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Unexpected admissions1
Nur Adawiyah Yusoff, RN, Changi General Hospital in Singapore, addressed unscheduled heart failure admissions. She pointed out that although globally the COVID-19 pandemic is weighing heavily on health systems, admissions for acute heart failure have actually dropped and that decrease may be the result of blockages, “leading potentially to undesirable outcomes, such as increased morbidity and mortality. “
With little data available on the effect of the pandemic on heart failure care in multi-ethnic Southeast Asian countries, its single-center study looked at acute heart failure admissions, assuming the totals were influenced by both the pandemic and its related lockdown restrictions and comparing results before (January 23-July 31, 2019; the monitoring period; n = 164) and during the pandemic (January 23-July 31, 2020; the period study; n = 183).
Of the patients in both groups, all were 67 years of age and older, and most were male and of Chinese descent. Their average hospital stay was 4 days. However, during the pandemic compared to before, a subgroup analysis of the period April 7 to June 1 for 2019 and 2020 showed patients to be sicker on admission, with mean (SD) scores of the Charlson comorbidity index of 2.88 (2.1) versus 1.97 (1.8) (P <.05). Despite this, overall admissions were found to be down at the start of the pandemic (the daily average fell from 2.44 to 1.39) compared to the same period in 2019 (January 23-April 6). They only rose again (to 2.28 on a daily average) after the reopening, when they were found to be higher compared to the same period in 2019 (2 June 31 July).
Noting the importance of seeing a doctor, Yusoff noted that “the lockdown measures implemented may have influenced a patient’s decision to leave the home for medical treatment, resulting in serious adverse effects from acute heart failure. “. Patient education is essential, she stressed, and telehealth can be used to advance care, but more studies need to look at patient behavior as it affects medication adherence, dietary restriction. / water and other lifestyle changes brought on by the pandemic.
Heart transplant recipients2
Daniel Miklin, MD, of the University of Southern California, discussed the results in heart transplant recipients, who face an even greater risk of COVID-19 due to immunosuppression, “which poses a risk significant morbidity and mortality ”among this patient population. In addition, due to the limited data on this patient population, he said, data is scarce on their initial management. The data, however, shows a 20-30% mortality among those infected with COVID-19, he said.
His retrospective review of 235 patients, with a median age (interquartile range) of 56.0 (41.0-63.5) years, of whom 71% were males, 55% had non-ischemic / dilated cardiomyopathy, and comorbidity the most common was hyperlipidemia (58%) – showed they were on average 7 years after heart transplant and were on a tacrolimus immunosuppressive regimen (97%). On admission to hospital, most presented with upper respiratory infection or acute hypoxic respiratory failure (29% each) or dyspnea (26%).
Most received supportive care (55%), but for those requiring care, they received steroids (19%), remdesevir (19%) or antibiotics (23%), the most common modification of immunosuppression regimens being to decrease mycophenolate (29%).
“Interestingly, our results showed only 7% mortality, with a survival rate of 93%,” Miklin said. Most patients (55%) received outpatient care, and of the 45% requiring hospitalization who did not succumb to their illness, all were successfully discharged.
The results contrast sharply with those of other studies, he added, which show mortality ranging from 20% in Israel to 37% in Italy. This may be because the patients in his study were younger, not so far from their transplants, and those on triple immunosuppression therapy may reap protective benefits in the form of a limited cytokine storm.
He, too, stressed the need for further research, particularly on long-term outcomes and optimization of therapy for this unique patient group.
Cardiac complications3
Gianluca Rigatelli, MD, PhD, Division of Cardiology at Rovigo General Hospital, Italy, summarized the findings on acute heart failure linked to COVID-19 infection. Its systematic review and meta-analysis aimed to assess “the combined incidence of acute heart failure as a cardiac complication of COVID-19 disease and to estimate the associated risk of mortality in these patients”.
Using a cutoff of December 26, 2020 and after researching MEDLINE, Scopus, and Web of Science, his and his team’s analysis focused on a cohort of 1064 patients, representing 6 studies, of which 6.9 % to 63.4% of patients hospitalized for COVID-19 had complications caused by acute heart failure. Pooled incidence analysis showed 20.2% (95% CI: 11.1% to 33.9%; P <0.0001) of patients with COVID-19 had complications of acute heart failure and had a significantly increased risk of mortality (odds ratio, 9.36; 95% CI, 4.76-18, 4; P <.0001).
“Acute heart failure is a common complication of COVID-19 infection,” noted Rigatelli, “and it is associated with a higher risk of short-term mortality. However, meta-regression analysis did not find a statistically significant relationship between age and the incidence of acute heart failure due to COVID-19 infection (P = .062) or overall risk of mortality (P = 0.053).
Prognostic biomarkers4
Patients with COVID-19-related pneumonia and no history of heart failure were summarized by Tufan Cinar, MD, Sultan Abdulhamid Han Training and Research Hospital in Istanbul, Turkey; in particular, the potential of the N-terminal pro-brain natriuretic peptide (NT-proBNP), an inactive prohormone, as a prognostic indicator of possible heart failure mortality. NT-proBNP levels are known to be above average in patients with heart failure compared to those without heart failure.5
Among the 137 patients included in his analysis, for whom the primary outcome was death in hospital, the overall mortality was 18.9%. The most common co-morbidities in those who died were hypertension, chronic kidney disease, coronary artery disease, stroke, and dementia. Elevated levels of white blood cells (WBC), glucose, creatinine, troponin I, and NT-proBNP were also observed, but only levels of NT-proBNP, WBC, and troponin I, in addition to age, were linked to an increase in hospital. mortality after multivariate analysis.
Further analysis of the ROC showed an ideal predictive level of NT-proBNP of 260 ng / L, at a sensitivity of 82% and specificity of 93% (AUC, 0.86; 95% CI, 0.76- 0.97), for in-hospital mortality, “clearly showing that NT-proBNP levels are independently related to in-hospital mortality rates in subjects with COVID-19 pneumonia and without heart failure. “
This indicates, he added, that the biomarker has value as a prognostic parameter in these cases.
Device therapy6
For their study on the effects of the COVID-19 pandemic on device therapy for patients with heart failure, presenter Rimma Hall of the Department of Cardiology, Cambridge University Hospital NHS Foundation Trust, and her fellow researchers examined the effects of the COVID-19 pandemic on device therapy for patients with heart failure. They compared the practice of implantation of defibrillators and cardiac resynchronization in patients with arrhythmia and heart failure to guidelines from the National Institute for Health and Care Excellence.
“The study period coincided with the COVID-19 pandemic,” Hall said, “this allowed us to assess its impact on device therapy.”
In particular, for infection control purposes, his team found that with care for patients admitted to hospital, there was a redistribution to ward care and away from specialist care, so they wanted to look at the impact. of this change on patients who needed specialized care but were not receiving it. Results from March to August 2020 were compared to the same time period in 2019, and there were 18 patients eligible for device therapy in both groups.
Among patients, although they saw a consistent prescription for device therapy between the two periods, particularly those with severe ventricular arrhythmia, familial heart disease with a high risk of sudden cardiac death, and a history of surgical repair of congenital heart disease. However, they found a reduction in the proportion of heart failure patients eligible for device therapy from 94% in 2019 to 79% in 2020 (P = .03).
Additional results show an 8% reduction in admissions for patients with heart failure during the pandemic and a trend toward a greater chance of patients who were considered too frail for device treatment. In 2020, 26 of 31 patients not receiving cardiology-focused care were found to be too fragile for device therapy.
Possible reasons for their findings, Hall noted, included the pressure for patients to be released quickly, a greater perception of the potential frailty of patients, and the lack of knowledge of lay physicians about the indications for device therapy.
“Cardiology departments should actively seek out patients with heart failure who may have missed life-saving therapies during the pandemic,” she concluded.
The references
1. Yusoff NA. The effect of the COVID-19 pandemic on unplanned heart failure admission: a single-center study. Presented at: ESC 2021 Congress; August 27-31, 2021. Virtual.
2. Miklin D. Results of COVID-19 infection in heart transplant recipients. Presented at: ESC 2021 Congress; August 27-31, 2021. Virtual.
3. Rigatelli G. Heart failure as a complication of covid-19 infection: systematic review and meta-analysis. Presented at: ESC 2021 Congress; August 27-31, 2021. Virtual.
4. Cinar T. Prognostic significance of N-terminal pro-BNP in patients with COVID-19 pneumonia without a history of heart failure. Presented at: ESC 2021 Congress; August 27-31, 2021. Virtual.
5. NT-proB-type natriuretic peptide (BNP). Cleveland Clinic. Accessed August 27, 2021. https://my.clevelandclinic.org/health/diagnostics/16814-nt-prob-type-natriuretic-peptide-bnp
6. Hall R. Impact of the covid-19 pandemic on device therapy for patients with heart failure. Presented at: ESC 2021 Congress; August 27-31, 2021. Virtual.
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