Background The independent prognostic value of troponin and other biomarker elevation among patients with coronavirus disease 2019 (COVID‐19) are unclear. We sought to characterize biomarker levels ...in patients hospitalized with COVID‐19 and develop and validate a mortality risk score. Methods and Results An observational cohort study of 1053 patients with COVID‐19 was conducted. Patients with all of the following biomarkers measured—troponin‐I, B‐type natriuretic peptide, C‐reactive protein, ferritin, and d‐dimer (n=446) —were identified. Maximum levels for each biomarker were recorded. The primary end point was 30‐day in‐hospital mortality. Multivariable logistic regression was used to construct a mortality risk score. Validation of the risk score was performed using an independent patient cohort (n=440). Mean age of patients was 65.0±15.2 years and 65.3% were men. Overall, 444 (99.6%) had elevation of any biomarker. Among tested biomarkers, troponin‐I ≥0.34 ng/mL was the only independent predictor of 30‐day mortality (adjusted odds ratio, 4.38; P<0.001). Patients with a mortality score using hypoxia on presentation, age, and troponin‐I elevation, age (HA2T2) ≥3 had a 30‐day mortality of 43.7% while those with a score <3 had mortality of 5.9%. Area under the receiver operating characteristic curve of the HA2T2 score was 0.834 for the derivation cohort and 0.784 for the validation cohort. Conclusions Elevated troponin and other biomarker levels are commonly seen in patients hospitalized with COVID‐19. High troponin levels are a potent predictor of 30‐day in‐hospital mortality. A simple risk score can stratify patients at risk for COVID‐19–associated mortality.
Historically, adrenocorticotropic hormone was used as a first-line treatment for infantile spasms; however, there has been increasing use of topiramate as initial therapy. Here, we report a ...retrospective study of adrenocorticotropic hormone (ACTH) and topiramate as initial treatment for infantile spasms. The neurology patient database at the Children's Hospital of Philadelphia was searched using the International Classification of Diseases, Ninth Revision code for infantile spasms, and 50 patients were randomly chosen for chart review. We identified 31 patients receiving either adrenocorticotropic hormone or topiramate monotherapy (adrenocorticotropic hormone n = 12, topiramate n = 19) as a first-line treatment for infantile spasms. A total of 26 patients were symptomatic and 5 cryptogenic. Six patients treated with adrenocorticotropic hormone had resolution of clinical spasms and hypsarrhithmia within a month, but 3 relapsed. Of the 19 patients treated with topiramate, 4 patients eventually, though over a period of 0, 1, 8, or 69 months, had resolution of spasms and hypsarrhythmia.
Introduction
The impact of atrial arrhythmias on coronavirus disease 2019 (COVID‐19)‐associated outcomes are unclear. We sought to identify prevalence, risk factors and outcomes associated with ...atrial arrhythmias among patients hospitalized with COVID‐19.
Methods
An observational cohort study of 1053 patients with severe acute respiratory syndrome coronavirus 2 infection admitted to a quaternary care hospital and a community hospital was conducted. Data from electrocardiographic and telemetry were collected to identify atrial fibrillation (AF) or atrial flutter/tachycardia (AFL). The association between atrial arrhythmias and 30‐day mortality was assessed with multivariable analysis.
Results
Mean age of patients was 62 ± 17 years and 62% were men. Atrial arrhythmias were identified in 166 (15.8%) patients, with AF in 154 (14.6%) patients and AFL in 40 (3.8%) patients. Newly detected atrial arrhythmias occurred in 101 (9.6%) patients. Age, male sex, prior AF, renal disease, and hypoxia on presentation were independently associated with AF/AFL occurrence. Compared with patients without AF/AFL, patients with AF/AFL had significantly higher levels of troponin, B‐type natriuretic peptide, C‐reactive protein, ferritin and
d‐dimer. Mortality was significantly higher among patients with AF/AFL (39.2%) compared to patients without (13.4%; p < .001). After adjustment for age and co‐morbidities, AF/AFL (adjusted odds ratio OR: 1.93; p = .007) and newly detected AF/AFL (adjusted OR: 2.87; p < .001) were independently associated with 30‐day mortality.
Conclusion
Atrial arrhythmias are common among patients hospitalized with COVID‐19. The presence of AF/AFL tracked with markers of inflammation and cardiac injury. Atrial arrhythmias were independently associated with increased mortality.
Direct oral anticoagulants (DOACs) and amiodarone are widely used in the treatment of nonvalvular atrial fibrillation. The DOACs are P-glycoprotein (P-gp) and cytochrome p-450 (CYP3A4) substrates. ...Direct oral anticoagulant levels may be increased by the concomitant use of potent dual P-gp/CYP3A4 inhibitors, such as amiodarone, which can potentially translate into adverse clinical outcomes. We aimed to assess the efficacy and safety of drug–drug interaction by the concomitant use of DOACs and amiodarone.
We performed a systematic review of MEDLINE, the Cochrane Central Register of Clinical Trials, and Embase, limiting our search to randomized controlled trials of patients with atrial fibrillation that have compared DOACs versus warfarin for prophylaxis of stroke or systemic embolism, to analyze the impact on stroke or systemic embolism, major bleeding, and intracranial bleeding risk in patients with concomitant use of amiodarone. Risk ratio (RR) 95% confidence intervals were measured using the Mantel-Haenszel method. The fixed effects model was used owing to heterogeneity (I2) < 25%.
Four trials with a total of 71,683 patients were analyzed, from which 5% of patients (n = 3212) were concomitantly taking DOAC and amiodarone. We found no statistically significant difference for any of the clinical outcomes (stroke or systemic embolism RR 0.85; 95% CI, 0.67-1.06, major bleeding RR 0.91; 95% CI, 0.77-1.07, or intracranial bleeding RR 1.10; 95% CI, 0.68-1.78) among patients taking DOAC and amiodarone versus DOAC without amiodarone.
On the basis of the results of this meta-analysis, co-administration of DOACs and amiodarone, a dual P-gp/CYP3A4 inhibitor, does not seem to affect efficacy or safety outcomes in patients with atrial fibrillation.
Patients with chronic kidney disease are at increased risk of cardiovascular disease (CVD). Even after kidney transplant, the rate of CVD events and death remain elevated. Early detection of patients ...at risk would be helpful for guiding aggressive preventive therapy. The purpose of this study was to evaluate global longitudinal strain (GLS) as a predictor of CVD events and death after kidney transplant.
Among patients with successful kidney transplant between 3/2009 and 12/2012 at our institution, 111 individuals had an echocardiogram within 6 months of the transplant. Medical records were evaluated for demographics and patient characteristics. Echocardiograms were analyzed for conventional measurements, and GLS was assessed using speckle-tracking analysis.
The median age of the study sample was 54 years. Overall, 60% were men; 35% were non-Hispanic black, and 50% Hispanic. After a mean follow-up of 3.8 ± 0.5 years, there were 21 cardiovascular events or deaths. Patients who experienced an event were older, more frequently had a history of coronary artery disease, and had higher LV filling/longitudinal diastolic annular velocity (E/e') than those who did not. GLS was significantly associated with event-free survival even after adjusting for age, sex, race-ethnicity, hypertension, diabetes, history of coronary artery disease or heart failure, and E/e'.
Reduced GLS peri-transplant is significantly associated with increased CVD events or death after kidney transplant. Larger studies are required to determine the incremental predictive value of GLS over clinical and other echocardiographic parameters for adverse CVD events following renal transplantation.
•CKD has long been identified as a risk factor for CVD.•Even after kidney transplant, the rate of CVD events and death remain elevated.•GLS identifies LV dysfunction even in the context of normal LV ejection fraction in various diseases.•GLS peri-transplant proved to be independently associated with CVD events and death.•GLS may be an important screening tool to stratify the risk of patients undergoing kidney transplant.
Purpose of review
In this review, we provide a practical approach to the catheter ablation of idiopathic focal ventricular arrhythmias (VAs) by summarizing the electrocardiographic (ECG) ...characteristics, mapping strategies, and ablation techniques for each of the major types of idiopathic VAs. We identify special considerations to be taken when treating specific forms of idiopathic VAs with catheter ablation that can increase success rates and reduce complications.
Recent findings
Insights on ECG morphologies of VAs have led to novel criteria that can aid in accurate identification and localization of VA sites of origin. Advancements in mapping catheters and software as well as the use of intracardiac echocardiography have allowed for more precise mapping and ablation of arrhythmias arising from complex cardiac structures.
Summary
Idiopathic VAs occurring in patients without overt structural heart disease can be categorized into four groups on the basis of anatomic location: (1) outflow tract VAs (which include the right ventricular outflow tract, left ventricular outflow tract, and left ventricular summit; (2) fascicular VAs; (3) papillary muscle VAs; and (4) annular VAs. Knowledge of the ECG characteristics of idiopathic VAs and the three-dimensional anatomy surrounding their sites of origin can guide pre-procedure planning, prioritization of cardiac regions for mapping, and approach for ablation.
Background Hydralazine-isosorbide dinitrate (H-ISDN) carries an indication for treating systolic heart failure (HF). A multivariate logistic regression model that included age, creatinine, coronary ...artery disease (CAD), diabetes, beta blocker, ACEi/ARB, spironolactone use, ejection fraction (EF) and race (self-identifying as African-American) was used for outcomes.
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