Prehospital Period in Patients with COVID-19: Cardiovascular Comorbidity and Pharmacotherapy During the First Epidemic Wave (Hospital Registry Data)

Aim. Based on the data from the register of patients with COVID-19 and community-acquired pneumonia (CAP), analyze the duration of the prehospital period, cardiovascular comorbidity and the quality of prehospital pharmacotherapy of concomitant cardiovascular diseases (CVD).Material and methods. Patients were included to the study which admitted to the FSBI "NMHC named after N.I. Pirogov" of the Ministry of Health of the Russian Federation with a suspected or confirmed diagnosis of COVID-19 and/or CAP. The data for prehospital therapy, information from medical histories and a patients’survey in the hospital or by telephone contact 1-2 weeks after discharge were study. The duration of the prehospital stage was determined from the date of the appearance of clinical symptoms of coronavirus infection to the date of hospitalization.Results. The average age of the patients (n=1130; 579 [51.2%] men and 551 [48.8%] women) was 57.5±12.8 years. The prehospital stage was 7 (5,0; 10,0) days and did not differ significantly in patients with the presence and absence of CVD, but was significantly less in the deceased than in the surviving patients, as well as in those who required artificial lung ventilation (ALV). 583 (51.6%) patients had at least one CVD. Cardiovascular comorbidity was registered in 222 (42.7%) patients with hypertension, 210 (95.5%) patients with coronary heart disease (CHD), 104 (91.2%) patients with atrial fibrillation (AF). The inclusion of non-cardiac chronic diseases in the analysis led to an increase in the total proportion of patients with concomitant diseases to 65.8%. Approximately a quarter of hypertensive patients did not receive antihypertensive therapy, a low proportion of patients receiving antiplatelet agents and statins for CHD was revealed – 53% and 31.8%, respectively, anticoagulants for AF – 50.9%.Conclusion. The period from the onset of symptoms to hospitalization was significantly shorter in the deceased than in the surviving patients, as well as in those who required ALV. The proportion of people with a history of at least one CVD was about half of the entire cohort of patients. In patients with CVD before COVID-19 disease, a low frequencies of prescribing antihypertensive drugs, statins, antiplatelet agents and anticoagulants (in patients with AF) were recorded at the prehospital stage.

Cardiovascular Risk in Patients with COPD: Cardiovascular Comorbidities in Patients with COPD Increase CAT and mMRC Dyspnea Scores

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with a number of different comorbidities. Cardiovascular diseases (CVD) are the most frequent comorbidities in COPD. The economic burden associated with cardiovascular comorbidity (CVC) in this population of patients is considerable. The COPD patients are related to the increased systemic inflammation, reduced capacity for physical activity, and airflow obstruction. AIM: The aim of our investigation was to evaluate the dyspnea as a disabling symptom in COPD patients with cardiovascular comorbidity (CVC) especially heart failure. The main aim of this study is to evaluate its intensity in patients with COPD in stages II according to GOLD. METHODS: The investigation was conducted from December 2019 to January 2020, on pulmonology and allergology clinic and cardiology clinic of medical faculty in Skopje. We investigated 65 outpatients with COPD, 44 with different type of CVD, Group I, and 21 without CVD, Group II. All patients were with partial chronic respiratory failure (In type 1 respiratory failure hypoxemic). Patients, according GOLD initiative, were in COPD stadium II, 70% < forced expiratory volume in 1 s (FEV1)>50%. Heart condition was diagnosed on the basis of clinical examination, electrocardiography, and echocardiography of the heart. Included patients with CVD were with ejection fraction (EF) <65%. Dyspnea was measured with modified MRC (mMRC) dyspnea scale. RESULTS: The forced vital capacity and forced expiratory volume in 1 s were statically significantly higher in Group II with CVD. Dyspnea measured with Modified Medical Research Council (MRC) dyspnea scale showed statistically significantly higher values in Group I COPD patients with CVC (2.9 ± 1.4) versus Group II without CVC (1.7 ± 1.4), (p < 0.05). The perception of the higher dyspnea in Group I was associated with increased COPD assessment test-scores, in Group I: Group I (19.8 ± 9.1) versus Group II: (9.8 ± 9.1), (p < 0.001). The number of exacerbations and what is more important the number of severe exacerbation leading to hospitalizations was statistically higher in patients of Group I with CVC than in Group II without CVC (3.0 ± 1.1 vs. 1.0 ± 2.1), (p < 0.001) and the number of hospitalizations (1.0 ± 1.1 vs. 0.3 ± 2.1) (p < 0.001). CONCLUSION: We can conclude that patients with COPD who have CVC have an increased risk of high symptoms, which mean poor quality of life and increased morbidity.

Survival of Patients Following First Diagnosis of Diabetic Foot Complications: A Nationwide 15-Year Longitudinal Analysis

Background and AimsThe long-term survival in people with type 2 diabetes following first diagnosis of diabetic foot complications (FDDFC) is unclear. The object is to evaluate the mortality rate in subjects with type 2 diabetes following FDDFC and the impacts of the major cardiovascular comorbidities.MethodsNationwide data were analyzed for subjects with T2D and DFC between 2003 and 2017 according to ICD-9 coding. DFC was defined with the codes of ulcers, infections, or severe peripheral artery disease that required intervention (PAD) to mimic the real world diagnosis. Criteria of FDDFC were preceded by a period without any DFC for at least 5 years. Major cardiovascular comorbidities: established PAD and cardiovascular diseases (CVD: including coronary heart disease (CHD), stroke, or heart failure) before the index date as well as lower-extremity amputations (LEA) at the index episode were analyzed.ResultsAmong 300,115 subjects with DFC, a total of 103,396 patients had FDDFC. The mean 5-year survival rate of these subjects was 81.05%. Using subjects without associated major cardiovascular comorbidity as baseline, the adjusted hazard ratios (aHR) were1.43 (95% confidence interval 1.38–1.49) in group PAD-/CVD+, followed by 1.70 (1.59–1.80) in PAD+/CVD- and 1.98 (1.89–2.08) in PAD+/CVD+. The aHR was further increased in patients with PAD who additionally had heart failure (3.77, 3.50–4.05), stroke (2.06, 1.95–2.18), or CHD (1.89, 1.79–2.00). Subjects with PAD rather than other CVD were associated with LEA at FDDFC. Patients with major LEA (above the ankle) at FDDFC episode had lower 5-year survival rate (65.01%) followed by those with minor LEA (72.24%) and without LEA (81.61%).ConclusionsCardiovascular comorbidity as well as LEA status at the event of FDDFCs were both associated with patient survival outcomes. Earlier identification of this large population could lead to higher survival rates.

Cardiovascular comorbidity in patients with nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent liver disease worldwide. It is characterized by hepatic steatosis and stetohepatitis and in some cases can progress to cirrhosis with or without hepatic failure and hepatocellular carcinoma. At present, NAFLD is deemed a predictor of cardiovascular risk. Besides, it can aggravate pre-existing cardiovascular conditions. Structural and functional changes in the heart, liver and blood vessels are interdependent and mutually aggravating. Metabolic factors (dyslipidemia, hyperglycemia and insulin resistance) contribute to hepatic, cardiac and vascular damage, and NAFLD and comorbid cardiovascular disorders together can activate fibrogenesis in the heart, blood vessels and liver.

Clinical Profiles in Acute Heart Failure

Background:Phenotypes could be more frequently related to outcomes than classical classifications of AHF. Our goal was to identify clinical profiles for acute heart failure (AHF) based on clinical variables at the time of the patient arrival to the Emergency Department (ED).Methods:Design: Prospective cohort study. Participants: Patients with symptoms of AHF were recruited at the EDs of seven Spanish National Health Service hospitals between April 2013 and December 2014. Main measures: Information on sociodemographic, baseline functional status, medical history, and time since diagnosis was collected when the patient arrived at the ED. In addition, the MLWHF questionnaire was administered at arrival and at 1 year after discharge from the ED. Change in MLWHF score and mortality, revisits and readmissions during this first year were considered as outcomes. We combined multiple correspondence analysis (MCA) and cluster analysis (CA) to create clinical profiles.Results:A total of 1599 subjects were included in the study. Patients were located on two axes: one was defined as duration of HF and the other as cardiovascular comorbidity. Cluster analysis identified three subtypes of patient (A, B, and C), group B being most frequently corresponding to a “de novo” case. Differences in outcome, including mortality, readmissions and changes in MLWHF score, were encountered between group B and the rest of the groups, results being similar in groups A and C.Conclusions:The clinical phenotypes found were associated with clinical and patient-reported outcomes. Such clinical phenotypes could be useful in decision making processes in ED settings.Clinical registration:ClinicalTrials.gov ID: NCT03512704

In-Hospital Mortality and Glycemic Control in Patients with Hospital Hyperglycemia

BACKGROUND: Stress-induced hyperglycemia is a phenomenon that occurs typically in patients hospitalized for acute disease and resolves spontaneously after regression of the acute illness. However, it can also occur in diabetes patients, a fact that is sometimes overlooked. It is thus important to make a proper diabetes diagnosis if hospitalized patients with episodes of hyperglycemia with and without diabetes are studied. AIMS: To estimate the extent of the association between stress-induced hyperglycemia and in-hospital mortality in patients with hospital hyperglycemia (HH), and to explore potential differences between patients diagnosed with diabetes (HH-DBT) and those with stress-induced hyperglycemia (SH), but not diagnosed with diabetes. METHODS: A cohort of adults with hospital hyperglycemia admitted to a tertiary, university hospital in Buenos Aires, Argentina, was analyzed retrospectively. RESULTS: In the study, 2,955 patients were included and classified for analysis as 1,579 SH and 1,376 HH-DBT. Significant differences were observed in glycemic goal (35.53% SH versus 25.80% HH-DBT, p < 0.01), insulin use rate (26.66% SH versus 46.58% HH-DBT, p < 0.01), and severe hypoglycemia rate (1.32% SH versus 1.74% HH-DBT, p < 0.01). There were no differences in hypoglycemia rate (8.23% SH versus 10.53% HH-DBT) and hospital mortality. There was no increase in risk of mortality in the SH group adjusted for age, non-scheduled hospitalization, major surgical intervention, critical care, hypoglycemia, oncological disease, cardiovascular comorbidity, and prolonged hospitalization. CONCLUSIONS: In this study, we observed better glycemic control in patients with SH than in those with HH-DBT, and there was no difference in hospital mortality.

Ischemic stroke in low risk patients with atrial fibrillation: a nationwide, registry-based cohort study

Background Despite the good evidence on the prevention of ischemic stroke in high risk patients with atrial fibrillation (AF), the knowledge in AF patients without any cardiovascular risk factors is still limited and the treatment has been highly questioned. Methods We linked data from Swedish health registers to identify all patients with AF but without any previous cardiovascular comorbidity. The risk of ischemic stroke was investigated by using Cox regression models and patients with AF compared with two controls without AF, matched for age and sex. Results Altogether, 229,613 patients with AF and 457,332 matched controls without AF were included in the study; 44.4% of the population were women. Both the 1-year and the 5-year risk to develop ischemic stroke was higher in patients with AF compared to their matched controls without AF, hazard ratio (HR) of 3.7 (95%, confidence interval (CI) 3.5–3.8) and 2.5 (95%, CI 2.5–2.6) respectively. According to the age groups, patients with age of 35 to 49 years had the highest risk to develop ischemic stroke within the first year after AF diagnosis, HR 8.3 (95%, CI 4.0–17.1). Women with AF had 4.4 times higher risk to develop ischemic stroke (HR 4.4, CI 4.2–4.7) compared to matched women without AF. Conclusions In this large, register-based, nationwide cohort study, we found that the 1-risk and 5-year risk to develop ischemic stroke was significantly higher in patients with AF but without any cardiovascular risk factor for stroke, compared to matched controls without AF. Women and middle-aged patients with AF carried the highest risk to develop ischemic stroke indicating the need of further research on risk stratification despite traditional factors. FUNDunding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): The Swedish state and The Swedish Research Council

Screening, Management, and Acceptance of Patients with Aorto-Iliac Vascular Disease for Kidney Transplantation: A Survey among 161 Transplant Surgeons

<b><i>Introduction:</i></b> Aorto-iliac vascular disease (AVD) is frequently found during the workup for kidney transplantation. However, recommendations on screening and management are lacking. We aimed to assess differences in screening, management, and acceptance of these patients for transplantation by performing a survey among transplant surgeons. Second, we aimed to identify center- and surgeon-related factors associated with decline or acceptance of kidney transplant candidates with AVD. <b><i>Methods:</i></b> A survey was sent to transplant surgeons and urologists. The survey contained general questions (part I) and 2 patient-based cases (part II) with Trans-Atlantic Inter-Society Consensus (TASC) D and B AVD supported with videos of their CT scans. <b><i>Results:</i></b> One hundred ninety-one (20.3%) participants responded; 171 were currently involved in kidney transplantation: 161 (94.2%) completed part I and 145 (84.8%) part II. Screening for AVD was often (38.5%) restricted to high-risk patients. The majority of respondents (67.7%) rated “technical problems” as the most important concern in case of AVD, followed by “increased mortality risk because of cardiovascular comorbidity” (29.8%). Pretransplant vascular interventions to facilitate transplantation were infrequently performed (71.4% mentioned &#x3c;10 per year). Ninety (64.3%) respondents answered that an open vascular procedure should preferably be performed prior to kidney transplantation while 42 (30.0%) respondents preferred a simultaneous open vascular procedure. The decline rate was higher in the TASC D case compared to the TASC B case (26.9% and 9.7%, respectively). Respondents from centers with expertise in pretransplant vascular interventions were more likely to accept both patients with TASC D and B for transplantation. <b><i>Conclusion:</i></b> There is no uniformity in the screening, management, and acceptance of patients with AVD for transplantation. If a center declines a patient with AVD because of technical concerns, the patient should be referred for a second opinion to a tertiary center with expertise in pretransplant vascular interventions. Multidisciplinary meetings including a vascular surgeon and a cardiologist could help optimize these patients for transplantation.