Critical COVID-19 rarely associated with left ventricular systolic impairment

Introduction

For some individuals infection with SARS-CoV-2 leading to COVID-19 can result in a life-threatening multi-system disease. Multiple potential pathophysiological mechanisms for the development of cardiovascular complications have been postulated [1]. Early reports suggested that more than a third of hospitalised patients undergoing TTE had evidence of LV impairment [2].

Purpose

To ascertain the incidence of ventricular impairment among critically ill adults with COVID-19 admitted to the intensive care unit (ICU).

Methods

Retrospective analysis of transthoracic echocardiograms (TTE) performed on patients admitted to ICU with COVID-19 between 10th March and 10th May 2020. Archived studies were reviewed by accredited professionals. Studies were performed according to a modified British Society of Echocardiography (BSE) Level 1 protocol [3], with the addition of right ventricle (RV) focused apical 4 chamber, as well as apical 2 and 3 chamber views, and without ECG synchronisation as per infection control protocols. In the majority of patients the left ventricular ejection fraction (LVEF) was estimated from biplane Simpson's method. The RV function was assessed using the TAPSE in most patients. In the remaining patients the LV or RV function was visually assessed.

Results

Of 179 patients admitted to ICU, 85 (47.5%) had at least one TTE of diagnostic quality. Studies were performed a median of 7 days after ICU admission (IQR 3–17 days). Baseline and clinical characteristics and key echocardiographic measurements are summarised in table 1. The majority of patients were undergoing mechanical ventilation at the time of the scan (94.1%). One hundred and fifty-nine patients (89%) had elevated Troponin T (≥14ng/L) on the day of the study. LV systolic impairment (LVSD) was present in 5 patients (6.0%). This was known to be chronic in 3 patients (1 with coronary artery disease, 1 with chemotherapy induced cardiomyopathy and 1 with dilated cardiomyopathy of unknown aetiology), whilst pre-morbid cardiac function was unknown in the other 2 patients. No patient had severe LVSD (LVEF ≤35%). RV systolic dysfunction (RVSD) was found in 25 patients (31.3%). Amongst patients receiving mechanical ventilation there was no significant difference in Positive End Expiratory Pressure (PEEP) between patients with and without RVSD (9.4cmH2O vs. 9.8cmH2O, p=0.64), however there was a non-significant trend towards lower PaO2/FiO2 (P/F ratio) amongst patients with RVSD (18.9kPa vs 25.7kPa, p=0.07).

Conclusions

In contrast to other studies which have reported high frequency of LV impairment amongst hospitalised patients with COVID-19 [3], de novo LVSD was rarely found in this study, occurring in just 2 patients (2.4%), and being severe in neither. RV dilatation and systolic impairment were commonly found. A trend towards lower P/F ratios in patients with RVSD suggests severity of lung injury may be a factor in developing RV impairment.

Funding Acknowledgement

Type of funding sources: None.

Association of left ventricular diastolic dysfunction with 24-h aortic ambulatory blood pressure: the SAFAR study

Aortic blood pressure (BP) and 24-h ambulatory BP are both better associated with target organ damage than office brachial BP. However, it remains unclear whether a combination of these two techniques would be the optimal methodology to evaluate patients' BP in terms of left ventricular diastolic dysfunction (LVDD) prevention. In 230 participants, office brachial and aortic BPs were measured by a validated BP monitor and a tonometry-based device, respectively. 24-h ambulatory brachial and aortic BPs were measured by a validated ambulatory BP monitor (Mobil-O-Graph, Germany). Systematic assessment of patients' LVDD was performed. After adjustment for age, gender, hypertension and antihypertensive treatment, septum and lateral E/Ea were significantly associated with office aortic systolic BP (SBP) and pulse pressure (PP) and 24-h brachial and aortic SBP and PP (P ⩽ 0.04), but not with office brachial BP (P ⩾ 0.09). Similarly, 1 standard deviation in SBP was significantly associated with 97.8 ± 20.9, 86.4 ± 22.9, 74.1 ± 23.3 and 51.3 ± 22.6 in septum E/Ea and 68.6 ± 2 0.1, 54.2 ± 21.9, 37.9 ± 22.4 and 23.1 ± 21.4 in lateral E/Ea, for office and 24-h aortic and brachial SBP, respectively. In qualitative analysis, except for office brachial BP, office aortic and 24-h brachial and aortic BPs were all significantly associated with LVDD (P ⩽ 0.03), with the highest odds ratio in 24-h aortic SBP. Furthermore, aortic BP, no matter in the office or 24-h ambulatory setting, showed the largest area under receiver operating characteristic curves (P ⩽ 0.02). In conclusion, 24-h aortic BP is superior to other BPs in the association with LVDD.

Prevalence of target organ damage in hypertensive subjects attending primary care: C.V.P.C. study (epidemiological cardio-vascular study in primary care)

Background

Except for the established risk factors, presence of target organ damage has an important role in the treatment of hypertensive subjects. The aim of the present study was to estimate the prevalence of target organ damage in primary care subjects.

Methods

This multi-centre, cross-sectional survey of 115 primary care physicians recruited 1095 consecutive subjects with hypertension: 611 men (55.8%); and 484 women (44.2%). A detailed history for the presence of cardiovascular disease and a thorough clinical examination was performed to each subject.

Results

Of the total study population, 44.5% (n = 487) had target organ damage (33.0% had left ventricular hypertrophy, 21.8% increased carotid intima media thickness, 11.0% elevated plasma creatinine levels and 14.6% microalbuminuria). Target organ damage was more prevalent in males than in females (P = 0.05). In addition, males had more often increased carotid intima media thickness than females (P = 0.009). On the contrary, females had more often microalbuminuria (P = 0.06) than males. No differences were observed between the two genders regarding left ventricular hypertrophy (P = 0.35) and elevated plasma creatinine levels (P = 0.21). Logistic regression analysis showed associations between target organ damage and dyslipidemia (P < 0.001), presence of metabolic syndrome (P = 0.005), diabetes (P < 0.001) and coronary artery disease (P < 0.001).

Conclusion

A significant proportion of hypertensive subjects in primary care had documented associated target organ damage, with left ventricular hypertrophy being the most prevalent target organ damage.

Risk factors for severe hypoglycaemia in type 2 diabetic patients admitted to hospital in Piraeus, Greece

A 3-year study assessed the prevalence and causes of severe treatment-related hypoglycaemia in type 2 diabetes mellitus patients admitted to hospital in Piraeus. Out of the 2858 patients admitted, 207 (7.2%) had severe hypoglycaemia: 72 were being managed with insulin, 132 oral hypoglycaemic drugs and 3 combined insulin/oral drugs. Only 28.5% of patients were attending a diabetes clinic. The cause of the hypoglycaemic attack could be determined for 86.1% of cases; 30.8% were due to a missed meal. Interviews showed that education and level of knowledge about diabetes mellitus, and particularly hypoglycaemia symptoms, was inadequate. Logistic regression analysis showed that knowledge about diabetes mellitus correlated with educational status and with follow-up in a diabetes clinic.

Vascular endothelium and inflammatory process, in patients with combined Type 2 diabetes mellitus and coronary atherosclerosis: the effects of vitamin C

AIMS

Type 2 diabetes mellitus (DM) and coronary artery disease (CAD) are both associated with endothelial dysfunction and elevated oxidative and inflammatory state. We examined the effect of vitamin C on endothelial function and levels of soluble vascular cell adhesion molecule (sVCAM-1), interleukin-6 (IL-6) and tumour necrosis factor (TNF-alpha), in DM patients with or without CAD and in non-diabetic subjects.

METHODS

Thirty-seven patients with DM + CAD, 17 patients with DM without CAD and 21 non-diabetic subjects were divided into groups receiving vitamin C 2 g/day or no anti-oxidant for 4 weeks. Forearm blood flow was determined using venous occlusion gauge-strain plethysmography. Forearm vasodilatory response to reactive hyperemia was considered as index of endothelium-dependent dilation.

RESULTS

Baseline levels of IL-6 and TNF-alpha were significantly higher in patients with DM + CAD compared with patients with DM (P < 0.01) or non-diabetic subjects (P < 0.01). IL-6 and TNF-alpha levels were also higher in DM compared with non-diabetic subjects (P < 0.05). sVCAM-1 levels were lower in non-diabetic controls compared with DM + CAD (P < 0.05) or DM (P < 0.05). Reactive hyperaemia was higher in non-diabetic controls compared with DM + CAD (P < 0.001) or DM (P < 0.001). Vitamin C significantly increased reactive hyperaemia only in the DM + CAD group, while it had no effect on serum levels of sVCAM-1, TNF-alpha and IL-6 in any of the groups.

CONCLUSIONS

Type 2 diabetes mellitus is associated with impaired endothelial function and increased levels of TNF-alpha, IL-6 and sVCAM-1, especially in patients with DM and CAD. Vitamin C significantly increased forearm vasodilatory response to reactive hyperaemia only in patients with combined DM and CAD.

Vitamin C affects thrombosis/ fibrinolysis system and reactive hyperemia in patients with type 2 diabetes and coronary artery disease

OBJECTIVE

To examine the effect of vitamin C on forearm vasodilatory response to reactive hyperemia and on plasma level of plasminogen activator inhibitor 1 (PAI-1), von Willebrand factor (vWF), tissue plasminogen activator (tPA), antithrombin III (ATIII), proteins C and S, and factors V (fV) and VII (fVII) in patients with both type 2 diabetes and CAD.

RESEARCH DESIGN AND METHODS

A total of 39 patients with type 2 diabetes and CAD were divided into two groups and received vitamin C (2 g/day) or no antioxidant for 4 weeks. Forearm blood flow was determined using venous occlusion gauge-strain plethysmography at baseline and after treatment. Forearm vasodilatory response to reactive hyperemia (RH%) or nitrate (NTG%) was defined as the percent change of flow from baseline to the maximum flow during reactive hyperemia or after administration of nitrate, respectively. Biochemical markers were determined by enzyme-linked immunosorbent assay (ELISA) or other standard methods.

RESULTS

RH% was significantly increased after treatment with vitamin C (from 62.4 +/- 7.2 to 83.1 +/- 9.3%, P = 0.024) but remained unaffected in the control group. Vitamin C decreased plasma levels of fV (from 143 +/- 5.4 to 123 +/- 6.03%, P = 0.038), vWF (from 133.5 +/- 14.5 to 109.5 +/- 11.4%, P = 0.016), and tPA (from 12.3 +/- 0.99 to 8.40 +/- 0.60 ng/ml, P = 0.001), whereas these levels remained unaffected in the control group. The changes in RH%, vWF, and tPA were significantly greater (P = 0.028, 0.036, and 0.007, respectively) in the vitamin C-treated group than in the control group. Levels of ATIII, proteins S and C, fVII, and PAI-1 remained unchanged in all groups.

CONCLUSIONS

Short-term treatment with high doses of vitamin C improved RH% and decreased plasma levels of tPA and vWF in patients with type 2 diabetes and CAD.

Voluntary self-poisoning as a cause of admission to a tertiary hospital internal medicine clinic in Piraeus, Greece within a year

BACKGROUND

Out of 1705 patients hospitalised for various reasons in the 3rd Internal Medicine Department of the Regional General Hospital of Nikaea, in Piraeus, 146(8,5%) persons were admitted for drug intoxication between November 1999 and November 2000.

METHODS

On average, these persons [male 50(34,2%)--female 96(65,8%)] were admitted to the hospital within 3.7 hours after taking the drug.

RESULTS

The drugs that were more frequently taken, alone or in combination with other drugs, were sedatives (67.1%), aspirins and analgesics (mainly paracetamol) (43.5%). 38.3% of patients had a mental illness history, 31.5% were in need of psychiatric help and 45.2% had made a previous suicide attempt. No death occurred during the above period and the outcome of the patients' health was normal. After mental state examination, the mental illnesses diagnosed were depression (20.96%), psychosis (15.32%), dysthymic disorder (16,2%), anxiety disorder (22.58%) and personality disorder (8.87%).

CONCLUSIONS

Self-poisoning remains a crucial problem. The use of paracetamol and sedatives are particularly important in the population studied. Interpersonal psychiatric therapy may be a valuable treatment after people tried to poison themselves.

Furosemide decreases the sensitivity of glucose transport to insulin in skeletal muscle in vitro

The effects of the diuretic furosemide on the sensitivity of glucose disposal to insulin were investigated in rat soleus muscle in vitro. At basal levels of insulin, the rates of 3-O-methylglucose transport, 2-deoxyglucose phosphorylation and lactate formation were not affected significantly by furosemide (0.5 mmol/l). However, furosemide significantly decreased these rates at physiological and maximal levels of insulin. The contents of 2-deoxyglucose and glucose 6-phosphate in the presence of furosemide were not significantly different from those in control muscles at all levels of insulin studied. It is concluded that furosemide decreases the sensitivity of glucose utilization to insulin in skeletal muscle by directly inhibiting the glucose transport process.

Evaluation of Tc-99m pyridoxal-phenylalanine as a hepatobiliary agent. Part 2. Clinical tests

Twenty-four patients with normal or diseased hepatobiliary systems were subjected to a clinical trial in order to evaluate Tc-99m pyridoxal-phenylalanine as a biliary imaging agent. The investigation was combined with i.v. cholecysto-cholangiography in most cases, and the results were compared. It is concluded that qualitative information derived from conventional i.v. cholangiography is better in demonstrating the normal biliary tree or gallstones. The radiotracer techniques, however, are valuable in dynamic studies of Oddi's sphincter, in showing patency of biliary by-pass procedures, and in differentiating hepatocellular from obstructive jaundice.

Short left coronary artery trunk as a risk factor in the development of coronary atherosclerosis. Pathological study

The relation between the length of the main left coronary artery and the degree of atherosclerosis in its branches was studied by postmortem examination in 204 subjects aged 20 to 90 years. The findings suggest that in cases with a short main left coronary artery the atherosclerotic lesions in the anterior descending and circumflex branches appear earlier, progress faster at higher levels of severity, and lead more frequently to myocardial infarction, than in cases with a long left coronary artery trunk. In cases over the age of 50 years, where disease is expected to have developed, it was shown that the degree of atherosclerosis in the left anterior descending and circumflex branches was inversely related to the length of the main left coronary artery. The correlation coefficients were -0-527 and -0-428, respectively, and in either case a test for zero correlations was significant (P less than 0-001). The possible changes in the haemodynamic and mechanical conditions associated with the variations of the anatomical pattern of the coronary arteries and their influence in the development of atherosclerosis are discussed. It is suggested that the length of the main left coronary artery is a congenital anatomical and possibly hereditary factor influencing the rate of development of atherosclerosis in the branches of the main left coronary artery.

Long-term results from use of fascia lata as arterial graft

Of twenty-four dogs, fifteen survived up to two years after aortic replacement with fresh fascial graft. Surviving dogs underwent hemodynamic study and cineaortography. Histology of the graft was examined after the dogs were sacrificed. Length of the graft used is an important factor for both dog survival and graft hemodynamics. The shorter the aortic segment replaced the better the chances for long-term graft patency.

Length of main left coronary artery in relation to atherosclerosis of its branches. A coronary arteriographic study

The relation between the length of the main left coronary artery and the presence of atherosclerosis in its branches or the presence of complete left bundle-branch block was studied by selective coronary arteriography in 43 persons. The length of the main left coronary artery was found to be significantly shorter in patients with coronary atherosclerosis than in subjects without angiographic evidence of coronary artery disease. In patients with electrocardiographic evidence of complete left bundle-branch block, the length of the left main coronary artery was significantly shorter than that in both previous groups. In view of these findings, it is suggested that a short main left coronary artery should be considered as a congenital factor predisposing to the development of coronary artery disease. The possible mechanisms leading to atherosclerosis of the left coronary arterial branches in the presence of a short main trunk are discussed.

Fistulas of the gastrointestinal tract. Experience with eighty-one cases

Eighty-one cases of gastrointestinal fistulas are reported. Sixty-seven of these fistulas occurred postoperatively, all of them external, and fourteen occurred spontaneously, all but one internal. Fifty-two patients were treated conservatively and twenty-nine underwent operation, with an overall mortality rate of 23.4 per cent. It is noted that the presence of severe intraperitoneal infection and a high location of the fistula were associated with an unfavorable prognosis, with mortality rates of 31.4 per cent and 48 per cent, respectively.

Results of treatment of experimental pulmonary embolism, as determined by radioactive microspheres

In this experimental study seventeen dogs subjected to pulmonary embolism were treated with either saline, heparine or streptokinase. Regional blood distribution was calculated in both, the healthy and infarcted lung tissue by means at the sequental injection of radioactive microspheres. Results of fibrinolytic treatment compare favourable over heparine or saline administration.

The single thyroid nodule and carcinoma

A review of 568 cases of single thyroid nodule operated upon during the period 1960–72 is presented.

Females were more frequently affected than males, the ratio being 8.6:1. The right lobe was more frequently involved (57.6 per rent) than the left. The nodules in our series were classified according to the scintiscan findings as follows: cold 466 cases (82 per cent), warm 32 cases (5.6 per cent) and hot or toxic 70 cases (12.4 per cent). The incidence of carcinoma was 12 per cent and 6.2 per cent in cold and warm nodules respectively. No malignancy was found in either hot nodules or toxic adenomas. The incidence of carcinoma was higher in male patients and significantly higher in patients of over 60 years.

The value of Tc99m-diphosphonate (HEDSPA) as a skeletal scanning agent

A new "bone seeking" agent, namely the organic compound diphosphonate labeled with Tc99m was tried in 21 patients for skeletal scanning. In 3 cases, although the clinical and roentgenographic evidence of bone lesions was absent, bone metastases were found, and these were confirmed histologically. The organic diphosphonate is more stable compared to the inorganic polyphosphates and the images obtained are excellent.

Vasopressin in the treatment of acute experimental pancreatitis

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