The value of ECG changes in risk stratification of COVID‐19 patients

BackgroundThere is growing evidence of cardiac injury in COVID‐19. Our purpose was to assess the prognostic value of serial electrocardiograms in COVID‐19 patients.MethodsWe evaluated 269 consecutive patients admitted to our center with confirmed SARS‐CoV‐2 infection. ECGs available at admission and after 1 week from hospitalization were assessed. We evaluated the correlation between ECGs findings and major adverse events (MAE) as the composite of intra‐hospital all‐cause mortality or need for invasive mechanical ventilation. Abnormal ECGs were defined if primary ST‐T segment alterations, left ventricular hypertrophy, tachy or bradyarrhythmias and any new AV, bundle blocks or significant morphology alterations (e.g., new Q pathological waves) were present.ResultsAbnormal ECG at admission (106/216) and elevated baseline troponin values were more common in patients who developed MAE (p = .04 and p = .02, respectively). Concerning ECGs recorded after 7 days (159), abnormal findings were reported in 53.5% of patients and they were more frequent in those with MAE (p = .001). Among abnormal ECGs, ischemic alterations and left ventricular hypertrophy were significantly associated with a higher MAE rate. The multivariable analysis showed that the presence of abnormal ECG at 7 days of hospitalization was an independent predictor of MAE (HR 3.2; 95% CI 1.2–8.7; p = .02). Furthermore, patients with abnormal ECG at 7 days more often required transfer to the intensive care unit (p = .01) or renal replacement therapy (p = .04).ConclusionsPatients with COVID‐19 should receive ECG at admission but also during their hospital stay. Indeed, electrocardiographic alterations during hospitalization are associated with MAE and infection severity.     

T‐wave heterogeneity in standard resting 12‐lead ECGs is associated with 90‐day cardiac mortality in women following emergency department admission: A nested case–control study

BackgroundWe investigated whether T‐wave heterogeneity (TWH) can identify patients who are at risk for near‐term cardiac mortality.MethodsA nested case–control analysis was performed in the 888 patients admitted to the Emergency Department (ED) of our medical center in July through September 2018 who had ≥2 serial troponin measurement tests within 6 hr for acute coronary syndrome evaluation to rule‐in or rule‐out the presence of acute myocardial infarction. Patients who died from cardiac causes during 90 days after ED admission were considered cases (n = 20; 10 women) and were matched 1:4 on sex and age with patients who survived during this period (n = 80, 40 women). TWH, that is, interlead splay of T waves, was automatically assessed from precordial leads by second central moment analysis.ResultsTWH_V4‐6 was significantly elevated at ED admission in 12‐lead resting ECGs of female patients who died of cardiac causes during the following 90 days compared to female survivors (100 ± 14.9 vs. 40 ± 3.6 µV, p < .0001). TWH_V4‐6 generated areas under the receiver‐operating characteristic (ROC) curve (AUC) of 0.933 in women (p < .0001) and 0.573 in men (p = .4). In women, the ROC‐guided 48‐µV TWH_V4‐6 cut point for near‐term cardiac mortality produced an adjusted odds ratio of 121.37 (95% CI: 2.89–6,699.84; p = .02) with 100% sensitivity and 82.5% specificity. In Kaplan–Meier survival analysis, TWH_V4‐6 ≥ 48 µV predicted cardiac mortality in women during 90‐day follow‐up with a hazard ratio of 27.84 (95% CI: 7.29–106.36, p < .0001).ConclusionElevated TWH_V4‐6 is associated with near‐term cardiac mortality among women evaluated for acute coronary syndrome.     

Clinical impact of long PR‐interval and presence of late gadolinium enhancement on hospitalized patients with non‐ischemic heart failure

BackgroundThe combination of electrical and structural remodeling may have a strong effect on the prognosis of non‐ischemic heart failure (HF). We aimed to clarify whether prolonged PR‐interval and the presence of late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) influence the outcomes of patients with non‐ischemic HF.MethodsWe studied 262 consecutive hospitalized patients with non‐ischemic HF. In a clinically stable condition, a 12‐lead electrocardiogram and CMR were performed, and the clinical characteristics and outcomes were investigated.ResultsDuring the follow‐up of 967.7 ± 851.8 days, there were 68 (25.9%) cardiac events (HF or sudden death, re‐hospitalization due to HF, or ventricular tachyarrhythmias). In a multivariable analysis, a median rate‐adjusted PR (PRa)‐interval of ≥173.5 ms and the presence of LGE were associated with cardiac events with a hazard ratio of 1.690 and 2.045 (p = .044 and p = .006, respectively). Study subjects were then divided into four groups based on long (≥173.5 ms) or short (<173.5 ms) PRa‐interval and LGE status: short PRa/non‐LGE (n = 80), long PRa/non‐LGE (n = 72), short PRa/LGE (n = 51), and long PRa/LGE (n = 59). Cardiac events were 16.2% in short PRa/non‐LGE, 25.0% in long PRa/non‐LGE, 27.4% in short PRa/LGE, and 38.9% in long PRa/LGE (p = .026), respectively. The multivariable Cox proportional hazard analysis showed that long PRa/LGE was an independent predictor for cardiac events compared to short PRa/non‐LGE (hazard ratio, 3.378, p = .001).ConclusionsThe combination of a long PRa‐interval and the presence of LGE provide a better predictive value of cardiac events in non‐ischemic HF.     

Noninvasive risk factors for the prediction of inducibility on programmed ventricular stimulation in post‐myocardial infarction patients with an ejection fraction ≥40% at risk for sudden cardiac arrest: Insights from the PRESERVE‐EF study

BackgroundIn the PRESERVE‐EF study, a two‐step sudden cardiac death (SCD) risk stratification approach to detect post‐myocardial infarction (MI) patients with left ventricle ejection fraction (LVEF) ≥40% at risk for major arrhythmic events (MAEs) was used. Seven noninvasive risk factors (NIRFs) were extracted from a 24‐h ambulatory electrocardiography (AECG) and a 45‐min resting recording. Patients with at least one NIRF present were referred for invasive programmed ventricular stimulation (PVS) and inducible patients received an Implantable Cardioverter ‐ Defibrillator (ICD).MethodsIn the present study, we evaluated the performance of the NIRFs, as they were described in the PRESERVE‐EF study protocol, in predicting a positive PVS. In the PRESERVE‐EF study, 152 out of 575 patients underwent PVS and 41 of them were inducible. For the present analysis, data from these 152 patients were analyzed.ResultsAmong the NIRFs examined, the presence of signal averaged ECG‐late potentials (SAECG‐LPs) ≥ 2/3 and non‐sustained ventricular tachycardia (NSVT) ≥1 eposode/24 h cutoff points were important predictors of a positive PVS study, demonstrating in the logistic regression analysis odds ratios 2.285 (p = .027) and 2.867 (p = .006), respectively. A simple risk score based on the above cutoff points in combination with LVEF < 50% presented high sensitivity but low specificity for a positive PVS.ConclusionCutoff points of NSVT ≥ 1 episode/24 h and SAECG‐LPs ≥ 2/3 in combination with a LVEF < 50% were important predictors of inducibility. However, the final decision for an ICD implantation should be based on a positive PVS, which is irreplaceable in risk stratification.     

Temporal variability of T‐wave morphology and risk of sudden cardiac death in patients with coronary artery disease

BackgroundThe possible relationship between temporal variability of electrocardiographic spatial heterogeneity of repolarization and the risk of sudden cardiac death (SCD) in patients with coronary artery disease (CAD) is not completely understood.MethodsThe standard deviation of T‐wave morphology dispersion (TMD‐SD), of QRST angle (QRSTA‐SD), and of T‐wave area dispersion (TW‐Ad‐SD) were analyzed on beat‐to‐beat basis from 10 min period of the baseline electrocardiographic recording in ARTEMIS study patients with angiographically verified CAD.ResultsAfter on average of 8.6 ± 2.3 years of follow‐up, a total of 66 of the 1,678 present study subjects (3.9%) had experienced SCD or were resuscitated from sudden cardiac arrest (SCA). TMD‐SD was most closely associated with the risk for SCD and was significantly higher in patients who had experienced SCD/SCA compared with those who remained alive (3.61 ± 2.83 vs. 2.64 ± 2.52, p = .008, respectively), but did not differ significantly between the patients who had experienced non‐SCD (n = 71, 4.2%) and those who remained alive (3.20 ± 2.73 vs. 2.65 ± 2.53, p = .077, respectively) or between the patients who succumbed to non‐cardiac death (n = 164, 9.8%) and those who stayed alive (2.64 ± 2.17 vs. 2.68 ± 2.58, p = .853). After adjustments with relevant clinical risk indicators of SCD/SCA, TMD‐SD still predicted SCD/SCA (HR 1.107, 95% CIs 1.035–1.185, p = .003).ConclusionsTemporal variability of electrocardiographic spatial heterogeneity of repolarization represented by TMD‐SD independently predicts long‐term risk of SCD/SCA in patients with CAD.     

The prognostic significance of T‐wave inversion according to ECG lead group during long‐term follow‐up in the general population

BackgroundInverted T waves in the electrocardiogram (ECG) have been associated with coronary heart disease (CHD) and mortality. The pathophysiology and prognostic significance of T‐wave inversion may differ between different anatomical lead groups, but scientific data related to this issue is scarce.MethodsA representative sample of Finnish subjects (n = 6,354) aged over 30 years underwent a health examination including a 12‐lead ECG in the Health 2000 survey. ECGs with T‐wave inversions were divided into three anatomical lead groups (anterior, lateral, and inferior) and were compared to ECGs with no pathological T‐wave inversions in multivariable‐adjusted Fine–Gray and Cox regression hazard models using CHD and mortality as endpoints.ResultsThe follow‐up for both CHD and mortality lasted approximately fifteen years (median value with interquartile ranges between 14.9 and 15.3). In multivariate‐adjusted models, anterior and lateral (but not inferior) T‐wave inversions associated with increased risk of CHD (HR: 2.37 [95% confidence interval 1.20–4.68] and 1.65 [1.27–2.15], respectively). In multivariable analyses, only lateral T‐wave inversions associated with increased risk of mortality in the entire study population (HR 1.51 [1.26–1.81]) as well as among individuals with no CHD at baseline (HR 1.59 [1.29–1.96]).ConclusionsThe prognostic information of inverted T waves differs between anatomical lead groups. T‐wave inversion in the anterior and lateral lead groups is independently associated with the risk of CHD, and lateral T‐wave inversion is also associated with increased risk of mortality. Inverted T wave in the inferior lead group proved to be a benign phenomenon.     

Longitudinal association between cognitive depressive symptoms and D‐dimer levels in patients following acute myocardial infarction

BackgroundA prothrombotic tendency could partially explain the poor prognosis of patients with coronary heart disease and depression. We hypothesized that cognitive depressive symptoms are positively associated with the coagulation activation marker D‐dimer throughout the first year after myocardial infarction (MI).MethodsPatients with acute MI (mean age 60 years, 85% men) were investigated at hospital admission (n = 190), 3 months (n = 154) and 12 months (n = 106). Random linear mixed regression models were used to evaluate the relation between cognitive depressive symptoms, assessed with the Beck depression inventory (BDI), and changes in plasma D‐dimer levels. Demographics, cardiac disease severity, medical comorbidity, depression history, medication, health behaviors, and stress hormones were considered for analyses.ResultsThe prevalence of clinical depressive symptoms (13‐item BDI score ≥ 6) was 13.2% at admission and stable across time. Both continuous (p < .05) and categorical (p < .010) cognitive depressive symptoms were related to higher D‐dimer levels over time, independent of covariates. Indicating clinical relevance, D‐dimer was 73 ng/ml higher in patients with a BDI score ≥ 6 versus those with a score < 6. There was a cognitive depressive symptom‐by‐cortisol interaction (p < .05) with a positive association between cognitive depressive symptoms and D‐dimer when cortisol levels were high (p < .010), but not when cortisol levels were low (p > .05). Fluctuations (up and down) of cognitive depressive symptoms and D‐dimer from one investigation to the next showed also significant associations (p < .05).ConclusionsCognitive depressive symptoms were independently associated with hypercoagulability in patients up to 1 year after MI. Hypothalamic–pituitary–adrenal axis could potentially modify this effect.     

Clinical predictors for bradycardia and supraventricular tachycardia necessitating therapy in patients with unexplained syncope monitored by insertable cardiac monitor

BackgroundInsertable cardiac monitors (ICMs) improve diagnostic yield in patients with unexplained syncope. The most of cardiac syncope is arrhythmic causes include paroxysmal bradycardia and supraventricular tachycardia (SVT) in patients with unexplained syncope receiving ICM. Predictors for bradycardia and SVT that necessitate therapy in patients with unexplained syncope are not well known.HypothesisThis study aimed to investigate predictors of bradycardia and SVT necessitating therapy in patients with unexplained syncope receiving ICMs.MethodsWe retrospectively reviewed medical records of consecutive patients who received ICMs to monitor unexplained syncope. We performed Cox''s stepwise logistic regression analysis to identify significant independent predictors for bradycardia and SVT.ResultsOne hundred thirty‐two patients received ICMs to monitor unexplained syncope. During the 17‐month follow‐up period, 19 patients (14%) needed pacemaker therapy for bradycardia; 8 patients (6%) received catheter ablation for SVT. The total estimated diagnostic rates were 34% and 48% at 1 and 2 years, respectively. Stepwise logistic regression analysis indicated that syncope during effort (odds ratio [OR] = 3.41; 95% confidence interval [CI], 1.21 to 9.6; p = .02) was an independent predictor for bradycardia. Palpitation before syncope (OR = 9.46; 95% CI, 1.78 to 50.10; p = .008) and history of atrial fibrillation (OR = 10.1; 95% CI, 1.96 to 52.45; p = .006) were identified as significant independent predictors for SVT.ConclusionSyncope during effort, and palpitations or history of atrial fibrillation were independent predictors for bradycardia and for SVT. ICMs are useful devices for diagnosing unexplained syncope.     

Acute cardiovascular hospitalizations and illness severity before and during the COVID‐19 pandemic

BackgroundCardiovascular disease (CVD) hospitalizations declined worldwide during the COVID‐19 pandemic. It is unclear how shelter‐in‐place orders affected acute CVD hospitalizations, illness severity, and outcomes.HypothesisCOVID‐19 pandemic was associated with reduced acute CVD hospitalizations (heart failure [HF], acute coronary syndrome [ACS], and stroke [CVA]), and worse HF illness severity.MethodsWe compared acute CVD hospitalizations at Duke University Health System before and after North Carolina''s shelter‐in‐place order (January 1–March 29 vs. March 30–August 31), and used parallel comparison cohorts from 2019. We explored illness severity among admitted HF patients using ADHERE (“high risk”: >2 points) and GWTG‐HF (“>10%”: >57 points) in‐hospital mortality risk scores, as well as echocardiography‐derived parameters.ResultsComparing hospitalizations during January 1–March 29 (N = 1618) vs. March 30–August 31 (N = 2501) in 2020, mean daily CVD hospitalizations decreased (18.2 vs. 16.1 per day, p = .0036), with decreased length of stay (8.4 vs. 7.5 days, p = .0081) and no change in in‐hospital mortality (4.7 vs. 5.3%, p = .41). HF hospitalizations decreased (9.0 vs. 7.7 per day, p = .0019), with higher ADHERE (“high risk”: 2.5 vs. 4.5%; p = .030), but unchanged GWTG‐HF (“>10%”: 5.3 vs. 4.6%; p = .45), risk groups. Mean LVEF was lower (39.0 vs. 37.2%, p = .034), with higher mean LV mass (262.4 vs. 276.6 g, p = .014).ConclusionsCVD hospitalizations, HF illness severity, and echocardiography measures did not change between admission periods in 2019. Evaluating short‐term data, the COVID‐19 shelter‐in‐place order was associated with reductions in acute CVD hospitalizations, particularly HF, with no significant increase in in‐hospital mortality and only minor differences in HF illness severity.     

The prognostic significance of electrocardiography findings in patients with coronavirus disease 2019: A retrospective study

BackgroundCoronavirus disease 2019 (COVID‐19) has reached a pandemic level. Cardiac injury is not uncommon among COVID‐19 patients. We sought to describe the electrocardiographic characteristics and to identify the prognostic significance of electrocardiography (ECG) findings of patients with COVID‐19.HypothesisECG abnormality was associated with higher risk of death.MethodsConsecutive patients with laboratory‐confirmed COVID‐19 and definite in‐hospital outcome were retrospectively included. Demographic characteristics and clinical data were extracted from medical record. Initial ECGs at admission or during hospitalization were reviewed. A point‐based scoring system of abnormal ECG findings was formed, in which 1 point each was assigned for the presence of axis deviation, arrhythmias, atrioventricular block, conduction tissue disease, QTc interval prolongation, pathological Q wave, ST‐segment change, and T‐wave change. The association between abnormal ECG scores and in‐hospital mortality was assessed in multivariable Cox regression models.ResultsA total of 306 patients (mean 62.84 ± 14.69 years old, 48.0% male) were included. T‐wave change (31.7%), QTc interval prolongation (30.1%), and arrhythmias (16.3%) were three most common found ECG abnormalities. 30 (9.80%) patients died during hospitalization. Abnormal ECG scores were significantly higher among non‐survivors (median 2 points vs 1 point, p < 0.001). The risk of in‐hospital death increased by a factor of 1.478 (HR 1.478, 95% CI 1.131–1.933, p = 0.004) after adjusted by age, comorbidities, cardiac injury and treatments.ConclusionsECG abnormality was common in patients admitted for COVID‐19 and was associated with adverse in‐hospital outcome. In‐hospital mortality risk increased with increasing abnormal ECG scores.     

Long‐term prognosis in patients with non‐type 1 Brugada electrocardiogram: Results from a large Japanese cohort of idiopathic ventricular fibrillation

BackgroundBrugada syndrome (BrS) is diagnosed in patients with ST‐segment elevation with spontaneous, drug‐induced, or fever‐induced type 1 morphology. Prognosis in type 2 or 3 Brugada electrocardiogram (Br‐ECG) patients remains unknown. The purpose of this study is to evaluate long‐term prognosis in non‐type 1 Br‐ECG patients in a large Japanese cohort of idiopathic ventricular fibrillation (The Japan Idiopathic Ventricular Fibrillation Study [J‐IVFS]).MethodsFrom 567 patients with Br‐ECG in J‐IVFS, a total of 28 consecutive non‐type 1 patients who underwent programmed electrical stimulation (PES) (median age: 58 years, all male, previous sustained ventricular tachyarrhythmias [VTs] 1, syncope 11, asymptomatic 16) were enrolled. Cardiac events (CEs: sudden cardiac death or sustained VT/ventricular fibrillation) during the follow‐up period were examined.ResultsDuring a median follow‐up of 136 months, four patients (14%) had CEs. None of patients with PES‐ have experienced CEs. There was no statistically significant clinical risk factor for the development of CEs. Using the Kaplan–Meier method, the event‐free rate significantly decreased in a group with all 3 risk factors (symptom, wide QRS complex in lead V₂, and positive PES) (p = .01).ConclusionsOur study revealed long‐term prognosis in patients with non‐type 1 Br‐ECG. The combination analysis of these risk factors may be useful for the risk stratification of CEs in non‐type 1 Br‐ECG patients. The present study suggests that the patients with all these parameters showed high risk for CEs and need to be carefully followed.     

Electrocardiographic markers of increased risk of sudden cardiac death in patients with COVID‐19 pneumonia

BackgroundLittle is known about the role of ECG markers of increased risk of sudden cardiac death during the acute period of coronavirus disease 2019 ( COVID‐19) pneumonia.ObjectivesTo evaluate ECG markers of sudden cardiac death on admission, including the index of cardiac electrophysiological balance (iCEB) (QTc/QRS) and transmural dispersion of repolarization (TDR) (T from peak to end (Tp‐e) interval and Tp‐e/QTc), in patients with COVID‐19 pneumonia.Patients and methodsThis cross‐sectional study included 63 patients with newly diagnosed COVID‐19 pneumonia who presented to the outpatient clinic or admitted to the respiratory care unit between August 20 and September 15, 2020. Forty‐six persons matched for sex and age were selected from data collected before COVID‐19 pandemic.ResultsQRS and QTc showed a significant prolongation in patients with COVID‐19 pneumonia compared to the controls (87 vs. 78, p < .00, and 429 versus. 400, p < .00, respectively). After categorization of patients with COVID‐19 pneumonia into 3 groups according to the severity of pneumonia as mild‐moderate, severe, and critical groups, a decreased values of QRS were observed in the critical COVID‐19 pneumonia group compared to severe and mild‐moderate COVID‐19 pneumonia groups (p = .04) while increased values of QTc and iCEB(QTc/QRS) were noted in critical COVID‐19 pneumonia group compared to other 2 groups(p < .00).ConclusionsPatients with COVID‐19 pneumonia showed significant changes in repolarization and conduction parameters compared to controls. Patients with mild to severe COVID‐19 pneumonia may be at low risk for torsades de pointes development.     

Prognostic implications of ST‐segment elevation in lead aVR in patients with acute coronary syndrome: A meta‐analysis

BackgroundST‐segment elevation (STE) in lead aVR is a useful tool in recognizing patients with left main or left anterior descending coronary obstruction during acute coronary syndrome (ACS). The prognostic implication of STE in lead aVR on outcomes has not been established.MethodsWe performed a systematic search for clinical studies about STE in lead aVR in four databases including PubMed, EMBASE, Cochrane Library, and Web of Science. Primary outcome was in‐hospital mortality. Secondary outcomes included in‐hospital (re)infarction, in‐hospital heart failure, and 90‐day mortality.ResultsWe included 7 studies with a total of 7,700 patients. The all‐cause in‐hospital mortality of patients with STE in lead aVR during ACS was significantly higher than that of patients without STE (OR: 4.37, 95% CI 1.63 to 11.68, p = .003). Patients with greater STE (>0.1 mV) in lead aVR had a higher in‐hospital mortality when compared to lower STE (0.05–0.1 mV) (OR: 2.00, 95% CI 1.11–3.60, p = .02), However, STE in aVR was not independently associated with in‐hospital mortality in ACS patients (OR: 2.72, 95% CI 0.85–8.63, p = .09). The incidence of in‐hospital myocardial (re)infarction (OR: 2.77, 95% CI 1.30–5.94, p = .009), in‐hospital heart failure (OR: 2.62, 95% CI 1.06–6.50, p = .04), and 90‐day mortality (OR: 10.19, 95% CI 5.27–19.71, p < .00001) was also noted to be higher in patients STE in lead aVR.ConclusionsThis contemporary meta‐analysis shows STE in lead aVR is a poor prognostic marker in patients with ACS with higher in‐hospital mortality, reinfarction, heart failure and 90‐day mortality. Greater magnitude of STE portends worse prognosis. Further studies are needed to establish an independent predictive role of STE in aVR for these adverse outcomes.     

Automatically assessed P‐wave predicts cardiac events independently of left atrial enlargement in patients with cardiovascular risks: The Japan Morning Surge‐Home Blood Pressure Study

A prolonged P‐wave in electrocardiography (ECG) reflects atrial remodeling and predicts the development of atrial fibrillation (AF). The authors enrolled 810 subjects in the Japan Morning Surge Home Blood Pressure (J‐HOP) study who had ≥1 cardiovascular (CV) risk factor. The duration of P‐wave was automatically analyzed by standard 12‐lead electrocardiogram. Left atrial (LA) enlargement and left ventricular hypertrophy (LVH) were measured on echocardiography. The primary end points were fatal/nonfatal cardiac events: myocardial infarction, sudden death, and hospitalization for heart failure. The maximum P‐wave duration (Pmax) from the 12 leads was selected for analysis. The authors compared four prolonged P‐wave cutoffs (Pmax = 120, 130, 140, 150 ms) and cardiac events. LA diameter and left ventricular mass index (LVMI) were significantly associated with Pmax (r = 0.08, P = .02 and r = 0.17, P < .001, respectively). When the cutoff level was Pmax 120 or 130 ms, prolonged P‐wave was not associated with cardiac events (P = .45 and P = .10), but when a prolonged P‐wave was defined as Pmax ≥ 140 ms (n = 50) or Pmax ≥ 150 ms (n = 19), the patients in those groups had significantly higher incidence of cardiac events than others (P < .001 and P = .03). A Cox proportional hazards model including age, gender, body mass index, smoking, regular drinker, hypertension, dyslipidemia, diabetes, office systolic blood pressure, heart rate, LA enlargement, and LVH revealed that prolonged P‐wave defined as Pmax ≥ 140 ms was independently associated with cardiac events (hazard ratio: 4.23; 95% confidence interval: 1.30–13.77; P = .02). In conclusion, the automatically assessed prolonged P‐wave was associated with cardiac events independently of LA enlargement and LVH in Japanese patients with CV risks.     

Viral epidemiology and SARS‐CoV‐2 co‐infections with other respiratory viruses during the first COVID‐19 wave in Paris,France

ObjectivesOur work assessed the prevalence of co‐infections in patients with SARS‐CoV‐2.MethodsAll patients hospitalized in a Parisian hospital during the first wave of COVID‐19 were tested by multiplex PCR if they presented ILI symptoms.ResultsA total of 806 patients (21%) were positive for SARS‐CoV‐2, 755 (20%) were positive for other respiratory viruses. Among the SARS‐CoV‐2‐positive patients, 49 (6%) had viral co‐infections. They presented similar age, symptoms, except for fever (P = .013) and headaches (P = .048), than single SARS‐CoV‐2 infections.ConclusionsSARS‐CoV‐2‐infected patients presenting viral co‐infections had similar clinical characteristics and prognosis than patients solely infected with SARS‐CoV‐2.     

Proenkephalin and the risk of new‐onset heart failure: data from prevention of renal and vascular end‐stage disease

BackgroundEnkephalins of the opioid system exert several cardiorenal effects. Proenkephalin (PENK), a stable surrogate, is associated with heart failure (HF) development after myocardial infarction and worse cardiorenal function and prognosis in patients with HF. The association between plasma PENK concentrations and new‐onset HF in the general population remains to be established.HypothesisWe hypothesized that plasma PENK concentrations are associated with new‐onset HF in the general population.MethodsWe included 6677 participants from the prevention of renal and vascular end‐stage disease study and investigated determinants of PENK concentrations and their association with new‐onset HF (both reduced [HFrEF] and preserved ejection fraction [HFpEF]).ResultsMedian PENK concentrations were 52.7 (45.1–61.9) pmol/L. Higher PENK concentrations were associated with poorer renal function and higher NT‐proBNP concentrations. The main determinants of higher PENK concentrations were lower estimated glomerular filtration rate (eGFR), lower urinary creatinine excretion, and lower body mass index (all p < .001). After a median 8.3 (7.8–8.8) years follow‐up, 221 participants developed HF; 127 HFrEF and 94 HFpEF. PENK concentrations were higher in subjects who developed HF compared with those who did not, 56.2 (45.2–67.6) versus 52.7 (45.1–61.6) pmol/L, respectively (p = .003). In competing‐risk analyses, higher PENK concentrations were associated with higher risk of new‐onset HF (hazard ratio [HR] = 2.09[1.47–2.97], p < .001), including both HFrEF (HR = 2.31[1.48–3.61], p < .001) and HFpEF (HR = 1.74[1.02–2.96], p = .042). These associations were, however, lost after adjustment for eGFR.ConclusionsIn the general population, higher PENK concentrations were associated with lower eGFR and higher NT‐proBNP concentrations. Higher PENK concentrations were not independently associated with new‐onset HFrEF and HFpEF and mainly confounded by eGFR.     

Impact of P‐wave indices in prediction of atrial fibrillation—Insight from loop recorder analysis

BackgroundSeveral P‐wave indices are associated with the development of atrial fibrillation (AF). However, previous studies have been limited in their ability to reliably diagnose episodes of AF. Implantable loop recorders allow long‐term, continuous, and therefore more reliable detection of AF.HypothesisThe aim of this study is to identify and evaluate ECG parameters for predicting AF by analyzing patients with loop recorders.MethodsThis study included 366 patients (mean age 62 ± 16 years, mean LVEF 61 ± 6%, 175 women) without AF who underwent loop recorder implantation between 2010–2020. Patients were followed up on a 3 monthly outpatient interval.ResultsDuring a follow‐up of 627 ± 409 days, 75 patients (20%) reached the primary study end point (first detection of AF). Independent predictors of AF were as follows: age ≥68 years (hazard risk [HR], 2.66; 95% confidence interval [CI], 1.668–4.235; p < .001), P‐wave amplitude in II <0.1 mV (HR, 2.11; 95% CI, 1.298–3.441; p = .003), P‐wave terminal force in V₁ ≤ −4000 µV × ms (HR, 5.3; 95% CI, 3.249–8.636; p < .001, and advanced interatrial block (HR, 5.01; 95% CI, 2.638–9.528; p < .001). Our risk stratification model based on these independent predictors separated patients into 4 groups with high (70%), intermediate high (41%), intermediate low (18%), and low (4%) rates of AF.ConclusionsOur study indicated that P‐wave indices are suitable for predicting AF episodes. Furthermore, it is possible to stratify patients into risk groups for AF using simple ECG parameters, which is particularly important for patients with cryptogenic stroke.     

Relation of atrial electromechanical delay to P‐wave dispersion on surface ECG using vector velocity imaging in patients with hypertrophic cardiomyopathy

ObjectivesHeterogeneity of structural and electrophysiologic properties of atrial myocardium is common characteristic in hypertrophic cardiomyopathy (HCM). We assessed the dispersion of atrial refractoriness on surface ECG using P‐wave dispersion (PWD) and its relation to atrial electromechanical functions using vector velocity imaging (VVI) in HCM population.MethodsSeventy‐nine HCM patients (mean age: 43.7 ± 13 years, 67% male) were compared with 25 healthy individuals as control. P‐wave durations, P_max and P_min, P‐wave dispersion (PWD), and P terminal force (PTF) were measured from 12‐lead ECG. LA segmental delay (TTP‐d) and dispersion (TTP‐SD) of electromechanical activation were derived from atrial strain rate curves.ResultsHCM patients had longer PR interval, PW duration, higher PWD, PTF, QT_c compared to control (p < .001). HCM patients were classified according to presence of PWD into two groups, group I with PWD > 46 ms (n = 25) and group II PWD ≤ 46 ms (n = 54). Group I showed higher prevalence of female gender, higher PTF, QTc interval, left ventricular outflow tract (LVOT) obstruction, p < .01, LVOT gradient (p < .001), LV mass index (p < .01), E/E'' (p < .01), and severe mitral regurgitation (p < .001). Moreover, PWD was associated with increased atrial electromechanical delay (TTP‐d) and LA mechanical dyssynchrony (TTP‐SD), p < .001. LA segmental delay and dispersion of electromechanical activation were distinctly higher among HCM patient.ConclusionPWD is simple ECG criterion, and it is associated with more severe HCM phenotype and LA electromechanical delay while PTF is linked only to atrial remodeling.     

Association between bicuspid aortic valve phenotype and patterns of valvular dysfunction: A meta‐analysis

BackgroundValvular dysfunction is a common complication in patients with bicuspid aortic valves (BAV). The aim of this study was to determine the relationship between BAV morphology patterns and valve dysfunction.MethodsWe searched the PubMed, The Cochrane Library, Web of Science, and CNKI until May 31, 2020, to identify all studies investigating the morphology of BAV and valvular dysfunction, and data were extracted according to the Preferred Reporting Items for Systematic reviews and Meta‐Analyses (PRISMA). Data were analyzed using Stata 15.1 software. The additional characteristics (gender, mean age) were collected to perform a meta‐regression analysis.ResultsThirteen studies on BAV‐RL (n = 2002) versus BAV‐RN (n = 1254) and raphe (n = 4001) versus without raphe (n = 673) were included. The BAV‐RL patients showed a higher incidence of aortic regurgitation than BAV‐RN patients (OR = 1.46; 95% CI: 1.12 to 1.90, p = .005), while the BAV‐RL patients showed a lower incidence of aortic stenosis than BAV‐RN patients (OR = 0.66, 95% CI: 0.58 to 0.76, p = .000); BAV patients with raphe presents a higher incidence of aortic regurgitation than those without raphe (OR = 1.95, 95% CI: 1.12–3.39, p = .017). No differences were found between raphe and without raphe group in the incidence of aortic stenosis (OR = 0.97, 95% CI: 0.53 to 1.76, p = .907). Mean age and gender had no influence on observed differences.ConclusionsOur results confirmed a relationship between different BAV phenotypes and aortic valve dysfunction. BAV‐RL and BAV with raphe are more likely to develop aortic regurgitation, while patients with BAV‐RN present a higher possibility to develop aortic stenosis.     

Cardiac troponins predict mortality and cardiovascular outcomes in patients with peripheral artery disease: A systematic review and meta‐analysis of adjusted observational studies

BackgroundA significant proportion of patients (pts) with peripheral artery disease (PAD) have concomitant coronary artery disease and polyvascular involvement contributes to increased risk of death and unfavorable cardiovascular events.HypothesisCardiac troponins are associated with adverse cardiovascular outcomes in PAD pts.MethodsWe systematically searched Medline and Scopus to identify all observational cohort studies published before June 2021 (combining terms “troponin,” “peripheral artery disease,” “peripheral arterial disease,” “intermittent claudication,” and “critical limb ischemia”) that evaluated the prognostic impact of troponin rise on admission on all‐cause mortality and/or major cardiovascular events (MACEs; composite of myocardial infarction, stroke, and cardiovascular death) in PAD pts followed up at least 6 months. A meta‐analysis was conducted using the generic inverse variance method. Heterogeneity between studies was investigated using Cochrane''s Q test and I ² statistic.ResultsEight studies were included in the final analysis (5313 pts) with a median follow‐up of 27 months (interquartile range: 12–59 months). The prevalence of troponin positivity was 5.3% (range: 4.4%–8.7%) in pts with intermittent claudication, and 62.6% (range: 33.6%–85%) in critical limb ischemia. Elevated troponins were significantly associated with an increased risk of all‐cause mortality (hazard ratio [HR]: 2.85, 95% confidence interval [CI]: 2.28–3.57; I ² = 50.97%), and MACE (HR: 2.58, 95% CI: 2.04–3.26; I ² = 4.00%) without publication bias (p = .24 and p = .10, respectively).ConclusionTroponin rise on admission is associated with adverse long‐term cardiovascular outcomes in symptomatic PAD.