Renin-Angiotensin-Aldosterone System Inhibitors and Risk of Covid-19
BACKGROUND:There is concern about the potential of an increased risk related to medications that act on the renin-angiotensin-aldosterone system in patients exposed to coronavirus disease 2019 (Covid-19), because the viral receptor is angiotensin-converting enzyme 2 (ACE2). METHODS:We assessed the relation between previous treatment with ACE inhibitors, angiotensin-receptor blockers, beta-blockers, calcium-channel blockers, or thiazide diuretics and the likelihood of a positive or negative result on Covid-19 testing as well as the likelihood of severe illness (defined as intensive care, mechanical ventilation, or death) among patients who tested positive. Using Bayesian methods, we compared outcomes in patients who had been treated with these medications and in untreated patients, overall and in those with hypertension, after propensity-score matching for receipt of each medication class. A difference of at least 10 percentage points was prespecified as a substantial difference. RESULTS:Among 12,594 patients who were tested for Covid-19, a total of 5894 (46.8%) were positive; 1002 of these patients (17.0%) had severe illness. A history of hypertension was present in 4357 patients (34.6%), among whom 2573 (59.1%) had a positive test; 634 of these patients (24.6%) had severe illness. There was no association between any single medication class and an increased likelihood of a positive test. None of the medications examined was associated with a substantial increase in the risk of severe illness among patients who tested positive. CONCLUSIONS:We found no substantial increase in the likelihood of a positive test for Covid-19 or in the risk of severe Covid-19 among patients who tested positive in association with five common classes of antihypertensive medications.
Coronary OCT and Cardiac MRI to Determine Underlying Causes of Minoca in Women [Meeting Abstract]
ASSISTED REPRODUCTIVE TECHNOLOGY IN WOMEN WITH HEART DISEASE [Meeting Abstract]
Response to most of the patients classified under "Myocardial infarction with non-obstructive coronary arteries (MI-NOCA)" have either no MI or no NOCA [Letter]
Spontaneous Coronary Artery Dissection in Patients With a Provisional Diagnosis of Takotsubo Syndrome
Background Takotsubo syndrome (TTS) mimics acute myocardial infarction in the absence of culprit coronary artery disease and is more common in women. Spontaneous coronary artery dissection (SCAD) shares a predilection for women, can result in left ventricular wall motion abnormalities similar to TTS, and may manifest subtle angiographic findings. The aim of this study was to determine the frequency of SCAD misdiagnosed as TTS. Methods and Results Coronary angiograms of patients presenting with a provisional diagnosis of TTS were retrospectively reviewed by an independent expert blinded to left ventriculography and the specific purpose of the study to assess for SCAD. TTS was defined using European Society for Cardiology criteria. SCAD was categorized according to the Saw angiographic classification. Among 80 women with a provisional diagnosis of TTS, 2 (2.5%) met angiographic criteria for definite SCAD. Both dissections were located in the distal left anterior descending coronary artery and classified as type 2b. The wall motion abnormality was apical in both cases. An additional 7 patients (9%) had angiography that was indeterminate for SCAD. Clinical characteristics of patients with and without SCAD were similar. Conclusions Among patients with a provisional diagnosis of TTS, definite SCAD in the left anterior descending coronary arteryÂ was present in 2.5% of cases, and coronary angiography was indeterminate for SCAD in an additional 9%. Careful review ofÂ coronary angiography may avoid missed diagnoses of SCAD in patients with myocardial infarction, nonobstructive coronaryÂ arteries, and wall motion abnormalities consistent with TTS. Intracoronary imaging maybe considered to establish a definitive diagnosis of SCAD when angiography is inconclusive.
Myocardial Injury after Non-Cardiac Surgery: A Systematic Review and Meta-analysis
Myocardial injury after non-cardiac surgery (MINS) is a common post-operative complication associated with adverse cardiovascular outcomes. The purpose of this systematic review was to determine the incidence, clinical features, pathogenesis, management, and outcomes of MINS. We searched PubMed, Embase, Central and Web of Science databases for studies reporting the incidence, clinical features, and prognosis of MINS. Data analysis was performed with a mixed-methods approach, with quantitative analysis of meta-analytic methods for incidence, management, and outcomes, and a qualitative synthesis of the literature to determine associated pre-operative factors and MINS pathogenesis. A total of 195 studies met study inclusion criteria. Among 169 studies reporting outcomes of 530,867 surgeries, the pooled incidence of MINS was 17.9% (95% CI 16.2%-19.6%). Patients with MINS were older, more frequently men, and more likely to have cardiovascular risk factors and known coronary artery disease. Post-operative mortality was higher among patients with MINS than those without MINS, both in-hospital (8.1%, 95% CI 4.4%-12.7% versus 0.4%, 95% CI 0.2%-0.7%; relative risk 8.3, 95% CI 4.2 - 16.6, p<0.001) and at 1-year after surgery (20.6%, 95% CI 15.9%-25.7% versus 5.1%, 95% CI 3.2%-7.4%; relative risk 4.1, 95% CI 3.0 - 5.6, p<0.001). Few studies reported mechanisms of MINS or the medical treatment provided. In conclusion, MINS occurs frequently in clinical practice, is most common in patients with cardiovascular disease and its risk factors, and is associated with increased short- and long-term mortality. Additional investigation is needed to define strategies to prevent MINS and treat patients with this diagnosis.
ST-segment elevation and cardiac magnetic resonance imaging findings in myocardial infarction with non-obstructive coronary arteries
PURPOSE/OBJECTIVE:Patients with myocardial infarction and non-obstructive coronary arteries (MINOCA) may present with or without ST-elevation (STE) on the electrocardiogram (ECG). Previous studies have shown that STE was associated with higher risk of early mortality and long-term major adverse coronary events, and that cardiac magnetic resonance imaging (CMR) can help to determine whether the cause of a MINOCA presentation is ischemic or non-ischemic. We set out to determine the relationship between STE and CMR findings in patients presenting with MINOCA. DESIGN/METHODS:Patients who underwent CMR based on a provisional diagnosis of MINOCA were pooled from three prospective cohort studies: the multicenter Stockholm Myocardial Infarction with Normal Coronaries, a prospective University of Adelaide study, and a prospective NYU School of Medicine diagnostic imaging study. STE was defined as â‰¥1â€¯mm in â‰¥2 contiguous leads. RESULTS:Among 292 patients, average age was 57.0â€¯years (Â±11.9), and 68% were female. Fifty-seven had STE, 231 had no STE and four had left bundle branch block. There was no difference between patients with vs. without STE in the likelihood of the CMR findings of infarction (21% vs. 18%), myocarditis (10% vs. 14%), left ventricular wall motion pattern consistent with takotsubo syndrome on CMR (16% vs. 14%). CONCLUSION/CONCLUSIONS:STE on the presenting ECG was not associated with CMR findings in patients with a provisional diagnosis of MINOCA. Based on these findings, increased risk among MINOCA patients with STE does not appear to be related to variation in these CMR findings.
Hospital Readmission Following Takotsubo Syndrome
Background/UNASSIGNED:Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction with symptoms and ECG changes mimicking acute myocardial infarction (AMI). The objective of the present study was to evaluate in-hospital death and hospital readmission in patients with TTS and to compare outcomes to patients with AMI. Methods/UNASSIGNED:Patients diagnosed with TTS and AMI were identified using the United States Nationwide Readmission Database from 2010-2014. In-hospital outcomes for the index admission, and rates and causes of 30-day readmissions were compared between TTS patients and AMI patients without TS. Results/UNASSIGNED:61,412 patients with TTS and 3,470,011 patients with AMI without TTS were identified. Patients with TTS were younger, more often women (89% vs. 41%), and less likely to have cardiovascular risk factors than AMI patients. Mortality during the index admission was lower in TTS compared to AMI (2.3% vs. 10.2%, pâ€‰<â€‰0.0001). Cardiogenic shock occurred at the same frequency (5.7%) with TTS or AMI. Among TTS survivors, 7,132 patients (11.9%) were readmitted within 30 days, and mortality associated with readmission was 3.5%. The most common reason for readmission after TTS was heart failure (10.6% of readmissions). Conclusions/UNASSIGNED:TTS is associated with substantial morbidity and mortality. Although outcomes are more favorable than AMI, âˆ¼2% of patients died in-hospital and âˆ¼12% of survivors were readmitted within 30-days; heart failure was the most frequent indication for re-hospitalization. Careful outpatient follow-up of TTS patients may be warranted to avoid readmissions. Condensed Abstract/UNASSIGNED:We evaluated in-hospital death and hospital readmission in patients with Takotsubo syndrome (TTS) and compared outcomes to those of patients after acute myocardial infarction (AMI) in the United States using the Nationwide Readmission Database from 2010-2014. Mortality during the index admission was lower with TTS than AMI (2.3% vs. 10.2%, pâ€‰<â€‰0.0001). Readmission within 30 days occurred in 11.9% of TTS survivors associated with 3.5% mortality during readmission. Readmission rates were lower after TTS than AMI (16.7%), pâ€‰<â€‰0.0001 vs. TTS. The most common reason for readmission was heart failure (10.6% of TTS survivors). TTS is associated with substantial morbidity and mortality.
SPONTANEOUS CORONARY ARTERY DISSECTION IN PATIENTS WITH A PROVISIONAL DIAGNOSIS OF TAKOTSUBO SYNDROME [Meeting Abstract]
PREDICTIVE PERFORMANCE OF THE INTERTAK SCORE FOR DIAGNOSIS OF TAKOTSUBO SYNDROME [Meeting Abstract]