Heart Failure Management through Telehealth: Expanding Care and Connecting Hearts

Heart failure (HF) is a leading cause of morbidity worldwide, imposing a significant burden on deaths, hospitalizations, and health costs. Anticipating patients' deterioration is a cornerstone of HF treatment: preventing congestion and end organ damage while titrating HF therapies is the aim of the majority of clinical trials. Anyway, real-life medicine struggles with resource optimization, often reducing the chances of providing a patient-tailored follow-up. Telehealth holds the potential to drive substantial qualitative improvement in clinical practice through the development of patient-centered care, facilitating resource optimization, leading to decreased outpatient visits, hospitalizations, and lengths of hospital stays. Different technologies are rising to offer the best possible care to many subsets of patients, facing any stage of HF, and challenging extreme scenarios such as heart transplantation and ventricular assist devices. This article aims to thoroughly examine the potential advantages and obstacles presented by both existing and emerging telehealth technologies, including artificial intelligence.

[Takotsubo syndrome with right ventricular involvement in biventricular arrhythmogenic cardiomyopathy]

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a heritable heart muscle disorder with fibro-fatty replacement that involves the right ventricle and in the advanced phases could become biventricular. Takotsubo syndrome (TTS) is characterized by reversible systolic dysfunction occurring after a stressful event and independent of the underlying coronary artery disease. A 70-year-old female with family history of sudden cardiac death and a previous diagnosis of biventricular ARVC presented to the emergency department after experiencing chest pain and elevation of myocardial enzymes. The ECG showed sinus bradycardia and negative T-waves from V1-V3. Coronary arteries were free from stenosing atheromatous lesions at coronary angiography. Transthoracic echocardiography showed severe biventricular dysfunction due to left ventricular apical/peri-apical akinesis with apical ballooning pattern. Cardiac magnetic resonance confirmed the presence of transmural biventricular edema in the mid-apical segments in T2 weighted sequences involving both ventricles along with fibro-fatty replacement in post-contrast sequences. At discharge, a cardioverter-defibrillator was implanted. This case report shows that TTS diagnosis is challenging for the clinician due to the presence of structural cardiomyopathy with biventricular involvement. Second-line imaging modalities could be useful to identify the presence of myocardial edema and to recognize those conditions associated with poor prognosis.

An Impairment in Resting and Exertional Breathing Pattern May Occur in Long-COVID Patients with Normal Spirometry and Unexplained Dyspnoea

Background: Long-term sequelae, called Long-COVID (LC), may occur after SARS-CoV-2 infection, with unexplained dyspnoea as the most common symptom. The breathing pattern (BP) analysis, by means of the ratio of the inspiratory time (TI) during the tidal volume (VT) to the total breath duration (TI/TTOT) and by the VT/TI ratio, could further elucidate the underlying mechanisms of the unexplained dyspnoea in LC patients. Therefore, we analysed TI/TTOT and VT/TI at rest and during maximal exercise in LC patients with unexplained dyspnoea, compared to a control group. Methods: In this cross-sectional study, we enrolled LC patients with normal spirometry, who were required to perform a cardio-pulmonary exercise test (CPET) for unexplained dyspnoea, lasting at least 3 months after SARS-CoV-2 infection. As a control group, we recruited healthy age and sex-matched subjects (HS). All subjects performed spirometry and CPET, according to standardized procedures. Results: We found that 42 LC patients (23 females) had lower maximal exercise capacity, both in terms of maximal O2 uptake (VO2peak) and workload, compared to 40 HS (22 females) (p < 0.05). LC patients also showed significantly higher values of TI/TTOT at rest and at peak, and lower values in VT/TI at peak (p < 0.05). In LC patients, values of TI/TTOT at peak were significantly related to ∆PETCO2, i.e., the end-tidal pressure of CO2 at peak minus the one at rest (p < 0.05). When LC patients were categorized by the TI/TTOT 0.38 cut-off value, patients with TI/TTOT > 0.38 showed lower values in VO2peak and maximal workload, and greater values in the ventilation/CO2 linear relationship slope than patients with TI/TTOT ≤ 0.38 (p < 0.05). Conclusions: Our findings show that LC patients with unexplained dyspnoea have resting and exertional BP more prone to diaphragmatic fatigue, and less effective than controls. Pulmonary rehabilitation might be useful to revert this unpleasant condition.

353 SARS-CoV-2 pulmonary vasculitis and Takotsubo myocarditis syndrome. Hypoxia, endothelial dysfunction, and inflammation are the trigger?

Aims

Nowadays the spread of respiratory infection caused by SARS-CoV-2 results in a global pandemic. The World Health Organization (WHO) declared about 450 000 deaths in more than 200 countries, until June 2020. SARS-CoV-2 pneumonia develops a stress condition through systemic hypoxygenation with activation of adrenergic pathways. Takotsubo syndrome is characterized by a temporary wall motion abnormality of the left ventricle (LV) and has common features with acute coronary syndrome (ACS), representing a form of myocardial infarction without coronary arteries thrombosis. Among possible causes there are several stress conditions, including physical, psychological, and illnesses, for example interstitial pneumonia.

Methods and results

A 54-years-old man, previous smoker, was admitted to emergency room (ER) complaining of dyspnoea and fever, initially treated with ceftriaxone. Physical examination was characterized by tachypnoea (respiratory rate 30 acts/min), tachycardia and hypotension (arterial pressure 90/60 mmHg), and hypoxaemia at transcutaneous saturation (Sat O2 85%). High-resolution computed tomography (HRCT) showed bilateral interstitial pneumonia with ground glass opacities (visual involvement of 80% of pulmonary parenchymal) (Figure 1). Nasopharyngeal swab was positive for SARS-CoV-2 and ECG revealed Atrio-Ventricular Nodal Reentrant Tachycardia (AVRNT) with heart rate of 140 b.p.m., partially responsive to Valsalva manoeuver (Figure 2). Echocardiogram showed severe ventricular dysfunction [ejection fraction (EF): 30–35%] with hypokinesia of apical region associated with hyperkinesia of medio-basal segments, mild mitral regurgitation, and slight pericardial effusion (Figure 2). Laboratory tests were TnI hs 10 ng/l first detection – 26 ng/l second detection (normal range: 2.3–17.8 ng/l), PCR &gt;250 mg/l (normal range 0.5–5 mg/l), d-dimer 1893 ng/ml (normal range: &lt;500 ng/ml), PCT 3.10 ng/ml (normal range: 0–0.5 ng/ml). The worsening of clinical condition needed an orotracheal intubation and a transfer to Intensive Care Unit (ICU). The patient was treated with many antiviral drugs (darunavir, ritonavir), tocilizumab, steroid therapy, colchicine, and plasmapheresis. We observed a progressive clinical and echocardiography improvement, evidenced by partial recovery of EF (45%). CT scan revealed a normal coronary tree. The patient underwent cardiac magnetic resonance (CMR) that showed typical Takotsubo cardiomyopathy characterized by thinning and hypo-akinesias of apical wall of left ventricle (‘apical ballooning’) and normokinesis of basal/medium segments; no late gadolinium enhancements (LGEs); no oedema in T2 weighted images (Figure 3). Follow-up echocardiogram confirmed recovery of EF (50%) associated with mild hypokinesia of apical segments. Acute myocardial injury, as evidenced by elevated levels of cardiac biomarkers or electrocardiogram abnormalities, was observed in 7–20% of patients with COVID-19 in early studies in China (4). In a multicentre cohort study of 191 patients with COVID-19, 33 patients (17%) had acute cardiac injury, of whom 32 died. Whether typical clinical features of myocarditis were present in patients, who had elevated levels of cardiac troponins during the course of COVID-19 is unclear because most of the early studies did not include echocardiography or MRI data. By contrast, several case reports have described typical signs of myocarditis in patients with COVID-19. A woman aged 53 years with myocardial injury, as evidenced by elevated levels of cardiac biomarkers and diffuse ST segment elevation on the electrocardiogram, had diffuse biventricular hypokinesis on cardiac MRI, especially in the apical segments, in addition to severe LV dysfunction (LVEF = 35%). MRI data also revealed marked biventricular interstitial oedema, diffuse LGE and circumferential pericardial effusion, features that are consistent with acute myocarditis. Furthermore, in a man aged 37 years with chest pain and ST segment elevation, echocardiography revealed an enlarged heart. The Lake-Louise Criteria gave good diagnostic accuracy in patients with suspected myocarditis, evaluating the principle tissue targets in myocarditis, including: myocardial oedema, using T2-based imaging; hyperaemia and capillary leak, using early gadolinium enhancement (EGE) imaging; and myocyte necrosis and fibrosis, using LGE imaging [14]. The presence of myocardial injury was associated with a significantly worse prognosis. In the initial report of 41 patients with COVID-19 in Wuhan, five patients had myocardial injury with elevated levels of high-sensitivity cardiac troponin I (&gt;28 pg/ml), and four of these five patients were admitted to an ICU. Histological evidence of myocardial injury or myocarditis in COVID-19 is also limited. An autopsy of a patient with COVID-19 and ARDS who died of a sudden cardiac arrest showed no evidence of myocardial structural involvement, suggesting that COVID-19 did not directly impair the heart. By contrast, another case report described a patient with low-grade myocardial inflammation and myocardial localization of coronavirus particles (outside of cardiomyocytes), as measured by endomyocardial biopsy, suggesting that SARS-CoV-2 might infect the myocardium directly. In this case report, CMR showed typical Takotsubo cardiomyopathy (with hypokinesis of apical wall of left ventricle and normokinesis of basal/medium segments), but it showed no oedema in T2-weighted images, no hyperaemia nor capillary leakage (no myocardial EGE), no signs of necrosis or fibrosis (no LGE), no pericardial effusion. This case-report CMR images demonstrated the absence of typical myocardial injury caused by myocarditis, evidenced by the absence of the main tissue markers.

Conclusions

Therefore, the ventricular dysfunction, presented with Takotsubo syndrome typical pattern, could hypothetically be secondary to systemic hypoxygenation and stress condition caused by the systemic inflammation and endothelial dysfunction developed by SARS-CoV-2 interstitial pneumonia. About the current diagnostic possibilities, CMR is a valuable option for the assessment of inflammatory heart diseases.

[A case of Wellens syndrome during the COVID-19 pandemic]

A 62-year-old male patient with a history of atypical chest pain ad dyspnea presented to the emergency room during the COVID-19 pandemic. On admission, the ECG showed sinus rhythm with diphasic T waves in lead V2. A high resolution computed tomography revealed signs suggestive of pulmonary infarction and a subsequent nasopharyngeal swab for SARS-CoV-2 was positive. An ECG performed in the absence of symptoms showed persistence of diphasic T waves in lead V2. In the suspect of Wellens syndrome, a coronary angiography study was performed and showed a subocclusion of the proximal left anterior descending artery.

[Late occurrence of pulmonary embolsim in SARS-CoV-2 pneumonia: a case series]

Several studies suggested that the acute phase of SARS-CoV-2 infection may be associated with a hypercoagulable state and increased risk for venous thromboembolism but the incidence of thrombotic complications in the late phase of the disease is currently unknown. The present article describes three cases of patients with SARS-CoV-2 pneumonia and late occurrence of pulmonary embolism. Case 1: a 57-year-old man diagnosed with pulmonary embolism and type B aortic dissection after 12 days from SARS-CoV-2 pneumonia. Laboratory panel at the time of pulmonary embolism showed no signs of ongoing inflammation but only an elevated D-dimer. Case 2: a 76-year-old man with a diagnosis of SARS-CoV-2 pneumonia followed by pulmonary embolism 20 days later, high-resolution computed tomography on that time showed a partial resolution of crazy paving consolidation. Case 3: a 77-year-old man with SARS-CoV-2 pneumonia who developed a venous thromboembolic event despite thromboprophylaxis with low molecular weight heparin. Also in this patients no markers of inflammation were present at the time of complication.The present cases raise the possibility that in SARS-CoV-2 infection the hypercoagulable state may persist over the active inflammation phase and cytokine storm. These findings suggest a role for medium-long term therapeutic anticoagulation started at the time of SARS-CoV-2 pneumonia diagnosis.

Predictive significance of detectable cardiac troponin I measured with a contemporary-sensitive assay in a real life experience

BACKGROUND

Cardiac troponin (cTn) testing has reduced the likelihood of erroneous discharge of patients with acute coronary syndrome (ACS) from the emergency department (ED), but doubts remain about optimal clinical use. This study was planned for evaluating the predictive significance of cTn values between the limit of detection of the method and the 99th percentile in ED patients evaluated for suspected ACS.

METHODS

In this retrospective study all hospital records of patients admitted over a 6-month period to the ED and with at least one cTnI value comprised between the limit of detection (0.01 ng/mL) and the 99th percentile of the assay (0.05 ng/mL) were analyzed.

RESULTS

A total of 4,749 patients with cTnI value between 0.01-0.05 ng/mL were identified among 57,879 ED visits throughout the study period. Overall, 2,189 patients (46.1%) were discharged from the ED, 2,529 (53.25%) were admitted to the hospital and 31 (0.65%) died during ED stay. A total number of 289 patients out of 2,189 who were discharged (i.e., 13.2%) had additional ED visits within 30 days. Among these, 6 were diagnosed with ACS, representing 0.27% of patients discharged [negative predictive value (NPV) 0.997; 95% CI, 0.994-0.999] and 2.1% of those with second admission (NPV 0.979; 95% CI, 0.955-0.992). Only one of the 2,529 patients admitted to the hospital (i.e., 0.04%) developed an ACS during hospital stay.

CONCLUSIONS

The results of our retrospective study suggest that the suitability of using a contemporary-sensitive cTnI immunoassay assay in the context of an appropriate protocol represents a safe and effective strategy for ruling in and ruling out ACS in patients presenting to the ED.