SARS-CoV-2 – ABC CARDIOL

IJCS

Review Article

The Role of Platelets in Long COVID Development: A Literature Review

Gabriel Ferreira Lima et al. Lucas Miossi Amanda Gonçalves Jesus Silva Olivia Barros Pedreira Novais Fernanda Carla Ferreira Brito

Abstract

At its peak during the pandemic, coronavirus disease 2019 profoundly impacted global populations and introduced numerous post-infection complications, collectively referred to as long coronavirus disease. The mechanisms underlying the syndrome’s chronicity are multifaceted; however, a notable aspect of long coronavirus disease pathophysiology is its intricate association with platelets. The chronic inflammatory response triggered by severe acute respiratory syndrome coronavirus 2 is closely related to platelet activity, wherein inflammatory molecules bind to specific platelet receptors, inducing the release of platelet granules containing procoagulant and proinflammatory molecules. Consequently, there is a marked elevation in coagulation-related proteins, fostering the development of abnormal microthrombi and a dysfunctional fibrinolytic system. All these changes are indicative of an imbalance in coagulation regulation. Therefore, investigating pharmacological targets linked to this process is crucial for syndrome management, aiming to enhance the quality of life for affected individuals. This review aimed to highlight the importance of platelet function and activity in the pathophysiology of long coronavirus disease, as well as to identify molecular targets directly related to long coronavirus disease or coronavirus disease 2019–related disturbances in platelet homeostasis.

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IJCS

Original Article

A Geoprocessing Approach for Mortality and Social Vulnerability Analysis during the COVID-19 Pandemic

Andres Felipe Valencia Rendon et al. Isabela Mendes Volschan Manoella Novais Pereira Wagner Lima Monteiro … Alessandra de Freitas Pimentel Emilia Matos do Nascimento Basilio de Bragança Pereira Glaucia Maria Moraes de Oliveira

Abstract

Background

Brazil had high COVID-19 lethality/mortality with multiple social inequalities, where color/race was highly relevant, especially in Rio de Janeiro. Therefore, we hypothesize that COVID-19 hospitalized patients with a highly socially vulnerable background would have more significant in-hospital mortality.

Objective

To analyze the socioeconomic factors of social vulnerability and their association with COVID-19 mortality.

Methods

This work was a prospective study of 274 confirmed adult COVID-19 hospitalized patients in the University Hospital of Clementino Fraga Filho (HUCFF). The clinical features/blood chemistry information were collected from the clinical record. The ArcGIS Pro Software (Esri Gis mapping software, Redlands California-US) and a Python-based algorithm were used to determine in-app/in-map variable management relevance to the socioeconomic variables, inequity markers, and vulnerability. Our study also analyzed the transfers from other primary care institutions to our hospital in order to examine its potential delays in advanced medical care. Logistic regression and ROC curve were used to investigate in-hospital mortality for our statistical analysis. The significance level adopted in the statistical analysis was 5% Results: Male sex, total days of hospitalization, age, having more than three comorbidities, intensive care unit (ICU) admission, hemodialysis, and transfer from other hospitals showed statistical significance. Patients living in low-adequate households (p = 0.030) with high in-house individual agglomeration markers (p = 0.017) and transfers from another Primary Health Care (PHC) institution (p = 0.047) were associated with increased in-hospital mortality, with high ICU admission and mechanical ventilation.

Conclusions

In-hospital mortality due to COVID-19 was influenced by social individual background characteristics of vulnerability. Among other clinical parameters, these markers should be considered to predict the likelihood of complications related to the COVID-19 pandemic.

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ABCHF

Original Article

Heart Failure in Children and Adolescents with Covid-19: A Systematic Review of the Literature

Lucas Quaresma Martins et al. Gabriel Ribeiro de Souza Daniel Garcia da Gama Alves Kaylane Fernanda Costa de Melo … Paula Cordeiro Aguiar de Almeida Ádria Rayane Lima Cascaes Antonio Maria Zacarias Araújo Monteiro

Abstract

Background:

Cardiovascular structural/functional changes caused by COVID-19 may be related to the presence of heart failure (HF), especially in children and adolescents, as the SARS-CoV-2 virus invades cardiomyocytes, leading to cardiac dysfunction.

Objective:

To assess the mechanism by which COVID-19 becomes a risk factor for the development of HF in children and adolescents.

Methods:

This was a systematic literature review of articles indexed in PubMed, BVS and SciELO, following the PRISMA recommendations. DeCS/MeSH descriptors were used in the search.

Results:

A total of 685 studies were identified: 418 in Pubmed, 264 in BVS and three in SciELO. After exclusion of 160 duplicate articles, and analysis of titles and abstracts, 14 articles were read in full, and 10 selected for the final sample. All articles were published between 2020 and 2022; there were 10 cohort studies (eight retrospective and two prospective). Six articles addressed the Multisystem Inflammatory Syndrome in Children (MIS-C), and four articles addressed the reduction in left ventricular ejection fraction in COVID-19 patients.

Conclusions:

Most patients recovered without cardiovascular sequelae, although MIS-C may cause severe systemic failure, which led to death in some studies. More research and more comprehensive studies on this theme are warranted.

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ABC

Editorial

Health-related Quality of Life and Long-term Outcomes after Mildly Symptomatic COVID-19: Exploring the Protocol

Lucas Borges Pereira et al. João Paulo Vilela Rodrigues Fabiana Rossi Varallo Leonardo Régis Leira Pereira

The post-COVID-19 condition has been defined by the World Health Organization as a “condition that occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, typically after three months from the onset of COVID-19, with symptoms lasting at least two months and that an alternative diagnosis can not explain.” The primary symptoms associated with this condition include fatigue, muscle and joint pain, shortness of breath, sleep difficulties, mental and neurological symptoms such as depression and anxiety, loss of smell and taste, headache, and difficulty in thinking and concentrating. ^, The cytopathic effect of the virus on the endothelium, along with endothelial damage as a consequence of systemic inflammation, has been associated with cardiovascular events such as myocarditis, myocardial infarction, arrhythmias, and thromboembolic events.

Various studies conducted worldwide have also found evidence of other signs and symptoms. ^– However, the incidence of these symptoms has shown significant variation due to the heterogeneity of the studies. This variation may be associated with factors such as the post-COVID study period, the region where the study was conducted, and the severity of the disease.

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ABC

Original Article

Health-Related Quality of Life and Long-Term Outcomes after Mildly Symptomatic COVID-19: The Post-COVID Brazil Study 2 Protocol

Marciane Maria Rover et al. Geraldine Trott Fernando Luís Scolari Mariana Motta Dias da Silva … Denise de Souza Rosa da Rosa Minho dos Santos Ana Paula Aquistapase Dagnino Juliana de Mesquita Neto Gabriel Pozza Estivalete Amanda Christina Kozesinski-Nakatani Milena Soriano Marcolino Bruna Brandão Barreto Paulo Roberto Schvartzman Ana Carolina Peçanha Antonio Caroline Cabral Robinson Maicon Falavigna Andreia Biolo Carisi Anne Polanczyk Regis Goulart Rosa

Abstract

Background

The long-term effects of mild COVID-19 on physical, cognitive, and mental health are not yet well understood.

Objective

The purpose of this paper is to describe the protocol for the ongoing “Post-COVID Brazil” study 2, which aims to evaluate the factors associated with health-related quality of life and long-term cardiovascular and non-cardiovascular outcomes one year after a mild episode of symptomatic COVID-19.

Methods

The “Post-COVID Brazil” study 2 is a prospective multicenter study that plans to enroll 1047 patients (NCT05197647). Centralized, structured telephone interviews are conducted at 1, 3, 6, 9, and 12 months after COVID-19 diagnosis. The primary outcome is the health-related quality-of-life utility score, assessed using the EuroQol-5D-3L (EQ-5D-3L) questionnaire at 12 months. Secondary endpoints include the EQ-5D-3L at 3, 6, and 9 months, as well as all-cause mortality, major cardiovascular events, hospitalization, return to work or education, persistent symptoms, new disabilities in instrumental activities of daily living, cognitive impairment, anxiety, depression, and post-traumatic stress symptoms at 3, 6, 9, and 12 months after SARS-CoV-2 infection. A p-value < 0.05 will be considered statistically significant for all analyses.

Results

The primary endpoint will be presented as the overall frequency of the EQ-5D-3L domains 12 months after SARS-CoV-2 infection. Main analysis will explore the association of independent variables with the study outcomes.

Conclusion

The “Post-COVID Brazil” study 2 aims to clarify the impact of long COVID on the quality of life and cardiovascular and non-cardiovascular outcomes of Brazilian patients who have had mild COVID-19.

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ABC

Original Article

Hydroxychloroquine for Non-Hospitalized COVID-19 Patients: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Rosa Lucchetta et al. Jessica Y. Matuoka Haliton Alves de Oliveira Junior Gustavo Oliveira … Alexandre Biasi Cavalcanti Luciano Azevedo Otavio Berwanger Renato Delascio Lopes Regis Goulart Rosa Viviane Cordeiro Veiga Álvaro Avezum

Abstract

Background:

Previous systematic reviews have identified no benefit of hydroxychloroquine and chloroquine in non-hospitalized COVID-19 patients. After publication of these reviews, the results of COPE, the largest randomized trial conducted to date, became available.

Objectives:

To conduct a systematic review and meta-analyses of randomized clinical trials (RCTs) to synthesize the evidence on the efficacy and safety of hydroxychloroquine and chloroquine for non-hospitalized COVID-19 patients compared to placebo or standard of care.

Methods:

Searches were conducted in PubMed, Embase, The Cochrane Library, and ClinicalTrials.gov complemented by manual search. Pairwise meta-analyses, risk of bias, and evidence certainty assessments were conducted, including optimal information size analysis (OIS). A level of significance of 0.05 was adopted in the meta-analysis. PROSPERO: CRD42021265427.

Results:

Eight RCTs with 3,219 participants were included. COVID-19 hospitalization and any adverse events rates were not significantly different between hydroxychloroquine (5.6% and 35.1%) and control (7.4% and 20.4%) (risk ratio, RR, 0.77, 95% confidence interval, CI, 0.57-1.04, I²: 0%; RR 1.78, 95%-CI 0.90; 3.52, I²: 93%, respectively). The OIS (7,880) was not reached for COVID-19 hospitalization, independently of the simulation for anticipated event rate and RR reduction estimate.

Conclusion:

Evidence of very low certainty showed lack of benefit with hydroxychloroquine in preventing COVID-19 hospitalizations. Despite being the systematic review with the largest number of participants included, the OIS, considering pre-vaccination response to infection, has not yet been reached.

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ABC

Editorial

Post-COVID Dysautonomias: The Importance of Early Recognition and Implementation of Recovery Programs

Denise Hachul et al. Tatiana Almeida Mauricio Scanavacca

The international scientific community has devoted all its efforts over the last three years to a better understanding and treatment of the SARS-COV-2 infection, which initially seemed to be limited to a severe acute respiratory syndrome. However, as time goes by, we are faced with a growing number of patients with multisystemic, persistent, intermittent, or late symptoms, which generate significant psycho-functional impairment of those affected and reveal to us the chronic and unpredictable nature of the disease.

The recognized Post-COVID Syndrome courses with a significant number of complaints described in case reports, population studies, and meta-analyses. Myocarditis, myocardial infarction, stroke, heart failure, arrhythmias, genitourinary, gastrointestinal, endocrinological, central, and peripheral neurological disorders of varying severities have been described in the subacute and chronic phases after contact with the virus.^–

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ABC

Research Letter

Left Ventricular Thrombosis and Pulmonary Thromboembolism in an Asymptomatic Covid-19 Patient

Natalia Lorenzo et al. Veronica Hernandez Alvaro Montes Fernando Rivero … Guillermo Reyes* Rio Aguilar

Research Letter

A 48-year-old-man presented to the emergency room with abdominal pain and vomiting of 12-hour duration. He had a history of porto-splenic venous thrombosis ten years before admission that was treated with 6 months of oral anticoagulation and felt to be due to moderate protein C deficiency, which was not confirmed in subsequent laboratory tests. Vital signs were normal, he was afebrile and no remarkable findings were found on physical examination except for pain on palpation in the left flank. The reverse transcriptase polymerase chain reaction (RT-PCR) test for COVID-19 was negative. Blood tests showed significant elevation of acute phase reactants (c-reactive protein: 138.3 mg/L, fibrinogen > 500mg/dL and leukocites 12.99 10^3/μL). Coagulation parameters where in normal range: phrotrombin time (PT) 12.1 seconds, partial thromboplastin time (PTT) 36.3 seconds, prothrombin activity (PA) 86%, international normalized ratio (INR) 1.08 and platelets 326.000/μL.

The abdominal ultrasound-scan did not show releant findings, so a computed tomography (CT) scan study was completed. CT abdominal scan found multiple infarcts in the right kidney () and isolated in spleen (), furthermore, a filling defect in the left ventricle was observed (). Transthoracic echocardiogram confirmed the presence of a pedunculated hyperechogenic and homogeneous mobile mass (3.1x2cm) with regular borders (, , ), anchored to the middle third of the septum of left ventricle (LV). Anatomy of LV was normal, with normal dimensions and normal ejection fraction without wall motion abnormalities.

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ABCIC

Image

Symptomatic Aortic Mural Thrombus in a Patient With COVID-19

Milton Sérgio Bohatch Júnior et al. Amanda Fernandes Vidal da Silva Marcelo Bellini Dálio Mauricio Serra Ribeiro Edwaldo Edner Joviliano

A 56-year-old male former smoker with a history of diabetes mellitus developed flu-like symptoms (cough, fever, and myalgia) that worsened after nine days (dyspnea and asthenia) sought medical attention in an emergency care unit. He was hospitalized with novel coronavirus (sudden acute respiratory syndrome coronavirus 2) infection confirmed by polymerase chain reaction testing. His condition progressed with sudden pain in the left lower limb, toe coldness and paresthesia without motor changes, and pain in the third finger of the left hand associated with non-fixed cyanosis. The patient was referred to the emergency room of Hospital das Clínicas of Ribeirão Preto with acute arterial occlusion. On evaluation, he presented non-fixed cyanosis in the distal phalanx of the third finger of the left hand with no pulse or neurological changes throughout the limb. The left lower limb presented no pulse of or arterial flow in the anterior and posterior tibial arteries. He underwent urgent thrombectomy (Rutherford class 2A) with thrombus removal, and limb perfusion was restored with pulsatile tibial artery flow. The patient remained on anticoagulant therapy with unfractionated heparin. Computed tomography angioplasty used to analyze the embolism demonstrated mural thrombi at the origin of the left subclavian artery and in the infrarenal aorta (, ). The patient progressed with good arterial condition (resolution of left upper limb non-fixed cyanosis and presence of pulse in the left leg), stayed in the intensive care unit for three days, and was discharged after two days of anticoagulant treatment (rivaroxaban [Xarelto^®]). In outpatient follow-up, he remained asymptomatic and presented no new embolic events, and the mural thrombi resolved completely after one year of anticoagulant therapy (, ).

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ABC

Editorial

How Can the Presence of Cardiovascular Diseases Impact Morbidity and Mortality in Patients with COVID-19?

Alexandre de Matos Soeiro

Since the pandemic’s beginning, the disease caused by the SARS-CoV-2 virus, called COVID-19, has shown itself to be a wide-spectrum and unpredictable condition, with patients being practically asymptomatic. In contrast, others had severe pulmonary involvement, the major cause of morbidity and mortality associated with the disease.^–

At an early stage, COVID-19 was shown to have a broad and potentially alarming link to the cardiovascular system. Angiotensin-2-converting enzyme receptors have been shown to directly interface with viral pathogenesis and maybe the cellular gateway for type 2 pneumocytes, macrophages and cardiomyocytes. Thus, patients with cardiovascular diseases were more susceptible to severe forms of the disease. Hypertension, arrhythmias, cardiomyopathies and coronary artery disease were among the main comorbidities in critically ill patients with COVID-19. Patients with cardiovascular diseases (particularly those with hypertension) have a morbidity rate of up to 10.5% after infection with COVID-19. In the present study, we can observe a similar relationship. It was clear in this Brazilian series how the presence of atherosclerotic disease and traditional risk factors alone or together were capable of impacting mortality and prognosis. Although the study has a limited series, it includes only high-risk patients with a high rate of outcomes, allowing the evaluation of results to be consistent and following exactly the same line as the international literature.

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ABCIC

Original Article

Tricuspid Annular Plane Systolic Excursion and Mitral Annular Systolic Excursion: Correlation with Left Ventricular Diastolic Function

André Américo Bedenko Martins et al. Leonardo Yoshida Osaku Ana Cristina Camarozano Cintia Rocha Fortes de Sá … Daniela de Castro Carmo Jerônimo Antonio Fortunato Rubens Zenóbio Darwich Liz Andréa Villela Baroncini

Abstract

Introduction:

Tricuspid annular plane systolic excursion and mitral annular systolic excursion are parameters used to assess the systolic function of the right ventricle and left ventricle, respectively. Little is known about its relationship with left ventricular diastolic function.

Objective:

To assess whether the values of mitral annular systolic excursion and tricuspid annular plane systolic excursion correlate with parameters used in the evaluation of left ventricular diastolic function.

Method:

Observational cross-sectional study. Two hundred nine individuals were selected, 116 women, with both ventricles normal systolic function. The analyzes were performed for men and women, through Pearson correlation coefficient and Sperman correlation coefficient. Tricuspid annular plane systolic excursion, mitral annular systolic excursion, atrial volumes and left ventricular diastolic function parameters on transthoracic echocardiogram were obtained.

Results:

In women, mitral annular systolic excursion was positively correlated with lateral e ‘(Sperman correlation coefficient of 0.22; p=0.016) and tricuspid annular plane systolic excursion was positively correlated with E / A ratio (Sperman correlation coefficient of 0.23; p=0.037), lateral e’ (Sperman correlation coefficient of 0.28; p=0.012), and septal e’ (Sperman correlation coefficient of 0.28; p=0.012), and negatively with the E/e’ ratio (Pearson correlation coefficient of -0.27; p=0.018), and A wave (Pearson correlation coefficient of -0.29; p=0.009). In men, only mitral annular systolic excursion correlated positively with E wave (Pearson correlation coefficient of 0.21; p=0.037), lateral e’ (Sperman correlation coefficient of 0.34; p <0.001) and the septal e’ (Sperman correlation coefficient of 0.26; p=0.008). There was no correlation between mitral annular systolic excursion and tricuspid annular plane systolic excursion and atrial volumes. Hypertension and diabetes mellitus influenced tricuspid annular plane systolic excursion and mitral annular systolic excursion values correlated to E and A waves, E/A ratio, septal and lateral e’ waves, and E/e’ ratio.

Conclusion:

In the present study, mitral annular systolic excursion and tricuspid annular plane systolic excursion values showed a significant correlation with some parameters of left ventricular diastolic function, with stronger evidence on female sex.

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ABCIC

Artigo Original

Right Ventricular Outflow Tract Acceleration Time: Correlation with Left Ventricular Diastolic Function, Sex, And Age

Renan Macedo Coimbra et al. Ana Cristina Camarozano Cintia Rocha Fortes de Sá Daniela de Castro Carmo … Jerônimo Antonio Fortunato Rubens Zenóbio Darwich Liz Andréa Villela Baroncini

Abstract

Background:

Pulmonary artery acceleration time (PAAT) can be used as a parameter in the evaluation of pulmonary hypertension and aids left ventricular diastolic function (LVDF) analyses.

Objective:

To assess whether there is a correlation between PAAT and LVDF parameters in individuals with a preserved left ventricular systolic function and by sex, age, and cardiovascular risk factors.

Methods:

Observational cross-sectional study. One hundred nineteen patients were selected (59 women [49.6%]). The subjects underwent transthoracic echocardiography including measurements of PAAT, E and A waves and E/A ratio, e’ septal and e’ lateral waves and E/e’ ratio, pulmonary artery systolic pressure (PASP), and left atrial volume.

Results:

In female patients, a positive correlation (Spearman’s correlation coefficient – Spearman correlation coefficient [SCC]) was found between the PAAT value and the lateral e’ (SCC, 0.47; p = 0.002), with the E/A ratio (SCC, 0.32; p = 0.04), and with septal e’ (SCC, 0.36; p = 0.023), and a negative correlation between PAAT and PASP (SCC, -0.43; p = 0.034). In men, no correlation was found between PAAT and any parameters. Lower PAAT values were found in women with systemic arterial hypertension (hypertension) than in women without hypertension (0.13 ± 0.03 s versus 0.16 ± 0.03 s; p = 0.015).

Conclusion:

The present study showed a significant correlation between PAAT and some LVDF parameters in female patients only. Hypertension was correlated with lower PAAT values in women.

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ABCIC

Original Article

Transthoracic Echocardiography Findings of Hospitalized Patients with COVID-19: Results from the Brazilian Echocardiography Registry During the COVID-19 Pandemic (ECOVID)

Silvio Henrique Barberato et al. Rafael Borsoi Fabio Roston Hudson Laerte Machado Miranda … Pedro Patriota Maria Estefânia Bosco Otto Adenalva Lima de Souza Beck Anderson da Costa Armstrong João Marcos Bemfica Barbosa Ana Cristina Camarozano Wermellinger Letícia Braga Paciello da Silva Marcos Valério Coimbra Resende Marcelo Luiz Campos Vieira Marcelo Miglioranza Miguel Morita Fernandes da Silva

Abstract

Background

Transthoracic echocardiography (TTE) may play a crucial role in the evaluation of cardiac manifestations of coronavirus disease 2019 (COVID-19).

Objective

We aimed to report the prevalence of the main echocardiographic abnormalities of hospitalized COVID-19 patients.

Methods

We performed a prospective multicenter observational study in patients with COVID-19 who underwent TTE during hospitalization. Patients with pre-existing heart failure, coronary artery disease, or atrial fibrillation were categorized as having previous cardiovascular disease (CVD). Clinical and echocardiographic data about cardiac structure and function were collected.

Results

We evaluated 310 patients with COVID-19 (mean age, 62±16 years; 61% men; 53% with arterial hypertension; 33% with diabetes; and 23% with previous CVD). Overall, 65% of the patients required intensive care unit support. The most prevalent echocardiographic abnormalities were LV hypertrophy (29%), pulmonary hypertension (25%), left ventricular (LV) systolic dysfunction (16.5%), right ventricular (RV) systolic dysfunction (15.9%), grade II/III LV diastolic dysfunction (11%), and LV regional wall motion abnormality (11%). Pericardial effusion was uncommon (7% of cases). LV hypertrophy (25% vs. 45%, p=0.001), LV systolic dysfunction (11% vs. 36%, p<0.001), regional wall motion abnormalities (6% vs. 29%, p<0.001), grade II/III LV diastolic dysfunction (9% vs. 19%, p=0.03), and pulmonary hypertension (22% vs. 36%, p=0.019) were less common in patients without previous CVD. RV systolic dysfunction occurred at similar frequencies in patients with versus without previous CVD (13% vs. 25%, p=0.07).

Conclusions

Among patients hospitalized with COVID-19, abnormal echocardiographic findings were common, but less so among those without previous CVD. RV systolic dysfunction appeared to affect similar proportions of patients with versus without previous CVD.

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ABC

Original Article

Rationale and Design of the COVID-19 Outpatient Prevention Evaluation (COPE – Coalition V) Randomized Clinical Trial: Hydroxychloroquine vs. Placebo in Non-Hospitalized Patients

Haliton Alves de Oliveira Junior et al. Cleusa P. Ferri Icaro Boszczowski Gustavo B. F. Oliveira … Alexandre B. Cavalcanti Regis G. Rosa Renato D. Lopes Luciano C. P. Azevedo Viviane C. Veiga Otavio Berwanger Álvaro Avezum

Abstract

Background

Despite the need for targeting specific therapeutic options for coronavirus disease 2019 (COVID-19), there has been no evidence of effectiveness of any specific treatment for the outpatient clinical setting. There are few randomized studies evaluating hydroxychloroquine (HCQ) in non-hospitalized patients. These studies indicate no benefit from the use of HCQ, but they assessed different primary outcomes and presented important biases for outcome evaluation.

Objective

To evaluate if HCQ may prevent hospitalization due to COVID-19 compared to a matching placebo.

Methods

The COVID-19 Outpatient Prevention Evaluation (COPE) study is a pragmatic, randomized, double-blind, placebo-controlled clinical trial evaluating the use of HCQ (800 mg on day 1 and 400 mg from day 2 to day 7) or matching placebo for the prevention of hospitalization due to COVID-19 in early non-hospitalized confirmed or suspected cases. Inclusion criteria are adults (≥ 18 years) seeking medical care with mild symptoms of COVID-19, with randomization ≤ 7 days after symptom onset, without indication of hospitalization at study screening, and with at least one risk factor for complication (> 65 years; hypertension; diabetes mellitus; asthma; chronic obstructive pulmonary disease or other chronic lung diseases; smoking; immunosuppression; or obesity). All hypothesis tests will be two-sided. A p-value < 0.05 will be considered statistically significant in all analyses. Clinicaltrials.gov: NCT04466540.

Results

Clinical outcomes will be centrally adjudicated by an independent clinical event committee blinded to the assigned treatment groups. The primary efficacy endpoint will be assessed following the intention-to-treat principle.

Conclusion

This study has the potential to reliably answer the scientific question of HCQ use in outpatients with COVID-19. To our knowledge, this is the largest trial evaluating HCQ in non-hospitalized individuals with COVID-19.

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IJCS

Editorial

Cause or Consequence? What is the Relationship between Cardiac Injury and COVID-19 Severity?

Claudio Tinoco Mesquita

In most patients, coronavirus disease-2019 (COVID-19) causes minor respiratory symptoms or even no symptoms. SARS-CoV-2 infection can also cause extrapulmonary manifestations and complications. COVID-19 is more severe and fatal among patients with pre-existing cardiovascular risk factors or diseases. Increases in cardiac troponin (cTn) are indicative of myocardial injury and frequently found in patients with COVID-19. The Chinese Center for Disease Control and Prevention published a survey demonstrating that among patients diagnosed with COVID-19, 13% had hypertension, 5% had diabetes mellitus, and 4% had a history of cardiovascular disease. However, in this same cohort, among patients who had not survived, 40% had hypertension, 20% had diabetes, and 22% had pre-existing cardiovascular disease. Patients with cardiovascular disease had the highest case fatality rate (10.5%).

In this issue of the International Journal of Cardiovascular Sciences, Rocha et al. , studied 192 patients admitted with COVID-19 in a quaternary care cardiac hospital in Rio de Janeiro, Brazil. Mortality rate was 28%. Multivariate analysis demonstrated that elevated cTnI levels (OR=9.504; 95% CI=1.281–70.528; P=0.028) upon admission and the need for mechanical ventilation during hospitalization (OR=46.691; 95% CI=2.360–923.706; P=0.012) were independent predictors of death during hospitalization. The main limitations of the study are a sample from a single Brazilian metropolitan region and a short follow-up period. However, these limitations do not invalidate the main message of the study: the measurement of cardiac troponin at hospital admission may be useful for identification of high-risk patients infected by SARS-CoV-2.

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ABCIC

Original Article

Analysis of the maintenance process and useful life of echocardiography equipment: An experience in a teaching hospital

Gabriel Peres Mazzoni et al. André Timóteo Sapalo André Schmidt Benedito Carlos Maciel Minna Moreira Dias Romano

Abstract

Introduction

Echocardiography is a diagnostic tool that is increasingly used in clinical practice in different medical scenarios; however, the preventive (PM) or corrective maintenance (CM) care and processes for this equipment are still poorly standardized. To describe the maintenance process currently implemented for echocardiographic equipment (ECHO) in a medium-sized laboratory in a tertiary-level public teaching hospital. The description of the process includes damage characterization and MP and MC implementation.

Methods

This was a descriptive and exploratory single-center observational study. Data on the maintenance process of echocardiographic equipment were obtained from electronic files from the hospital’s equipment management system between 2003 and 2018.

Results

Together with the description of the equipment maintenance process, the ten most common types of malfunctions were identified, including software (23.8%), parts (23.1%), and power outage and accessory damage (13.8%). The implementation of the PM process significantly decreased the maintenance costs (USD 44,472.10 vs USD 25,807.59, p = 0.029). Even after the MP, the CM costs related to transesophageal echocardiography equipment (TEE) (USD 7,789.17) were higher than those with other equipment modalities (USD 3,184.37 for transthoracic echocardiography equipment (TTE) and USD 1,813.00 for stress testing).

Conclusion

The maintenance process for ECHO equipment was described. ECHO equipment damage has high costs, especially in special modalities such as TEE. PM significantly reduced maintenance costs.

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ABC

Research Letter

SARS-CoV-2 and Myocardical Injury with ST-Elevation without Coronary Disease

Carolina Ragonetti et al. Enzo Oku Martinazzo Felipe Montesano Fazionato Guilherme Osório Guimarães Ferreira … Milena Piccolo Santana Camila Hartmann

Introduction

Throughout the SARS-CoV-2 pandemic, there have been reports of infection leading to acute myocardial injury, causing worse clinical outcomes. The manifestations can include troponin elevation, imaging exam abnormalities and electrocardiographic changes. Accordingly, ST-segment elevation (STE) acute myocardial injury has been observed in some patients. However, despite the electrocardiogram (ECG) ischemic changes, complementary exams may not show any obstruction, excluding coronary occlusion as the cause of the injury.

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IJCS

Original Article

Predictive Value of Myocardial injury in Patients with COVID-19 Admitted to a Quaternary Hospital in the City of Rio de Janeiro

Antônio Sérgio Cordeiro da Rocha et al. Andre Volschan Luiz Antonio Almeida Campos Roberta Pereira dos Santos Coelho … Dominique Cardoso de Almeida Thielmann Carlos Augusto Lobbe Cotta Ferreira Alexandre Siciliano Colafranceschi

Abstract

Background

In Brazil the factors involved in the risk of death in patients with COVID-19 have not been well established.

Objective

To analyze whether elevations of high-sensitivity troponin I (hTnI) levels influence the mortality of patients with COVID-19.

Methods

Clinical and laboratory characteristics of hospitalized patients with COVID-19 were collected upon hospital admission. Univariate and binary logistic regression analyzes were performed to assess the factors that influence mortality. P-value<0.05 was considered significant.

Results

This study analyzed192 patients who received hospital admission between March 16 and June 2, 2020 and who were discharged or died by July 2, 2020. The mean age was 70±15 years, 80 (41.7%) of whom were women. In comparison to those who were discharged, the 54 (28.1%) who died were older (79±12 vs 66±15years; P=0.004), and with a higher Charlson´s index (5±2 vs 3±2; P=0.027). More patients, aged≥60years (P 1 (P=0.004), lung injury>50% in chest computed tomography (P=0.011), with previous coronary artery disease (P=0.037), hypertension (P=0.033), stroke (P=0.008), heart failure (P=0.002), lymphocytopenia (P=0.024), high D-dimer (P=0.024), high INR (P=0.003), hTnI (P<0.0001), high creatinine (P<0.0001), invasive mechanical ventilation (P<0.0001), renal replacement therapy (P<0.0001), vasoactive amine (P<0.0001), and transfer to the ICU (P=0.001), died when compared to those who were discharged. In logistic regression analysis, elevated hTnI levels (OR=9.504; 95% CI=1.281–70.528; P=0.028) upon admission, and the need for mechanical ventilation during hospitalization (OR=46.691; 95% CI=2.360–923.706; P=0.012) increased the chance of in-hospital mortality.

Conclusion

This study suggests that in COVID-19 disease, myocardial injury upon hospital admission is a harbinger of poor prognosis.

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IJCS

Editorial

COVID-19: An Insult to Injury on Equity

Biljana Parapid et al. Rachel M. Bond

SARS-CoV-2, which causes COVID-19, created a pandemic that not only overwhelmed the world in December 2019, but also challenged humanity in every way.

While a significant portion of the global population remained in a standstill, waiting for an end and adapting to limits of all sorts, including working from home, a new workforce category emerged: the “frontline” workers. Doctors, nurses, and all allied professions employed by the healthcare system were joined by a long line of diverse service providers. The latter faced different forms of discrimination from their surroundings, fearing the risk of infection based on high rates of medical misinformation; for the former group, Pandora’s box of bias was yet to be opened, in particular for women.

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Research Letter

Changes in the Profile of Emergency Room Patients during the COVID-19 Outbreak in a General Hospital Specialized in Cardiovascular Care in Brazil

Thiago Veiga Jardim et al. Flavio Veiga Jardim Luciana Muniz Veiga Jardim Juliana Tranjan Coragem … Cristovão Fernandes Castro Guilherme Moreira Firmino Paulo Cesar B. Veiga Jardim

Introduction

The coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). On March 11, 2020, COVID-19 was declared a pandemic by the World Health Organization, and the first case was reported in Brazil by the end of February.

Given the absence of specific treatment and the high morbidity and mortality of COVID-19, particularly in high-risk groups, extraordinary public health measures have been implemented worldwide. Considering public health, the traditional outbreak response strategy of isolation, quarantine, social distancing, and community containment has been implemented in multiple countries and has played an important role in preventing disease spread.

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Editorial

The Astronaut and the Jabuticaba

Andre d’Avila et al. Marco F. Vidal Melo

Jabuticaba

Brazil has a peculiar medical environment. Although interventions like hydroxychloroquine and ivermectin disappeared from the international scientific debate once disproved in clinical trials, Brazilian practitioners continue to debate the validity of these studies. Like jabuticaba – a fruit native to and predominant (but not exclusive) in Brazil – this debate is still current only in this country. Previous attempts to discount the results of studies with the argument that they had been conducted abroad and could not be extended to the Brazilian population can no longer be justified as many of these studies have included Brazilian patients. As individuals, we do understand the difficulty in accepting evidence opposing someone’s conviction; however, as a doctor, this attitude is indefensible.

In this context of conviction and belief over evidence and data, several practitioners have created websites and even solicited the government to support and disseminate their practice despite proven inefficacy of the proposed interventions. Even though many are excellent physicians in their fields, this situation has only been possible because, under the auspices of trying to help, almost anything has been allowed in Brazil. If there were any regulation proposing a fine or termination of medical license to those who supported unproven medical practices, none of this would have happened. This regulation would be, in fact, similar to previous decisions of ethics committees in cases of charlatanism, when medical practices based on consensual decisions are not accepted as justification to exempt the infringer. However, these types of regulations are defective or absent in Brazil. Curiously, the term “accountability”, that in English means an obligation or willingness to accept responsibility for one’s actions, does not exist in Portuguese. On the other hand, there is no English word for “jabuticaba”.

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Original Article

COVID-19 and Myocardial Injury in a Brazilian ICU: High Incidence and Higher Risk of In-Hospital Mortality

Jorge Henrique Paiter Nascimento et al. Rafael Lessa da Costa Luiz Fernando Nogueira Simvoulidis João Carlos de Pinho … Roberta Santos Pereira Andrea Dornelles Porto Eduardo Costa de Freiras Silva Liszt Palmeira Oliveira Max Rogerio Freitas Ramos Gláucia Maria Moraes de Oliveira

Abstract

Background

The incidence of myocardial injury (MI) in patients with COVID-19 in Brazil and the prognostic impact of MI have not been elucidated.

Objectives

To describe the incidence of MI in patients with COVID-19 in the intensive care unit (ICU) and to identify variables associated with its occurrence. The secondary objective was to assess high-sensitivity troponin I as a predictor of in-hospital mortality.

Methods

Retrospective, observational study conducted between March and April 2020 with cases of confirmed COVID-19 admitted to the ICU. Numerical variables were compared by using Student t test or Mann-Whitney U test. The chi-square test was used for categorical variables. Multivariate analysis was performed with variables associated with MI and p<0.2 to determine predictors of MI. The ROC curve was used to determine the troponin value capable of predicting higher in-hospital mortality. Survival functions were estimated by use of the Kaplan-Meier method from the cut-off point indicated in the ROC curve.

Results

This study assessed 61 patients (63.9% of the male sex, mean age of 66.1±15.5 years). Myocardial injury was present in 36% of the patients. Systemic arterial hypertension (HAS) [OR 1.198; 95%CI: 2.246-37.665] and body mass index (BMI) [OR 1.143; 95%CI: 1.013-1.289] were independent risk predictors. High-sensitivity troponin I >48.3 ng/mL, which was determined in the ROC curve, predicts higher in-hospital mortality [AUC 0.786; p48.3 ng/mL was lower than that in the group with values ≤48.3 ng/dL [20.3 x 43.5 days, respectively; p<0.05].

Conclusion

There was a high incidence of MI in severe COVID-19 with impact on higher in-hospital mortality. The independent risk predictors of MI were SAH and BMI. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

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Case Report

Pulmonary Thromboembolism in a Young Patient with Asymptomatic COVID-19

Nicolas H. Borges et al. Thiago M. Godoy Marcos Roberto Curcio Pereira Rebecca B. Stocco … Viviane Maria de Carvalho Hessel Dias Cristina Pellegrino Baena Gustavo Lenci Marques

Case presentation

A male patient, 22 years old, with no previous comorbidities and medication use was referred to our hospital on 06/24/2020. Without symptoms, on 06/12/2020 he was diagnosed with COVID-19 after a PCR screening test required at his company and remained in bed rest during most of his isolation. He continued asymptomatic for 11 days; however, on 06/24/2020, he was admitted to the emergency department with ventilatory-dependent pain in the right hemithorax. Vital signs revealed hypertension (132/78 mmHg), tachycardia (127 bpm), hypoxia (SpO₂of 90% at ambient air), and fever (38.7 °C). On physical examination, attention was drawn to the decrease in breath sounds in the right hemithorax during pulmonary auscultation. Padua and Wells risk stratification scores were applied, and the criteria indicated a low risk (3 points) and a moderated risk (6 points), respectively. D-dimer (6.652 μg/L), C-Reactive Protein (94 mg/L) and Troponin (119 pg/mL) were among the laboratory tests performed. A computed tomography (CT) scan of the chest was requested ( ), which demonstrated the presence of Hampton’s hump, a pleural-based opacification in the lung most commonly due to pulmonary embolism. Moreover, consolidative pulmonary opacities and peripheral ground-glass areas, both multifocal and bilateral, associated with septal thickening, with a small area of consolidation in between, more accentuated in the right lower lobe and with moderate pulmonary involvement (25-50%) were also found. On 06/25/2020, a computed tomography pulmonary angiogram (CTPA) was also requested ( ), which demonstrated filling defects in the pulmonary arteries bilaterally, extending to its upper, middle and lingual branches, compatible with massive acute pulmonary thromboembolism. The patient was transferred on 06/25/2020 to the Intensive Care Unit (ICU), hemodynamically stable, and then nasal swab and oropharynx material collection for SARS-CoV-2 was requested, which came back with a positive diagnosis on 06/26/2020. Therapy was started with Ceftriaxone (2g daily), Azithromycin (500mg daily), Dexamethasone (6mg daily) and Oseltamivir (75mg daily), associated with Enoxaparin (80mg full dose) as prophylaxis for venous thrombosis. The patient showed progressive improvement. He was discharged from the ICU to the infirmary on 06/28/2020 and on 06/29/2020 he was discharged from the hospital, using Rivaroxaban (15mg BID), being referred for future outpatient reassessment. After the discharge, tests were requested to investigate thrombophilia, including: Functional Protein S, Functional Protein C, Homocysteine, Leiden Factor V, Prothrombin gene mutation, Antithrombin III, Lupus Anticoagulant and Anticardiolipin IgM. The increase in Antithrombin III (999%), the weak presence of Lupus Anticoagulant (1.43) and undetermined IgM Anticardiolipin levels stand out. In addition, echocardiography and Doppler ultrasonography of the lower limbs were requested, which were both within normal standards, ruling out possible signs of thrombosis, either recent or late.

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Research Letter

Mechanical Aortic Prosthetic Thrombosis in a 65-Year-Old Woman with SARS-CoV-2 Infection

Marcos H. F. Jacob et al. Tatiana C.A.T. Leal Paulo Rogério Soares Alexandre de Matos Soeiro

Clinical data

A 65-year-old female patient was hospitalized, initially due to an episode of melena. Anticoagulation was suspended, and upper gastrointestinal endoscopy was performed, without detecting bleeding. In 2005, she had late post-operative history of mechanical aortic prosthesis and Bentall and de Bono surgery due to Stanford A aortic dissection; she was a former tobacco user, with obesity and chronic atrial fibrillation under regular use of warfarin. The following day, she had an acute myocardial infarction with ST-segment elevation in the anterior wall; she was submitted to angioplasty with an anterior descending drug-eluting stent, and she received aspirin, clopidogrel 75 mg daily, and anticoagulation with enoxaparin 100 mg every 12 hours. On that occasion, she underwent transthoracic echocardiogram that demonstrated mild ventricular dysfunction (LVEF: 50%) and aortic prosthesis leaflets with preserved mobility; the peak systolic pressure gradient between the left ventricle and the aorta was 58 mmHg, with a mean of 33 mmHg. Two days later, she began to present anosmia, headache, subfebrile temperature, and hypoxemia, and diagnosis of SARS-CoV-2 was confirmed by oropharyngeal swab PCR. Seven days later, while still on full enoxaparin, the patient started presenting atypical chest pain associated with dyspnea. During physical examination, the patient’s overall condition was regular; she had dyspnea, without cyanosis. Pulse was present and full in all 4 limbs, and she had Glasgow score of 15, blood pressure 120/86 mmHg, heart rate 130 bpm, peripheral oximetry 97% while using a nasal oxygen catheter at 3 L/min, and capillary filling time of less than 3 seconds. Ictus cordis was in the left hemiclavicular line, at the level of the fifth intercostal space. She had normophonetic heart sounds, with moderate intensity ejective systolic murmur with metallic click in aortic focus. The patient’s liver was not palpable, and there were mild and sparking crackles in the pulmonary fields bilaterally.

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