Severe Acute Respiratory Syndrome – ABC CARDIOL

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Editorial

COVID-19 and Atrial Fibrillation: Predicting to Prevent

Lucas Simonetto Faganello et al. Leandro Ioschpe Zimerman

Atrial fibrillation (AF) is the most common chronic arrhythmia worldwide, with significant morbidity and mortality. The causes for the development and maintenance of AF are multifactorial, with advanced-age patients and comorbidities such as hypertension, diabetes, and coronary artery disease being at greater risk. Increased sympathetic tone and inflammatory states are also associated with the development of AF.^,

The new coronavirus disease pandemic that began at the end of 2019 (COVID-19) quickly spread across the world, bringing catastrophic consequences for public health and the global economy. The infection can lead to illness with varying severities, ranging from mild upper airway infection to severe pneumonia, resulting in severe acute respiratory syndrome requiring mechanical ventilation. Although COVID-19 is primarily a lung disease as a consequence of an immune inflammatory response, cardiovascular system may be involved as well.^, Cardiac manifestations include myocarditis, heart failure, acute coronary syndrome, and arrhythmias and are associated with increased mortality. The exact arrhythmogenic mechanism is not yet completely known, but hypoxia, myocarditis, exaggerated immune response, myocardial ischemia, electrolyte disturbance, and adverse effects of medications are potential causes.^,

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Original Article

Clinical Aspects Of Hypertensive Patients With COVID-19 Hospitalized In A Campaign Hospital In Northeast Brazil

Luan George Xavier et al. Renato Sampaio Mello Neto Marcos Henrique de Oliveira Morais Pedro Jorge Cronemberger … Maria do Carmo Carvalho Martins Marta Rosal

Abstract

Background

In view of the absence of effective therapy for COVID-19, many studies have been conducted seeking to identify determining factors for the development of severe forms, aiming to direct efforts to avoid the worst outcomes in patients susceptible to severe conditions. One of the main comorbidities associated with complicated forms of the disease is systemic arterial hypertension (SAH).

Objective

To assess aspects of the clinical, demographic, laboratory, and radiological characteristics of hypertensive patients with COVID-19 to contribute to the knowledge of the relationship between the presence of this comorbidity and the severity of the disease.

Methods

A total of 380 patients with a diagnosis of acute SARS-CoV-2 infection hospitalized between June and August 2020 were included. Patients were divided into two groups according to the presence or absence of a previous diagnosis of hypertension. For comparison between groups, a significant difference was established if p < 0.05.

Results

Of the total of 380 patients, 202 (53.16%) had a clinical diagnosis of SAH. Hypertensive patients were significantly older (p < 0.01) and had more comorbidities (p < 0.01) than the non-hypertensive group. In laboratory tests, hypertensive patients had higher levels of blood glucose (p = 0.014), creatinine (p = 0.002), and urea (p = 0.003), while values for alanine aminotransferase (ALT) (p < 0.01), aspartate aminotransferase (AST) (p = 0.006), and sodium (p = 0.024) were lower. There was no difference between groups in radiographic parameters.

Conclusions

This study showed that, although the hypertensive group had some laboratory alterations that elicited severe disease, these patients did not have worse outcomes.

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Editorial

Systematic Reviews and Meta-Analyses: Lighthouses in the Data Storm from the COVID-19 Pandemic

Henrique Turin Moreira et al. André Schmidt

Since recognizing the COVID-19 pandemic as a public health emergency, the global scientific community has driven efforts to understand the infection by the new coronavirus SARS-CoV-2. The World Health Organization soon proclaimed the need to fast-track research to reduce mortality and avoid crisis escalation. As a result, we now observe an extraordinary amount of data on COVID-19 obtained in a short time. Indeed, a search in the Pubmed database promptly reveals more than 164,000 papers on the disease in less than two and a half years, an unprecedented phenomenon in the medical literature. Putting this into perspective, this profusion of publications is numerically greater than papers identified by the term “myocardial infarction” in the last four decades.

Although this outstanding scientific advance has been crucial to fighting the pandemic, at the same time, it went along with a data storm with marked adverse effects. Health professionals had challenges searching, interpreting, and summarizing this dizzying volume of evidence. Conflicting results, typical of the twisted paths of science, were frequent causes of confusion and disagreement. In this setting, systematic reviews and meta-analyses can serve as lighthouses, guiding us to safer routes. They offer organized and integrated assessment of multiple data sources, thus allowing more robust estimates and reliable answers to clinical practice dilemmas.

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Editorial

How Should We Investigate Cardiovascular Injury In Critically Ill COVID-19 Pediatric Patients In A Scenario Of Socioeconomic Vulnerability?

Gabriela Nunes Leal

Literature published worldwide has extensively documented cardiovascular injury among COVID-19 critically ill patients. Cardiac involvement appears to be a prominent feature of the disease in adults, occurring in 20% to 30% of hospitalized patients and contributing to 40% of deaths. Children and adolescents are mostly spared by COVID-19, with few having severe symptoms and even fewer deaths. However, the description of the multisystem inflammatory syndrome in children (MIS-c) reinforced that, although rare, severe clinical presentation and death are possible in the pediatric population. Cardiovascular compromise in MIS-c associated with COVID-19 is frequent and is one of the World Health Organization (WHO) diagnostic criteria for this pathologic condition ( ).^,

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Editorial

Severe Acute Respiratory Distress Syndrome (ARDS) Caused by COVID-19: A Regional Factor

Jussara A. Oliveira Baggio et al. Ana Luiza Exel Ana Carolina do Nascimento Calles Vinicius Minatel

The COVID-19 (Coronavirus disease-19), a disease caused by the SARS-CoV-2, was identified in China at the end of 2019 and announced as a pandemic by the World Health Organization (WHO) in March 2020, with more than 20 million cases confirmed in Brazil, and more than 583 thousand deaths from complications of the disease, by the end of epidemiological week 35, on September 4, 2021.^– According to the WHO, Brazil is the third country in number of cases, with the USA on the top of the list, followed by India,^– which is also considered an emerging country with problems similar to those faced by the Brazilian population.

Symptoms of the SARS-CoV-2 infection may vary from a flu-like syndrome, with mild symptoms and signs like fever, cough, nasal congestion and fatigue, to acute respiratory distress syndrome (ARDS), with symptoms including dyspnea, O₂ saturation ≤ 93%, respiratory rate ≥ 30 breaths per minute, partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2)< 300, lymphopenia, and alveolar edema.^, Nearly 1,775,816 cases of ARDS secondary to COVID-19 were recorded in Brazil and 32.2% of the cases progressed to death. Of the 342,636 deaths for ARDS due to COVID-19 recorded up to the epidemiological week 36 in 2021, 59.5% had at least one comorbidity, with heart diseases, cerebrovascular diseases, systemic arterial hypertension and diabetes mellitus (DM) as the most common ones.^,

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Review Article

The Role of the Immune System on the Cardiac Complications Observed in SARS-CoV-2

Larissa Carvalho Vigário et al. Guilherme Muradas Claudia Neto Paiva Emiliano Medei

Abstract

An acute respiratory syndrome caused by SARS-CoV2 was declared a pandemic by the World Health Organization. Current data in the world and in Brazil show that approximately 40% of patients who died have some type of cardiac comorbidity. There are also robust reports showing an increase in IL-6 / IL-1B / TNF-alpha and the presence of lymphopenia in patients with COVID-19. Our team and others have shown that increased cytokines are the link between arrhythmias/Left ventricular dysfunction and the immune system in different diseases. In addition, it has been well demonstrated that lymphopenia can not only be a good marker, but also a factor that causes heart failure. Thus, the present review focused on the role of the immune system upon the cardiac alterations observed in the SARS-CoV2 infection. Additionally, it was well described that SARS-CoV-2 is able to infect cardiac cells. Therefore, here it will be reviewed in deep.

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Editorial

What have we Learned about the Different COVID-19 Phenotypes in the Pediatric Population so Far?

Andressa Mussi Soares et al. Bernardo Mussi Soares

The understanding of SARS-CoV-2 related syndromes in the pediatric population needs to grow worldwide. In its severe presentation, COVID-19 is a systemic disease characterized by hyperinflammation, cytokine storm and increased myocardial injury markers. Cardiac involvement in seen in 20-30% of hospitalized adult patients and accounts for about 40% of deaths.

An intriguing aspect of the COVID-19 is the fact that most children and adolescents have mild or asymptomatic forms of the disease, perhaps related to a lower expression of virus receptors, recent exposure to other coronaviruses generating cross-protection, more developed innate immunity, among others. In fact, it is known that 40% of individuals under the age of 18 exposed to the virus get infected and that only 20-30% of children and adolescents infected with SARS-Cov-2 have symptoms.

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Original Article

Prevalence and Associated Factors of SARS by Covid-19 in Adults and Aged People with Chronic Cardiovascular Disease

Karina Mary de Paiva et al. Danúbia Hillesheim Cassiano Ricardo Rech Rodrigo Sudatti Delevatti … Rodrigo Vasconi Sáez Brown Ana Inês Gonzáles Patricia Haas

Abstract

Background

The presence of Cardiovascular Disease (CVD) in individuals infected with COVID-19 may imply a worse prognosis.

Objective

To describe the prevalence of Severe Acute Respiratory Syndrome (SARS) by COVID-19 and to analyze the factors associated with this condition in adults and the elderly with cardiovascular disease in Brazil until the 30th Epidemiological Week of 2020.

Methods

Cross-sectional study conducted with data from the Influenza Epidemiological Surveillance Information System (Sistema de Informação de Vigilância Epidemiológica da Gripe – SIVEP-Gripe), referring to the SARS notification forms of hospitalized individuals in Brazil, between the 1st and 30th Epidemiological Week of 2020. Adults and the aged (≥ 18 years old) with CVD. The dependent variable was SRAG confirmation by COVID-19 and factors related to sociodemographic characteristics, signs and symptoms, and clinical factors were analyzed. Poisson regression with robust variance was applied. The level of significance adopted was 5%.

Results

Notifications from 116,343 individuals were analyzed. Of these, 61.9% were diagnosed with SARS by COVID-19. The prevalence of the outcome was 4% lower in women (95%CI: 0.94–0.99) and 18% lower in rural areas (95%CI: 0.77–0.87). There was a higher prevalence in the 50 to 59 age group (95%CI: 1.09–1.48) and in the northeast region (95%CI: 1.72–1.91). Fever, cough, admission to the ICU, use of ventilatory support, and nosocomial cases were also significantly associated with a higher probability of SRAS by COVID-19 in these individuals.

Conclusion

There is a high prevalence of SARS by COVID-19 in adults and aged people with CVD in Brazil. Factors associated with sociodemographic and clinical characteristics, signs, and symptoms were associated.

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Viewpoint

A Probable Relationship between Physical Exercise and COVID-19 Mediated by the Renin-Angiotensin-Aldosterone System

Renato Aparecido de Souza et al. Priscila Missaki Nakamura Inaian Pignatti Teixeira Marco Tulio de Souza Wonder Passoni Higino

The Pathways of the RAAS

The classical pathway of the RAAS is initiated by the release of angiotensinogen by the liver, which, combined with renin secreted by the kidneys, produces angiotensin I (Angio I). Angio I is converted to angiotensin II (Angio II) by the action of the angiotensin-converting enzyme (ACE) in the lungs. The physiological effects of Angio II are mediated primarily through membrane receptors, especially of the Angio II type 1 (AT1) receptor. These receptors, when stimulated, promote vasoconstriction, hypertrophy and hyperplasia of vascular cells, sodium retention, generation of reactive oxygen species (ROS), and inflammatory, thrombotic and fibrotic processes, which can cause tissue damage.

A counter-regulatory pathway of the RAAS involves the conversion of Angio II to angiotensin 1–7 (Angio-1–7) and membrane receptors (MAS) through the enzymatic activity of angiotensin-converting enzyme 2 (ACE2), which promotes a vasodilatory, anti-inflammatory, anti-fibrotic, and anti-proliferative effect on the tissues. Under appropriate physiological conditions, there is a balance between these two RAAS pathways ().

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Case Report

Covid-19 in Heart Transplant Recipients in São Paulo: A Case Series

Rafaela Vale de Miranda Soriano et al. João Manoel Rossi Neto Marco A. Finger Carolina Casadei Santos

Introduction

The disease caused by the new coronavirus (Covid-19), SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. By analogy to others respiratory infections, mainly based on the 2009 pandemic of the influenza virus H1N1,^, an increase in cases of pneumonia and progression to septic shock with acute respiratory distress syndrome was expected among recipients of solid-organ transplantation with Covid-19 in comparison with the non-transplanted population. However, immunosuppression in transplantation could theoretically revoke the hyperinflammatory syndrome secondary to the cytokine storm, responsible for the majority of deaths by Covid-19.^, Data on immunosuppression potentially leading to atypical clinical presentations or increasing the risk of adverse events in the presence of Covid-19 are conflicting.^,

We report our experience with heart transplant (HT) recipients diagnosed with Covid-19 at an institution with an HT program since 1992 in São Paulo, Brazil.

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Research Letter

COVID-19 in Early Postoperative Heart Transplantation – Initial Experience

Gustavo Pampolha Guerreiro et al. Lucas Molinari Veloso da Silveira Valdano Manuel Samuel Padovani Steffen … Fernando Bacal Fabio Antonio Gaiotto Fabio Biscegli Jatene

Introduction

The coronavirus disease (COVID-19) pandemic is rapidly increasing worldwide. Brazil is the country with the second highest number of cases, and it is considered South America’s epicenter.

Cardiovascular disease is known to be an important risk factor for infection susceptibility, illness severity, and poor prognosis in COVID-19. Heart transplantation (HT) recipients may have an increased risk due to their comorbidities; however, it has been theorized that immunosuppression might protect them from the cytokine storm responsible for worse outcomes.^, On the other hand, infection by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been reported in HT patients with disease presentation similar to general population, questioning the theorized immunosuppression protective mechanism.^–

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Research Letter

COVID-19 Infection in a Cardiopatic Pregnant Woman

Lucianna Serfaty de Holanda et al. Laíses Vieira Maria Talita Campos Vitor Bruno Teixeira de Holanda … Ivy Almeida Cavalcante e Silva Daniel Serfaty Feliciano Mendes Vieira Junior

Introduction

Regarding the obstetric aspects of COVID-19 infection, one should consider that it is a recent disease, with no specific knowledge on the theme to draft medical care protocols. For this reason, various guidelines are based on its comparison with infections caused by other viruses (SARS-CoV, MERS-CoV, and H1N1); therefore, all information concerning current evidence on the issue is subject to change due to new discoveries.

Infections caused by SARS-CoV and MERS-CoV have tended to be regionally bound, but the few obstetric cases published in the literature point to the need for advanced medical support for pregnant women with severe involvements identified in maternal prognoses. All of these highlight the importance of care against the dissemination of the virus.^–

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Letter to the Editor

Circulatory System Diseases in Patients with COVID-19: Description of Clinical and Epidemiological Profile of 197 Deaths

Carlos Dornels Freire de Souza et al. Thiago Cavalcanti Leal Lucas Gomes Santos

Dear Editor,

On December 31, 2019, China notified the World Health Organization (WHO) of an outbreak of pneumonia in the city of Wuhan, capital of the Hubei province. A few days later, the causative agent, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified.

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Editorial

COVID-19: A New Challenge in Pregnancy and Heart Disease

Walkiria Samuel Avila et al. Regina Coeli de Carvalho

The outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic by the World Health Organization on March 11, 2020. Although SARS-CoV-2 isolation, gene sequencing, and structural analysis have been completed,therapies for COVID-19.

The first epidemiological data have pointed to a worse outcomes and higher mortality of COVID-19 in patients with chronic diseases, such as heart disease and arterial hypertension. Subsequently, the Brazilian Health Ministry included in the high-risk group pregnant, puerperal and post-abortion women.

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Case Report

SARS-Cov-2 Infection and Pulmonary Thromboembolism – The Prothrombotic State in COVID-19

Hellen Dutra Passos et al. Mariana Carvalho Alves Leonardo Baumworcel João Paulo Cerqueira Vieira … Juliane Dantas Seabra Garcez Antônio Carlos Sobral Sousa

Introduction

The COVID-19 caused by new coronavirus, named by the World Health Organization as Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2), has spread all over the world with astonishing speed. In Brazil, the spread risk (R0) of COVID-19 has been 3.0, which explains its rapid dissemination all over the states.

Individuals with cardiovascular diseases, systemic arterial hypertension, diabetes mellitus, chronic obstructive pulmonary disease, and immunosuppressed patients are at higher risk for adverse outcomes.

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Case Report

The Association between Covid-19 and ST Elevation Myocardial Infarction: Variable Clinical Presentations on a Case Report Series

Vinicius Esteves et al. Cleverson Neves Zukowski Fabio Augusto de Luca Italo Bruno dos Santos Sousa … Bruno Santana Bandeira Angelina Camiletti Guilherme Arruda André Feldman Olga Ferreira de Souza

Introduction

The current global pandemic caused by the new coronavirus (COVID-19) already reaches 185 countries with approximately 3 million infected people and more than 200 thousand deaths.^, With continental dimensions and an elevated socioeconomic disparity, Brazil, by the beginning of May, presents with increasing infection rates and mortality close to 8%. The numbers may be higher considering the lack of adequate testing of the population and healthcare professionals.

According to the World Health Organization (WHO), cardiovascular diseases represent the leading cause of deaths around the world. . Recent reports confirmed that patients with cardiovascular comorbidities are at a higher risk to develop the most severe form of the COVID-19.^– The association between these two pathologies can lead to high morbidity and mortality rates and has been the object of continuous efforts by the medical community. In this sense the management of Acute Coronary Syndrome (ACS) has undergone changes in both diagnosis and treatment since the beginning of the pandemic.^– Another aggravating factor regarding the approach of ACS during this period is the multiple clinical presentations and differential diagnosis associated with COVID-19, such as myopericarditis, pulmonary embolism and arrhythmia.^–

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Editorial

COVID-19: A Matter Close to the Heart

Gláucia Maria Moraes de Oliveira et al. Fausto J. Pinto

The world is facing a new challenge, the novel coronavirus disease 2019 (COVID-19), caused by a betacoronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), phylogenetically identical to the SARS-CoV (severe acute respiratory syndrome coronavirus) and the MERS-CoV (Middle East respiratory syndrome coronavirus) responsible for innumerable deaths in China in 2003 and in the Middle East in 2012, respectively.

On March 11, 2020, the COVID-19 outbreak was characterized as a pandemic by the World Health Organization (WHO). Twenty-three days after that announcement, the cases reported reached 1,056,777 in 182 countries, with 55,781 deaths, most of which occurring in Italy, Spain, France, China and Iran. So far, Brazil has registered 8,195 cases and 335 deaths, while Portugal, 9,886 cases and 246 deaths, figures that have increased steeply since the beginning of the pandemic.

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Editorial

COVID-19 and the Heart

Tânia Mara Varejão Strabelli et al. David Everson Uip

We have been living with the new coronavirus pandemic since March 11, 2020. Initially, on January 1, 2020, the World Health Organization (WHO) declared the new coronavirus infection a global emergency and proceeded to name the disease COVID-19. The Coronavirus Study Group of the International Committee on Taxonomy of Viruses proposed the adoption of the name SARS-Cov-2. Genomic sequencing and phylogenetic analysis have indicated that it is a betacoronavirus from the same subgenus as the severe acute respiratory syndrome (SARS) that caused an epidemic in China in 2003 and the Middle East respiratory syndrome (MERS) that caused the same condition in the Middle East in 2012. It has 96.2% genetic identity with betaCoV/bat/Yunnan, a virus isolated in bats. The structure of the virus’s cell-binding receptor gene is very similar to that of the SARS coronavirus, and the virus appears to use the same angiotensive-converting enzyme 2 (ACE2) receptor to enter the cell.

The clinical picture of COVID-19 is similar to that of other respiratory viruses, namely, fever, generally dry cough, fatigue, and, in severer cases (5%), dyspnea, pulmonary bleeding, severe lymphopenia, and renal failure. Symptoms are mild in 80% of cases. Diagnosis of symptomatic cases should be confirmed by testing for the virus via polymerase chain reaction (PCR) of a nasal swab.

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