Electrocardiographic abnormalities in COVID-19 patients visiting the emergency department: a multicenter retrospective study

Abstract Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can be associated with myocardial injury. Identification of at-risk patients and mechanisms underlying cardiac involvement in COVID-19 remains unclear. During hospitalization for COVID-19, high troponin level has been found to be an independent variable associated with in-hospital mortality and a greater risk of complications. Electrocardiographic (ECG) abnormalities could be a useful tool to identify patients at risk of poor prognostic. The aim of our study was to assess if specific ECGs patterns could be related with in-hospital mortality in COVID-19 patients presenting to the ED in a European country. Methods From February 1st to May 31st, 2020, we conducted a multicenter study in three hospitals in France. We included adult patients (≥ 18 years old) who visited the ED during the study period, with ECG performed at ED admission and diagnosed with COVID-19. Demographic, comorbidities, drug exposures, signs and symptoms presented, and outcome data were extracted from electronic medical records using a standardized data collection form. The relationship between ECG abnormalities and in-hospital mortality was assessed using univariate and multivariable logistic regression analyses. Results An ECG was performed on 275 patients who presented to the ED. Most of the ECGs were in normal sinus rhythm (87%), and 26 (10%) patients had atrial fibrillation/flutter on ECG at ED admission. Repolarization abnormalities represented the most common findings reported in the population (40%), with negative T waves representing 21% of all abnormalities. We found that abnormal axis (adjusted odds ratio: 3.9 [95% CI, 1.1–11.5], p = 0.02), and left bundle branch block (adjusted odds ratio: 7.1 [95% CI, 1.9–25.1], p = 0.002) were significantly associated with in-hospital mortality. Conclusions ECG performed at ED admission may be useful to predict death in COVID-19 patients. Our data suggest that the presence of abnormal axis and left bundle branch block on ECG indicated a higher risk of in-hospital mortality in COVID-19 patients who presented to the ED. We also confirmed that ST segment elevation was rare in COVID-19 patients.

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National trends in coronary intensive care unit admissions, resource utilization, and outcomes

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872619883400 ◽

2019 ◽

Vol 9 (8) ◽

pp. 923-930

Author(s):

Sarah Woolridge ◽

Wendimagegn Alemayehu ◽

Padma Kaul ◽

Christopher B Fordyce ◽

Patrick R Lawler ◽

...

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Hospital Mortality ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Mortality Rates ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

St Segment

Background: Emerging evidence suggests that coronary intensive care units are evolving into intensive care environments with an increasing burden of non-cardiovascular illness, but previous studies have been limited to older populations or single center experiences. Methods: Canadian national health-care data was used to identify all patients ≥18 years admitted to dedicated coronary intensive care units (2005–2015) and admissions were categorized as primary cardiac or non-cardiac. The outcomes of interest included longitudinal trends in admission diagnoses, critical care therapies, and all-cause in-hospital mortality. Results: Among the 373,992 patients admitted to a coronary intensive care unit, minimal changes in the proportion of patients admitted with a primary cardiac (88.2% to 86.9%; p<0.001) and non-cardiac diagnoses (11.8% to 13.1%; p<0.001) were observed. Among cardiac admissions, a temporal increase in the proportion of ST-segment elevation myocardial infarction (19.4% to 24.1%, p<0.001), non-ST-segment elevation myocardial infarction (14.6% to 16.2%, p<0.001), heart failure (7.3% to 8.4%, p<0.001), shock (4.9% to 5.7%, p<0.001), and decline in unstable angina (4.9% to 4.0%, p<0.001) and stable coronary diseases (21.3% to 12.4%, p<0.001) was observed. The proportion of patients requiring critical care therapies (57.8% to 63.5%, p<0.001) including mechanical ventilation (9.6% to 13.1%, p<0.001) increased. In-hospital mortality rates for patients with primary cardiac (4.9% to 4.4%; adjusted odds ratio 0.71, 95% confidence interval 0.63–0.79) and non-cardiac (17.8% to 16.1%; adjusted odds ratio 0.84, 0.73–0.97) declined; results were consistent when stratified by academic vs community hospital, and by the presence of on-site percutaneous coronary intervention. Conclusion: In a national dataset we observed a changing case-mix among patients admitted to a coronary intensive care unit, though the proportion of patients with a primary cardiac diagnosis remained stable. There was an increase in clinical acuity highlighted by critical care therapies, but in-hospital mortality rates for both primary cardiac and non-cardiac conditions declined across all hospitals. Our findings confirm the changing coronary intensive care unit case-mix and have implications for future coronary intensive care unit training and staffing.

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Temporal Trends, Predictors, and Outcomes of Acute Ischemic Stroke in Acute Myocardial Infarction in the United States

Journal of the American Heart Association ◽

10.1161/jaha.120.017693 ◽

2021 ◽

Author(s):

Gaurav Aggarwal ◽

Sri Harsha Patlolla ◽

Saurabh Aggarwal ◽

Wisit Cheungpasitporn ◽

Rajkumar Doshi ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Hospital Mortality ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Temporal Trends ◽

St Segment Elevation ◽

Endoscopic Gastrostomy ◽

St Segment ◽

Hospitalization Costs

Background There are limited contemporary data prevalence and outcomes of acute ischemic stroke (AIS) complicating acute myocardial infarction (AMI). Methods and Results Adult (>18 years) AMI admissions using the National Inpatient Sample database (2000–2017) were evaluated for in‐hospital AIS. Outcomes of interest included in‐hospital mortality, hospitalization costs, length of stay, discharge disposition, and use of tracheostomy and percutaneous endoscopic gastrostomy. The discharge destination was used to classify survivors into good and poor outcomes. Of a total 11 622 528 AMI admissions, 183 896 (1.6%) had concomitant AIS. As compared with 2000, in 2017, AIS rates increased slightly among ST‐segment–elevation AMI (adjusted odds ratio, 1.10 [95% CI, 1.04–1.15]) and decreased in non–ST‐segment–elevation AMI (adjusted odds ratio, 0.47 [95% CI, 0.46–0.49]) admissions ( P <0.001). Compared with those without, the AIS cohort was on average older, female, of non‐White race, with greater comorbidities, and higher rates of arrhythmias. The AMI‐AIS admissions received less frequent coronary angiography (46.9% versus 63.8%) and percutaneous coronary intervention (22.7% versus 41.8%) ( P <0.001). The AIS cohort had higher in‐hospital mortality (16.4% versus 6.0%; adjusted odds ratio, 1.75 [95% CI, 1.72–1.78]; P <0.001), longer hospital length of stay, higher hospitalization costs, greater use of tracheostomy and percutaneous endoscopic gastrostomy, and less frequent discharges to home (all P <0.001). Among AMI‐AIS survivors (N=153 318), 57.3% had a poor functional outcome at discharge with relatively stable temporal trends. Conclusions AIS is associated with significantly higher in‐hospital mortality and poor functional outcomes in AMI admissions.

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Early Invasive Versus Ischemia-Guided Strategy in Non-ST-Segment Elevation Acute Coronary Syndrome With Chronic Obstructive Pulmonary Disease: A National Inpatient Sample Analysis

Angiology ◽

10.1177/0003319719877096 ◽

2019 ◽

Vol 71 (4) ◽

pp. 372-379 ◽

Cited By ~ 1

Author(s):

Tomo Ando ◽

Oluwole Adegbala ◽

Hisato Takagi ◽

Luis Afonso ◽

Alexandros Briasoulis

Keyword(s):

Chronic Obstructive Pulmonary Disease ◽

Hospital Mortality ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Chronic Obstructive ◽

Obstructive Pulmonary Disease ◽

Invasive Strategy ◽

St Segment Elevation ◽

St Segment ◽

Early Invasive Strategy

Chronic obstructive pulmonary disease (COPD) is a risk factor for non-ST-segment elevation–acute coronary syndromes (NSTE-ACS). Whether early invasive strategy (EIS) or ischemia-guided strategy (IGS) confers better outcomes in NSTE-ACS with COPD is largely unknown. Nationwide Inpatient Sample database of the United States was queried from 2010 to 2015 to identify NSTE-ACS with and without COPD. Early invasive strategy was defined as coronary angiogram with or without revascularization on admission day 0 or 1, whereas IGS included patients who did not receive EIS. Standardized morbidity ratio weight was used to calculate the adjusted odds ratio. A total of 228 175 NSTE-ACS admissions with COPD were identified of which 34.0% received EIS. In-hospital mortality was lower with EIS in patients with COPD (3.1% vs 5.5%, adjusted odds ratio 0.57, 95% confidence interval 0.50-0.63) compared to IGS, but the magnitude of mortality reduction observed in EIS in patients with COPD was less compared to non-COPD patients ( P interaction = .02). Length of stay was shorter (4.2 vs 4.7 days, P < .0001) but the cost was higher (US$23 804 vs US$18 533, P < .0001) in EIS in COPD. Early invasive strategy resulted in lower in-hospital mortality and marginally shorter length of stay but higher hospitalization cost in NSTE-ACS with COPD.

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Differences in presentation and clinical outcomes between left or right bundle branch block and ST segment elevation in patients with acute myocardial infarction

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872620905101 ◽

2020 ◽

Vol 9 (8) ◽

pp. 848-856

Author(s):

Matthias R Meyer ◽

Dragana Radovanovic ◽

Giovanni Pedrazzini ◽

Hans Rickli ◽

Marco Roffi ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Hospital Mortality ◽

Right Bundle Branch Block ◽

Left Bundle Branch Block ◽

Bundle Branch Block ◽

St Segment Elevation ◽

Cerebrovascular Events ◽

St Segment ◽

Ischaemic Attack

Background: In patients with acute myocardial infarction, the presence of a left bundle branch block or right bundle branch block may be associated with worse prognosis compared to isolated ST segment elevation. However, specificities in clinical presentation and outcomes of acute myocardial infarction patients with left bundle branch block or right bundle branch block are poorly characterized. Methods: We analysed acute myocardial infarction patients with left bundle branch block ( n=880), right bundle branch block ( n=732) or ST segment elevation without bundle branch block ( n=15,852) included in the Acute Myocardial Infarction in Switzerland-Plus registry between 2008–2019. Results: Acute myocardial infarction patients with bundle branch block were older and had more pre-existing cardiovascular conditions compared to ST segment elevation. Pulmonary oedema and cardiogenic shock were most frequent in patients with left bundle branch block (18.8% vs 12.0% for right bundle branch block and 7.9% for ST segment elevation, p<0.001). Acute myocardial infarction patients with bundle branch block had more three-vessel (40.6% vs 25.3%, p<0.001 vs ST segment elevation) and left main disease (5.6% vs 2.0%, p<0.001 vs ST segment elevation). Major adverse cardiac and cerebrovascular events, a composite of reinfarction, stroke/transient ischaemic attack, and death during hospitalization, were highest in acute myocardial infarction patients with left bundle branch block (13.9% vs 9.9% for right bundle branch block and 6.7% for ST segment elevation, p<0.05), which was driven by hospital mortality. After multivariate adjustment, however, mortality was similar in patients with left bundle branch block and lower in patients with right bundle branch block, respectively, when compared to ST segment elevation. Mortality was only increased when a right bundle branch block with concomitant STE was present (odds ratio 1.77, 95% confidence interval 1.19–2.64, p<0.01 vs ST segment elevation). Conclusions: Compared to ST segment elevation, an isolated bundle branch block reflects high-risk clinical characteristics but does not independently determine increased hospital mortality in acute myocardial infarction.

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An Unusual Cause of Concordance in the Setting of Left Bundle Branch Block

Journal of Family Medicine ◽

10.26420/jfammed.2021.1245 ◽

2021 ◽

Vol 8 (2) ◽

Author(s):

Alqaisi O ◽

◽

Carter J ◽

Xu J ◽

Paydak H ◽

...

Keyword(s):

Left Bundle Branch Block ◽

Normal Sinus Rhythm ◽

International Normalized Ratio ◽

Verbal Response ◽

Sensory Loss ◽

Initial Examination ◽

Bundle Branch Block ◽

St Segment Elevation ◽

Normal Sinus ◽

Glascow Coma Scale

A 73-year-old female with a past medical history of atrial fibrillation, mechanical mitral valve replacement on warfarin, hypertension and hypothyroidism presented to the emergency department with a fall. She fell and hit her head upon standing up from a seated position. She reported a constant posteriorly located headache along with episodes of nausea and vomiting. She denied chest pain, shortness of breath, syncope and fever. The initial examination showed blood pressure of 107/64mmHg, respiratory rate of 13/Min, pulse of 76/Min, oxygen saturation of 96% and Glascow Coma Scale (GCS) of 13, verbal response 4, motor response 6 and eye response 3. Pupils were round and reactive to light. No focal weakness or sensory loss were noted. The patient’s mental status and GCS progressively worsened for which she eventually was intubated. The patient had a mild leukocytosis of 14.11×109 (4.0-10.0). Her sodium, calcium, magnesium, phosphorus and potassium were normal. International Normalized Ratio (INR) was 2.9. The troponin upon presentation was 0.69ng/ml and trended down throughout the hospitalization. Her EKG showed normal sinus rhythm with a left bundle branch block with ST segment elevation in leads V3 - V5 and concordant ST elevation >1mm in V5. Sgarbossa criteria for acute myocardial infarction in the presence of LBBB was 5 points. Computed tomography (CT) scan of the head without contrast showed large bilateral cerebellar hemorrhages with mild inferior herniation of the cerebellar tonsils. Echocardiogram showed ejection fraction of 55-60% with no wall motion abnormalities. Immediate supportive treatment, including fluids and reversal of anticoagulation with prothrombin complex concentrate and vitamin K were administered. The patient underwent a successful suboccipital decompressive craniotomy.

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Intraventricular conduction defects in patients with st-segment elevation myocardial infarction – the paradox of right bundle branch block

European Heart Journal ◽

10.1093/ehjci/ehaa946.1615 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

S Fernandes ◽

F Montenegro ◽

M Cabral ◽

R Carvalho ◽

L Santos ◽

...

Keyword(s):

Hospital Mortality ◽

Right Bundle Branch Block ◽

Independent Predictor ◽

Left Ventricular Ejection ◽

Bundle Branch Block ◽

Hospital Outcomes ◽

St Segment Elevation ◽

Intraventricular Conduction ◽

St Segment ◽

Worse Prognosis

Abstract Intraventricular conduction defects (IVCD) in patients with acute myocardial infarct (AMI) are predictors of a worse prognosis. When acquired they can be the result of an extensive myocardial damage. Purpose To assess the impact of IVCD, regardless of being previously known or presumed new, on in-hospital outcomes of patients with AMI with ST segment elevation (STEMI) or undetermined location. Methods From a series of patients included in the National Registry of Acute Coronary Syndrome between 10/1/2010 and 9/1/2019, were selected patients with STEMI or undetermined AMI, undergoing coronary angiography. Results 7805 patients were included: 461 (5.9%) presenting left bundle branch block (LBBB), 374 (4.8%) with right bundle branch block (RBBB) and 6970 (89.3%) with no IVCD. Clinical characteristics as well as in-hospital outcomes are described in the table 1. An unexpected worse prognosis in patients with RBBB has motivated a multivariate analysis. RBBB remained an independent predictor of in-hospital mortality (OR 1.91, 95% CI 1.04–3.50, p=0.038), along with female gender (OR 1.73, 95% CI 1.11–2.68, p=0.015), Killip Class>1 (OR 2.26, 95% CI 1.45–3.53, p<0.001), left ventricular ejection fraction <50% (OR 3.93, 95% CI 2.19–7.05, p<0.001) and left anterior descending artery as the culprit lesion (OR 1.85, 95% CI 1.16–2.91, p=0.009). Conclusion In spite of an apparent better clinical profile, in the current large series of unselected STEMI patients, the presence of RBBB is associated with the worst in-hospital outcome. RBBB doubles the risk of death, being an independent predictor of in-hospital mortality. Funding Acknowledgement Type of funding source: None

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Outcomes of Neutropenic Patients with Clostridium difficile Infection

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.950 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s339-s340

Author(s):

Roopali Sharma ◽

Deepali Dixit ◽

Sherin Pathickal ◽

Jenny Park ◽

Bernice Lee ◽

...

Keyword(s):

Clostridium Difficile ◽

Length Of Stay ◽

Hospital Mortality ◽

Treatment Failure ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Hospital Length ◽

Hospital Length Of Stay ◽

End Point ◽

Neutropenic Patients

Background: Data from Clostridium difficile infection (CDI) in neutropenic patients are still scarce. Objective: To assess outcomes of CDI in patients with and without neutropenia. Methods: The study included a retrospective cohort of adult patients at 3 academic hospitals between January 2013 and December 2017. The 2 study arms were neutropenic patients (neutrophil count <500/mm3) and nonneutropenic patients with confirmed CDI episodes. The primary outcome evaluated the composite end point of all-cause in-hospital mortality, intensive care unit (ICU) admissions, and treatment failure at 7 days. The secondary outcome evaluated hospital length of stay. Results: Of 962 unique cases of CDI, 158 were neutropenic (59% men) and 804 were nonneutropenic (46% men). The median age was 57 years (IQR, 44–64) in the neutropenic group and 68 years (IQR, 56–79) in the nonneutropenic group. The median Charlson comorbidity score was 5 (IQR, 3–7.8) and 4 (IQR, 3–5) in the neutropenic and nonneutropenic groups, respectively. Regarding severity, 88.6% versus 48.9% were nonsevere, 8.2% versus 47% were severe, and 3.2% versus 4.1% were fulminant in the neutropenic and nonneutropenic groups, respectively. Also, 63% of patients (60.9% in nonneutropenic, 65.2% in neutropenic) were exposed to proton-pump inhibitors. A combination CDI treatment was required in 53.2% of neutropenic patients and 50.1% of nonneutropenic patients. The primary composite end point occurred in 27% of neutropenic patients versus 22% of nonneutropenic patients (P = .257), with an adjusted odds ratio of 1.30 (95% CI, 0.84–2.00). The median hospital length of stay after controlling for covariates was 21.3 days versus 14.2 days in the neutropenic and nonneutropenic groups, respectively (P < .001). Complications (defined as hypotension requiring vasopressors, ileus, or bowel perforation) were seen in 6.0% of the nonneutropenic group and 4.4% of the neutropenic group (P = .574), with an adjusted odds ratio of 0.61 (95% CI, 0.28–1.45). Conclusions: Neutropenic patients were younger and their cases were less severe; however, they had lower incidences of all-cause in-hospital mortality, ICU admissions, and treatment failure. Hospital length of stay was significantly shorter in the neutropenic group than in the nonneutropenic group.Funding: NoneDisclosures: None

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P982 Correlation between electrocardiographic and imaging data in patients with acute myocarditis: a single centre retrospective analysis

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.611 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

A Caretta ◽

L A Leo ◽

V L Paiocchi ◽

G M Viani ◽

S A Schlossbauer ◽

...

Keyword(s):

Retrospective Analysis ◽

Wall Motion ◽

Acute Myocarditis ◽

Left Ventricular Ejection ◽

Imaging Data ◽

Bundle Branch Block ◽

St Segment Elevation ◽

St Segment ◽

Wall Motion Abnormalities ◽

Ecg Abnormalities

Abstract Funding Acknowledgements None Background Acute myocarditis is a clinical and pathological condition defined as an inflammation of the myocardium. Its diagnosis is often challenging and requires multiple information derived from different diagnostic modalities. Purpose The aim of the study is to evaluate the correlation between electrocardiographic and imaging data in patients with acute myocarditis. Methods We made a retrospective analysis of 102 patients admitted to our Centre between January 2012 and April 2019 for suspected acute myocarditis. Diagnosis was confirmed with cardiac magnetic resonance (CMR) by identification of myocardial edema in T2-weighted images and/or typical subepicardial or midwall pattern of late gadolinium enhancement (LGE). Significant coronary artery disease was ruled out with coronary angiography. Electrocardiogram (ECG) was analysed on admission - in order to evaluate the presence of ST segment abnormalities, atrio-ventricular or bundle-branch block and heart rhythm disorders - and at the time of discharge. Every patient underwent echocardiography and CMR: from both these exams we reported the presence of regional wall motion abnormalities and left ventricular ejection fraction (LVEF). Results Mean age of our population was 39 ± 18 years; 92 people (90%) were males. At admission, 85 patients (83%) presented ECG abnormalities; the most frequent was ST-segment elevation (65 cases). Conduction or rhythm disorders were observed in 26 cases (25%). At the time of discharge, 41 out of 85 patients had complete regression of ECG changes. Mean value of LVEF measured with echocardiography was 56.4 ± 7.6%. In patients with normal ECG on admission it was 59.9 ± 3.1%, whereas in patients with abnormal ECG 55.7 ± 7.9% (p = 0.045). Considering CMR, mean LVEF in the population was 58.5 ± 8.6%, varying between 64.0 ± 8.9% in the group with normal ECG and 57.4 ± 10.1% in the group with ECG abnormalities (p = 0.02). Moreover, subjects with altered ECG on admission had a higher prevalence of wall motion abnormalities both in echocardiography (47/85 – 55% vs 3/17 – 18%, p < 0.01) and in CMR (45/85 – 53% vs 3/17 – 18%, p < 0.01). Patients with ECG normalization at discharge had a higher prevalence of ST-segment elevation (88 vs 66%, p = 0.02), while the group with persistent ECG alterations had a higher incidence of AV or bundle-branch block (23 vs 7%, p = 0.048). No statistical difference was noted between these two groups regarding echocardiographic or CMR values. Conclusion In our experience evaluation of ECG at admission in patients with suspected acute myocarditis identifies a subgroup of individuals with lower values of LVEF and a higher prevalence of wall motion abnormalities both in echocardiography and in CMR, while data derived by imaging techniques had no significant predictive value on ECG evolution at the time of discharge.

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