTE) could be recommended in patients recovering from COVID-19 to detect subtle LV and RV lesions.

Antibody Therapy for COVID-19: Categories, Pros, and Cons

COVID-19 is a life-threatening respiratory disease triggered by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has been considered a pandemic viral infection since December 2019. The investigation of the effective prophylaxis or therapeutic strategies for emergency management of the current condition has become a priority for medical research centers and pharmaceutical companies. This article provides a comprehensive review of antibody therapy and its different categories with their advantages and disadvantages for COVID-19 over the last few years of the current pandemic. Antibodies can be generated by active immunization, including natural infection with a pathogen and vaccination, or by the passive immunization method such as convalescent plasma therapy (CPT) and antibody synthesis in laboratories. Each of these ways has its characteristics. Arming the immune system with antibodies is the main aim of antiviral therapeutic procedures toward SARS-CoV-2. Collecting and discussing various aspects of available data in this field can give researchers a better perspective for the production of antibody-based products or selection of the most appropriate approach of antibody therapies to improve different cases of COVID-19. Moreover, it can help them control similar viral pandemics that may happen in the future appropriately.

Is the revascularisation strategy and outcome different in patients with acute coronary syndrome in COVID-19 pandemic era: a tertiary centre experience

BACKGROUND

In this study, we aimed to compare the management and clinical outcomes of patients with acute coronary syndrome (ACS) before and during pandemic.

METHODS

A total of 239 patients with ACS were enrolled into the study. Patients who were admitted during pandemic were compared with pre-pandemic patients according to their demographic, biochemical, angiographic features, revascularisation strategies and clinical outcomes.

RESULTS

During the pandemic period, we observed an increase in total number of patient with ST elevation myocardial infarction patients compared to the pre-pandemic period. Initial high sensitive troponin and CK-MB levels were statistically higher in the pandemic group patients (1953 pg/ml versus 259 pg/ml for troponin I and 14 ng/ml versus 6 ng/ml for CK-MB p < 0.0001, p = 0.02, respectively). Type 4a myocardial infarction due to stent thrombosis was more frequent in pandemic group relative to the pre-pandemic group (10 versus 0, p = 0.003). Post-procedural TIMI flow grade was lower in the pandemic group and distal embolisation and TIMI thrombus score were significantly higher in the pandemic group compared to the pre-pandemic group (p = 0.001, p = 0.02, and p = 0.002, respectively). The number of patients who underwent bypass surgery was much lower compared to pre-pandemic period (27 versus 8, p < 0.0001). There was no statistically significant difference in hospital mortality and short-term all-cause mortality among groups (p > 0.05).

CONCLUSION

Although clinical, laboratory, and angiographic features were worse in ACS patients during pandemic, the mortality rate of ACS was similar in both pre-pandemic and pandemic era. It is important to keep coronary intensive care units and catheter labs open and fully-functioning during the pandemic.

Catheter-directed interventions for pulmonary embolism

Pulmonary embolism (PE) is common, life-threatening, and often recurrent among survivors. The clinical manifestations of PE range from incidental detection to sudden death, with approximately one-third of PE deaths occurring suddenly. State-of-the-art management of acute PE relies on early detection, risk stratification based on clinical, imaging, and biomarker criteria, and multidisciplinary decision-making. The primary goal of catheter-directed interventions for acute PE is to interrupt the cycle of right ventricular failure, hypoperfusion, and oxygen supply/demand imbalance by increasing the cross-sectional area of the patent pulmonary vasculature, thereby lowering resistance and alleviating V/Q mismatch. Innovations in percutaneous interventions have led to several approaches described in this review: rheolytic thrombectomy, catheter-directed thrombolysis, and aspiration or mechanical thrombectomy. The central challenge moving forward will be integrating growing clinical trial evidence into multidisciplinary, individualized care pathways meeting the diverse clinical needs of patients presenting with acute PE.

Effects of COVID-19 on Arrhythmia

The World Health Organization announced that COVID-19, with SARS-CoV-2 as its pathogen, had become a pandemic on 11 March 2020. Today, the global epidemic situation is still serious. With the development of research, cardiovascular injury in patients with COVID-19, such as arrhythmia, myocardial injury, and heart failure, is the second major symptom in addition to respiratory symptoms, and cardiovascular injury is related to the prognosis and mortality of patients. The incidence of arrhythmia in COVID-19 patients ranges from 10% to 20%. The potential mechanisms include viral infection-induced angiotensin-converting enzyme 2 expression change, myocarditis, cytokine storm, cardiac injury, electrophysiological effects, hypoxemia, myocardial strain, electrolyte abnormalities, intravascular volume imbalance, drug toxicities and interactions, and stress response caused by virus infection. COVID-19 complicated with arrhythmia needs to be accounted for and integrated in management. This article reviews the incidence, potential mechanisms, and related management measures of arrhythmia in COVID-19 patients.

The usefulness of speckle tracking echocardiography in identifying subclinical myocardial dysfunction in young adults recovered from mild COVID-19

Background

Myocardial strain assessed with speckle tracking echocardiography is a sensitive marker of cardiac dysfunction. Both left‐ventricular global longitudinal strain (LV‐GLS) and right ventricular longitudinal strain (RV‐LS) were affected by severe SARS‐CoV‐2 infection. However, data about cardiac involvement in patients with asymptomatic/mild Coronavirus disease‐19 (COVID‐19) is still lacking.

Aim

To evaluate myocardial function using LV‐GLS and RV‐LS in patients with previous asymptomatic/mild COVID‐19.

Methods

Forty young adults without previously known comorbidities/cardiovascular risk factors and with a confirmed diagnosis of asymptomatic or paucisymptomatic SARS‐CoV‐2 infection were retrospectively included. A 2D‐transthoracic echocardiogram with speckle tracking analysis was performed at least 3 months after the diagnosis. Forty healthy subjects, matched for age, sex, and body surface area in a 1:1 ratio were used as the control group.

Results

Left ventricular ejection fraction (LVEF), tricuspid annular plane systolic excursion (TAPSE) and RV‐LS were comparable between the two groups. LV‐GLS was significantly lower in the cases compared to the control group (−22.7 ± 1.6% vs. −25.7 ± 2.3%; p < .001). Moreover, the prevalence of regional peak systolic strain below −16% in at least two segments was three times higher in patients with previous COVID‐19 compared to controls (30% vs. 10%, p = .02). In multivariable logistic regression, previous COVID‐19 infection was independently associated with reduced LV‐GLS values (p < .001).

Conclusion

SARS‐CoV‐2 infection may affect left ventricular deformation in 30% of young adult patients despite an asymptomatic or only mildly symptomatic acute illness. Speckle‐tracking echocardiography could help early identification of patients with subclinical cardiac involvement, with potential repercussions on risk stratification and management.

Immunomodulatory therapy for the management of critically ill patients with COVID-19: A narrative review

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of the ongoing coronavirus disease 2019 (COVID-19) pandemic. Understanding the physiological and immunological processes underlying the clinical manifestations of COVID-19 is vital for the identification and rational design of effective therapies.

AIM

To describe the interaction of SARS-CoV-2 with the immune system and the subsequent contribution of hyperinflammation and abnormal immune responses to disease progression together with a complete narrative review of the different immunoadjuvant treatments used so far in COVID-19 and their indication in severe and life-threatening subsets.

METHODS

A comprehensive literature search was developed. Authors reviewed the selected manuscripts following the PRISMA recommendations for systematic review and meta-analysis documents and selected the most appropriate. Finally, a recommendation of the use of each treatment was established based on the level of evidence of the articles and documents reviewed. This recommendation was made based on the consensus of all the authors.

RESULTS

A brief rationale on the SARS-CoV-2 pathogenesis, immune response, and inflammation was developed. The usefulness of 10 different families of treatments related to inflammation and immunopathogenesis of COVID-19 was reviewed and discussed. Finally, based on the level of scientific evidence, a recommendation was established for each of them.

CONCLUSION

Although several promising therapies exist, only the use of corticosteroids and tocilizumab (or sarilumab in absence of this) have demonstrated evidence enough to recommend its use in critically ill patients with COVID-19. Endotypes including both, clinical and biological characteristics can constitute specific targets for better select certain therapies based on an individualized approach to treatment.

COVID-19 and cardiovascular disease: manifestations, pathophysiology, vaccination, and long-term implication

The coronavirus disease 2019 (COVID-19) pandemic is caused by a new coronavirus family member, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is linked with many disease manifestations in multiple organ systems on top of pulmonary manifestations. COVID-19 is also accompanied by several cardiovascular pathologies including myocarditis, acute myocardial infarction, stress cardiomyopathy, arterial and venous thromboembolism, pericarditis, and arrhythmias. The pathophysiological mechanisms explaining these clinical symptoms are multifactorial including systemic inflammation (cytokine storm), coagulopathy, direct viral invasion through angiotensin-converting enzyme 2, hypoxemia, electrolyte imbalance, and fever. Several case reports have shown the development of an unusual cardiovascular event after receiving SARS-CoV-2 vaccines. The current article aimed to review cardiovascular involvement in the COVID-19 pandemic with respect to clinical features, pathogenesis, long-term effects, and the adverse effects of treatments and vaccines based on the latest evidence.

Colchicine for the Treatment of Cardiac Injury in Hospitalized Patients With Coronavirus Disease-19

Introduction

The impact of colchicine on hospitalized patients with Coronavirus disease-19 (COVID-19) related cardiac injury is unknown.

Materials and Methods

In this multicenter randomized controlled open-label clinical trial, we randomized hospitalized adult patients with documented COVID-19 and evidence of cardiac injury in a 1:1 ratio to either colchicine 0.6 mg po twice daily for 30 days plus standard of care or standard of care alone. Cardiac injury was defined as elevated cardiac biomarkers, new arrhythmia, new/worsened left ventricular dysfunction, or new pericardial effusion. The primary endpoint was the composite of all-cause mortality, need for mechanical ventilation, or need for mechanical circulatory support (MCS) at 90 days. Key secondary endpoints included the individual components of the primary endpoint and change in and at least 2-grade reduction in the World Health Organization (WHO) Ordinal Scale at 30 days. The trial is registered with clinicaltrials.gov (NCT04355143).

Results

We enrolled 93 patients, 48 patients in the colchicine arm and 45 in the control arm. There was no significant difference in the primary outcome between the colchicine and control arms (19 vs. 15%, p = 0.78), nor in the individual components of all-cause mortality (17 vs. 15%, p = 1.0) and need for mechanical ventilation (8 vs. 5%, p = 0.68); no patients in either group required MCS. The change in (-1.8 ± 2.4 vs. -1.2 ± 2.0, p = 0.12) and at least 2-grade reduction (75 vs. 75%, p = 1.0) in the WHO ordinal scale was also similar between groups.

Conclusion

Patients hospitalized with COVID-19 and evidence of cardiac injury did not benefit from colchicine therapy.

Histopathological and molecular links of COVID-19 with novel clinical manifestations for the management of coronavirus-like complications

Coronavirus disease 2019 (COVID-19) causes transmissible viral illness of the respiratory tract prompted by the SARS-CoV-2 virus. COVID-19 is one of the worst global pandemics affecting a large population worldwide and causing catastrophic loss of life. Patients having pre-existing chronic disorders are more susceptible to contracting this viral infection. This pandemic virus is known to cause notable respiratory pathology. Besides, it can also cause extra-pulmonary manifestations. Multiple extra-pulmonary tissues express the SARS-CoV-2 entry receptor, hence causing direct viral tissue damage. This insightful review gives a brief description of the impact of coronavirus on the pulmonary system, extra-pulmonary systems, histopathology, multiorgan consequences, the possible mechanisms associated with the disease, and various potential therapeutic approaches to tackle the manifestations.

Post-acute sequelae of COVID-19 (PASC): a meta-narrative review of pathophysiology, prevalence, and management

Coronavirus Disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Over 220 countries and territories have been affected by this virus, and the infection rate has continued to rise. As patients recover from the virus, many are experiencing lingering symptoms. Understanding the impact of demographics and comorbidities on symptom prevalence, manifestations, and severity is not only relevant during acute infection, it is critical to the clinical management of patients with post-acute sequelae of COVID-19, also known as PASC. Herein, we provide a comprehensive review on the most recent research related to PASC. Specifically, we focus on the description of the disorder itself, compared to acute COVID-19, and which types of patients are most affected by long-term sequelae. Further, we share recommendations for management of the most common complications of PASC.

A Case Series of Diverse Cardiac Abnormalities in Collegiate Athlete with COVID-19: Role for Multimodality Imaging

Introduction

Since the COVID-19 pandemic there is concern for subclinical cardiac pathology in the absence of clinical symptoms in collegiate athletes, we present 4 cases of abnormal left ventricular global longitudinal strain (LVGLS), a “red-flag” for potential COVID-19 myocardial disease, following diagnosis with diverse abnormalities reported via multimodality imaging weeks into recovery.

Methods

Cardiac imaging studies consisting of transthoracic echocardiography (TTE) and cardiovascular magnetic resonance imaging (CMR) were performed 10 days post-COVID-19 diagnosis and several weeks into recovery.

Results

Initial TTE revealed abnormal left ventricular global longitudinal strain (LVGLS), an identified “red-flag” for potential COVID-19 myocardial disease. Further CMR imaging revealed potential recent/prior myocarditis in 1 athlete. Follow-up TTE several weeks later revealed a return to normal LVGLS. Conversely, 2 cases with normal CMR imaging had a LVGLS that remained abnormal >30 days into recovery.

Conclusions

These individual cases highlight the substantial differences in echocardiographic and CMR abnormalities between athletes with confirmed COVID-19.

COVID-19 and thrombosis: The role of hemodynamics

Severe coronavirus disease 2019 (COVID-19) is characterized by an increased risk of thromboembolic events, a leading cause for adverse outcomes in patients afflicted by the more serious manifestation of the disease. These thromboembolic complications expressed as sepsis-induced coagulopathy, disseminated intravascular coagulation, venous and arterial thromboembolism, pulmonary embolism, microthrombosis, and thrombotic microangiopathy have been observed to affect different organs such as the lungs, heart, kidneys, and brain. Endothelial injury and dysfunction have been identified as the critical pathway towards thrombogenesis, and contributions of other mechanisms such as hypercoagulability, cytokine storm, neutrophils have been studied. However, the contribution of hemodynamic pathways towards thrombosis in severe COVID-19 cases has not been investigated. From the classical theory of Virchow's triad to the contemporary studies on the effect of shear enhanced platelet activation, it is well established that hemodynamics plays a role in the initiation and growth of thrombosis. This article reviews recent studies on COVID-19 related thrombotic events and offers hypotheses on how hemodynamics may be responsible for some of the adverse outcomes observed in severe COVID-19 cases. While thrombogenesis through endothelial injury and the effects of hypercoagulability on thrombosis are briefly addressed, the crux of the discussion is focused on hemodynamic factors such as stasis, turbulent flow, and non-physiological shear stress and their effects on thrombosis. In addition, hemodynamics-dependent venous, arterial, and microvascular thrombosis in COVID-19 cases is discussed. We also propose further investigation of diagnostic and therapeutic options that address the hemodynamics aspects of COVID-19 thrombus formation to assess their potential in patient care.