Impact of the withdrawal of renin-angiotensin-aldosterone inhibitors on mortality in COVID-19 patients

Background

Methods

Results

Conclusion

Lung ultrasound can predict heart failure developing and mortality during hospitalization in ST-segment elevation myocardial infarction

Introduction

About 10% of patients admitted for ST-segment elevation myocardial infarction (STEMI) present with signs of heart failure at admission. Heart failure developed during hospitalization and mortality are uncommon complications in patients admitted for STEMI with no signs of heart failure at admission (Killip-Kimball class I, KKI). Most of these patients have a good prognosis during hospitalization. B-lines in lung ultrasound (LUS) provide useful diagnostic and prognostic information in heart failure patients with the potential to stratify the risk of complications in patients presenting with STEMI KKI.

Purpose

To evaluate the predictive value of the LUS to develop heart failure and death during hospitalization in patients admitted with STEMI KKI.

Methods

This is a prospective observational multicenter study. Consecutive patients admitted for STEMI KKI in two tertiary hospitals were included. Exclusion criteria were patients with cardiac arrest at presentation, severe lung disease or hemodialysis. The LUS was carried out by an independent operator blinded to clinical data in the first 24 hours after admission. We counted B-lines using 8-scan site LUS protocol and divided patients in two groups: wet lung group (3 or more B-lines in at least one zone) and dry lung (no positive zone). The primary endpoint was a composite of clinical congestive heart failure, cardiogenic shock or mortality during the index hospitalization.

Results

From June 2020 to February 2021, 135 patients STEMI KKI patients were included. Twenty-nine patients (21,5%) had a wet lung according to the LUS. Ten patients (7,4%) presented the primary outcome (all of them developed heart failure, 1 of them cardiogenic shock and 2 of them died during hospitalization). Eight in 29 wet-lung patients (27,6%) presented the primary outcome whereas only 2 in 106 (1,9%) of the dry-lung patients [relative risk of 14,6 (IC 95% 3,3–65,1)]. Patients who develop the primary outcome had no differences in NTproBNP at admission but had higher NTproBNP peak, higher troponin T peak, lower left ventricular ejection fraction and longer length of stay (Figure 1).

Conclusions

In patients admitted with STEMI KKI, presenting 3 or more B-lines at least at one lung zone in the LUS at first 24 hours after admission was strongly associated with worse prognosis during hospitalization.

LUS allows a better risk classification of patients and may potentially discriminate those with potential risk of complications during hospitalization from those with an excellent prognosis who can benefit from early discharge.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): 2020 grant for training and research of the Association of Ischemic Heart Disease and Critical Cardiological Care, Spanish Society of Cardiology Figure 1. Baseline data in event/no event groupsFigure 2. Wet lung/dry lung groups events graphic

Characterization of myocardial injury in a cohort of patients with SARS-CoV-2 infection

BACKGROUND

Myocardial injury has been identified as a common complication in patients with COVID-19. However, recent research has serious limitations, such as non-guideline definition of myocardial injury, heterogenicity of troponin sampling or very short-term follow-up. Using data from a large European cohort, we aimed to overcome these pitfalls and adequately characterize myocardial damage in COVID-19.

METHODS

Consecutive patients with confirmed SARS-CoV-2 infection and available high-sensitive troponin I (hs-TnI), from March 1st to April 20th, 2020 who completed at least 1-month follow-up or died, were studied.

RESULTS

A total of 918 patients (mean age 63.2 ± 15.5 years, 60.1% male) with a median follow-up of 57 (49-63) days were included. Of these, 190 (20.7%) fulfilled strict criteria for myocardial injury (21.1% chronic, 76.8% acute non-ischemic, 2.1% acute ischemic). Time from onset of symptoms to maximum hs-TnI was 11 (7-18) days. Thrombotic and bleeding events, arrhythmias, heart failure, need for mechanical ventilation and death were significantly more prevalent in patients with higher hs-TnI concentrations, even without fulfilling criteria for myocardial injury. hs-TnI was identified as an independent predictor of mortality [HR 2.52 (1.57-4.04) per 5-logarithmic units increment] after adjusting for multiple relevant covariates.

CONCLUSION

Elevated hs-TnI is highly prevalent among patients with SARS-CoV-2 infection. Even mild elevations well below the 99th URL were significantly associated with higher rates of cardiac and non-cardiac complications, and higher mortality. Future research should address the role of serial hs-TnI assessment to improve COVID-19 prognostic stratification and clinical outcomes.

Characterization of myocardial injury in a cohort of patients with SARS-CoV-2 infection

BACKGROUND

Myocardial injury has been identified as a common complication in patients with COVID-19. However, recent research has serious limitations, such as non-guideline definition of myocardial injury, heterogenicity of troponin sampling or very short-term follow-up. Using data from a large European cohort, we aimed to overcome these pitfalls and adequately characterize myocardial damage in COVID-19.

METHODS

Consecutive patients with confirmed SARS-CoV-2 infection and available high-sensitive troponin I (hs-TnI), from March 1st to April 20th, 2020 who completed at least 1-month follow-up or died, were studied.

RESULTS

A total of 918 patients (mean age 63.2±15.5 years, 60.1% male) with a median follow-up of 57 (49-63) days were included. Of these, 190 (20.7%) fulfilled strict criteria for myocardial injury (21.1% chronic, 76.8% acute non-ischemic, 2.1% acute ischemic). Time from onset of symptoms to maximum hs-TnI was 11 (7-18) days. Thrombotic and bleeding events, arrhythmias, heart failure, need for mechanical ventilation and death were significantly more prevalent in patients with higher hs-TnI concentrations, even without fulfilling criteria for myocardial injury. hs-TnI was identified as an independent predictor of mortality [HR 2.52 (1.57-4.04) per 5-logarithmic units increment] after adjusting for multiple relevant covariates.

CONCLUSION

Elevated hs-TnI is highly prevalent among patients with SARS-CoV-2 infection. Even mild elevations well below the 99th URL were significantly associated with higher rates of cardiac and non-cardiac complications, and higher mortality. Future research should address the role of serial hs-TnI assessment to improve COVID-19 prognostic stratification and clinical outcomes.

Prediction of thromboembolic events and mortality by the CHADS2 and the CHA2DS2-VASc in COVID-19

AIMS

Age, sex, and cardiovascular disease have been linked to thromboembolic complications and poorer outcomes in COVID-19. We hypothesize that CHADS2 and CHA2DS2-VASc scores may predict thromboembolic events and mortality in COVID-19.

METHODS AND RESULTS

COVID-19 hospitalized patients with confirmed SARS-CoV-2 infection from 1 March to 20 April 2020 who completed at least 1-month follow-up or died were studied. CHADS2 and CHA2DS2-VASc scores were calculated. Given the worse prognosis of male patients in COVID-19, a modified CHA2DS2-VASc score (CHA2DS2-VASc-M) in which 1 point was given to male instead of female was also calculated. The associations of these scores with laboratory results, thromboembolic events, and death were analysed. A total of 3042 patients (mean age 62.3 ± 20.3 years, 54.9% male) were studied and 115 (3.8%) and 626 (20.6%) presented a definite thromboembolic event or died, respectively, during the study period [median follow 59 (50-66) days]. Higher score values were associated with more marked abnormalities of inflammatory and cardiac biomarkers. Mortality was significantly higher with increasing scores for CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-M (P < 0.001 for trend). The CHA2DS2-VASc-M showed the best predictive value for mortality [area under the receiver operating characteristic curve (AUC) 0.820, P < 0.001 for comparisons]. All scores had poor predictive value for thromboembolic events (AUC 0.497, 0.490, and 0.541, respectively).

CONCLUSION

The CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-M scores are significantly associated with all-cause mortality but not with thromboembolism in COVID-19 patients. They are simple scoring systems in everyday use that may facilitate initial 'quick' prognostic stratification in COVID-19.

Characterization of NT-proBNP in a large cohort of COVID-19 patients

Aims

Extensive research regarding the association of troponin and prognosis in coronavirus disease 2019 (COVID‐19) has been performed. However, data regarding natriuretic peptides are scarce. N‐terminal pro B‐type natriuretic peptide (NT‐proBNP) reflects haemodynamic stress and has proven useful for risk stratification in heart failure (HF) and other conditions such as pulmonary embolism and pneumonia. We aimed to adequately characterize NT‐proBNP concentrations using a large cohort of patients with COVID‐19, and to investigate its association with prognosis.

Methods and results

Consecutive patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection and available NT‐proBNP determinations, from March 1st to April 20th, 2020 who completed at least 1‐month follow‐up or died, were studied. Of 3080 screened patients, a total of 396 (mean age 71.8 ± 14.6 years, 61.1% male) fulfilled all the selection criteria and were finally included, with a median follow‐up of 53 (18–62) days. Of those, 192 (48.5%) presented NT‐proBNP levels above the recommended cut‐off for the identification of HF. However, only 47 fulfilled the clinical criteria for the diagnosis of HF. Patients with higher NT‐proBNP during admission experienced more frequent bleeding, arrhythmias and HF decompensations. NT‐proBNP was associated with mortality both in the whole study population and after excluding patients with HF. A multivariable Cox model confirmed that NT‐proBNP was independently associated with mortality after adjusting for all relevant confounders (hazard ratio 1.28, 95% confidence interval 1.13–1.44, per logarithmic unit).

Conclusion

NT‐proBNP is frequently elevated in COVID‐19. It is strongly and independently associated with mortality after adjusting for relevant confounders, including chronic HF and acute HF. Therefore, its use may improve early prognostic stratification in this condition.