The natural history of QTc interval and its clinical impact in coronavirus disease 2019 survivors after 1 year

Background and objectiveProlonged QTc interval on admission and a higher risk of death in SARS-CoV-2 patients have been reported. The long-term clinical impact of prolonged QTc interval is unknown. This study examined the relationship in COVID-19 survivors of a prolonged QTc on admission with long-term adverse events, changes in QTc duration and its impact on 1-year prognosis, and factors associated with a prolonged QTc at follow-up.MethodsWe conducted a single-center prospective cohort study of 523 SARS-CoV-2-positive patients who were alive on discharge. An electrocardiogram was taken on these patients within the first 48 h after diagnosis and before the administration of any medication with a known effect on QT interval and repeated in 421 patients 7 months after discharge. Mortality, hospital readmission, and new arrhythmia rates 1 year after discharge were reviewed.ResultsThirty-one (6.3%) survivors had a baseline prolonged QTc. They were older, had more cardiovascular risk factors, cardiac disease, and comorbidities, and higher levels of terminal pro-brain natriuretic peptide. There was no relationship between prolonged QTc on admission and the 1-year endpoint (9.8% vs. 5.5%, p = 0.212). In 84% of survivors with prolonged baseline QTc, it normalized at 7.9 ± 2.2 months. Of the survivors, 2.4% had prolonged QTc at follow-up, and this was independently associated with obesity, ischemic cardiomyopathy, chronic obstructive pulmonary disease, and cancer. Prolonged baseline QTc was not independently associated with the composite adverse event at 1 year.ConclusionsProlonged QTc in the acute phase normalized in most COVID-19 survivors and had no clinical long-term impact. Prolonged QTc at follow-up was related to the presence of obesity and previously acquired chronic diseases and was not related to 1-year prognosis

Historia natural del intervalo QTc e impacto pronóstico a corto y medio plazo en pacientes afectos por la COVID-19

Al desembre del 2019 es van reportar els primers casos de la COVID-19, un síndrome respiratori agut que evolucionava en un nombre important de casos cap a una insuficiència respiratòria greu, fracàs multiorgànic i fins i tot mort. En els primers estudis realitzats es descriu un quadre proinflamatori sever que comporta complicacions a nivell cardiovascular. En el moment en què el nostre primer estudi va ser dissenyat, les dades relacionades amb l'affectació multisistèmica i els predictors de mala evolució de la infecció eren escasses. La presència d'un QTc prolongat semblava poder empitjorar el pronòstic, però la majoria d'aquesta informació provenia d'estudis que analitzaven el tractament amb hidroxicloroquina i azitromicina. D'altra banda, la prolongació de l'interval QTc de causa no farmacològica s'havia relacionat prèviament amb estats proinflamatoris. El nostre treball va estudiar la prevalença d'un interval QTc basal prolongat en pacients infectats pel SARS-CoV-2, la seva evolució a mitjà termini i la seva implicació pronòstica. Es va observar que hi havia una prevalença d'un interval QTc basal prolongat a l'ingrés en gairebé un 10% dels pacients, el que es va associar de forma independent amb una major mortalitat durant el mateix. El seguiment clínic dels supervivents durant un any i l'electrocardiogràfic als 8 mesos van mostrar que la majoria dels pacients normalitzaven l'interval QTc durant el seguiment. No es va observar una relació significativa entre un QTc prolongat, ni basal ni durant el seguiment, amb una major mortalitat, reingrés hospitalari o nova arrítmia. Això indicaria que la prolongació de l'interval QTc en la infecció aguda per SARS-CoV-2 és freqüent i es relaciona, en fase aguda, amb una major mortalitat, resolent-se de forma espontània en la majoria dels pacients durant el seguiment i no condicionant un pitjor pronòstic a mitjà termini.En diciembre del 2019 se reportaron los primeros casos de la COVID-19, un síndrome respiratorio agudo que evolucionaba en un número importante de casos a una insuficiencia respiratoria grave, fracaso multiorgánico e incluso muerte. En los primeros estudios realizados se describía un cuadro proinflamatorio severo que conllevaba complicaciones a nivel cardiovascular. En el momento que nuestro primer estudio fue diseñado, los datos en relación a la afectación multisistémica y a los predictores de mala evolución de la infección eran escasos. La presencia de un QTc prolongado parecía que podía empeorar el pronóstico, pero la mayoría de esta información se derivaba de estudios que analizaban el tratamiento con hidroxicloroquina y azitromicina. Por otro lado, la prolongación del intervalo QTc de causa no farmacológica, se había relacionado previamente con estados proinflamatorios. Nuestro trabajo estudió la prevalencia de un intervalo QTc basal prolongado en pacientes infectados por el SARS-CoV2, su evolución a medio plazo y su implicación pronóstica. Se observó que una prevalencia de un QTc basal prolongado al ingreso en casi un 10% de los pacientes, lo que se asoció de forma independiente con una mayor mortalidad durante el mismo. El seguimiento clínico de los supervivientes durante un año y electrocardiográfico a los 8 meses mostró que la mayoría de los pacientes normalizaban el intervalo QTc en el seguimiento. No se observó una relación significativa entre un QTc prolongado ni basal ni en el seguimiento con mayor mortalidad, reingreso hospitalario o nueva arritmia. Esto indicaría que la prolongación del intervalo QTc en la infección aguda por SARS-CoV-2 es frecuente y se relaciona en fase aguda con mayor mortalidad, resolviéndose de forma espontánea en la mayoría de los pacientes en el seguimiento y no condicionando un peor pronóstico a medio plazo.In December 2019, the first cases of COVID-19 were reported, an acute respiratory syndrome that progressed to severe respiratory failure, multiorgan failure, and even death in a significant number of cases. The initial studies described a severe proinflammatory condition associated with cardiovascular complications. At the time our first study was designed, there was limited data regarding multisystem involvement and predictors of poor infection outcomes. The presence of a prolonged QTc interval appeared to worsen the prognosis, but most of this information was derived from studies analyzing the treatment with hydroxychloroquine and azithromycin. Additionally, the prolongation of the QTc interval due to non-pharmacological causes had previously been associated with proinflammatory states. Our study examined the prevalence of prolonged baseline QTc interval in patients infected with SARS-CoV-2, its medium-term evolution, and its prognostic implications. It was observed that nearly 10% of patients had a prolonged baseline QTc interval upon admission, which was independently associated with higher mortality during the same period. Clinical follow-up of survivors for one year, along with electrocardiographic monitoring at 8 months, revealed that the majority of patients normalized their QTc interval over the course of follow-up. No significant relationship was observed between prolonged QTc interval, either at baseline or during follow-up, and increased mortality, hospital readmission, or new arrhythmia. These findings suggest that the prolongation of the QTc interval in acute SARS-CoV-2 infection is frequent and acutely associated with higher mortality, but it resolves spontaneously in the majority of patients during follow-up and does not contribute to a worse medium-term prognosis

Cardiac tomography and cardiac magnetic resonance to predict the absence of intracardiac thrombus in anticoagulated patients undergoing atrial fibrillation ablation

Background: pulmonary veins isolation (PVI) is a standard treatment for recurrent atrial fibrillation (AF). Uninterrupted anticoagulation for a minimum of 3 weeks before ablation and exclusion of left atrial (LA) thrombus with transesophageal echography (TEE) immediately before or during the procedure minimize peri-procedural risk. We aimed to demonstrate the utility of cardiac tomography (CT) and cardiac magnetic resonance (CMR) to rule out LA thrombus prior to PVI. Methods: patients undergoing PVI for recurrent AF were retrospectively evaluated. Only patients that started anticoagulation at least 3 weeks prior to the CT/CMR and subsequently uninterrupted until the ablation procedure were selected. An intracardiac echo (ICE) catheter was used in all patients to evaluate LA thrombus. The results of CT/CMR were compared to ICE imaging. Results: we included 272 consecutive patients averaging 54.5 years (71% male; 30% persistent AF). Average CHA2DS2VASC score was 0.9 ± 0.83 and mean LA diameter was 42 ± 5.7 mm, 111 (41%) patients were on Acenocumarol and 161 (59%) were on direct oral anticoagulants. Anticoagulation was started 227 ± 392 days before the CT/CMR, and 291 ± 416 days before the ablation procedure. CT/CMR diagnosed intracardiac thrombus in two cases, both in the LA appendage. A new CT/CMR revealed resolution of thrombus after six additional months of uninterrupted anticoagulation. No macroscopic thrombus was observed in any patients with ICE (negative predictive value of 100%; p < 0.01). Conclusions: CT and MRI are excellent surrogates to TEE and ICE to rule out intracardiac thrombus in patients adequately anticoagulated prior AF ablation. This is true even for delayed procedures as long as anticoagulation is uninterrupted

Impact of and reasons for not performing exercise training after an acute coronary syndrome in the setting of an interdisciplinary cardiac rehabilitation program: results from a risk-op- acute coronary syndrome ambispective registry

Background and Aims: exercise training (ET) is a critical component of cardiac rehabilitation (CR), but it remains underused. The aim of this study was to compare clinical outcomes between patients who completed ET (A-T), those who accepted ET but did not complete it (A-NT), and those who did not accept to undergo it (R-NT), and to analyze reasons for rejecting or not completing ET. Methods and Results: a unicenter ambispective observational registry study of 497 patients with acute coronary syndrome (ACS) was carried out in Barcelona, Spain, from 2016 to 2019. The primary endpoint was a composite of all-cause mortality, hospitalization for ACS, or need for revascularization during follow-up. Multivariable analysis was carried out to identify variables independently associated with the primary outcome. Initially, 70% of patients accepted participating in the ET, but only 50.5% completed it. The A-T group were younger and had fewer comorbidities. Baseline characteristics in A-NT and R-NT groups were very similar. The main reason for not undergoing or completing ET was rejection (reason unknown) or work/schedule incompatibility. The median follow-up period was 31 months. Both the composite primary endpoint and mortality were significantly lower in the A-T group compared to the A-NT and R-NT (primary endpoint: 3.6% vs. 23.2% vs. 20.4%, p < 0.001, respectively; mortality: 0.8% vs. 9.1% vs. 8.2%, p < 0.001; respectively). During multivariable analysis, the only variables that remained statistically significant with the composite endpoint were ET completion, previous ACS, and anemia. Conclusion: Completion of ET after ACS was associated with improved prognosis. Only half of the patients completed the ET program, with the leading reasons for not completing it being refusal (reason unknown) and work/schedule incompatibility. These results highlight the need to focus on the needs of patients in order to guarantee that structural barriers to ET no longer exist

Prognostic utility of a new risk stratification protocol for secondary prevention in patients attending cardiac rehabilitation

Several risk scores have been used to predict risk after an acute coronary syndrome (ACS), but none of these risk scores include functional class. The aim was to assess the predictive value of risk stratification (RS), including functional class, and how cardiac rehabilitation (CR) changed RS. Two hundred and thirty-eight patients with ACS from an ambispective observational registry were stratified as low (L) and no-low (NL) risk and classified according to exercise compliance; low risk and exercise (L-E), low risk and control (no exercise) (L-C), no-low risk and exercise (NL-E), and no-low risk and control (NL-C). The primary endpoint was cardiac rehospitalization. Multivariable analysis was performed to identify variables independently associated with the primary endpoint. The L group included 56.7% of patients. The primary endpoint was higher in the NL group (18.4% vs. 4.4%, p &lt; 0.001). After adjustment for age, sex, diabetes, and exercise in multivariable analysis, HR (95% CI) was 3.83 (1.51-9.68) for cardiac rehospitalization. For RS and exercise, the prognosis varied: the L-E group had a cardiac rehospitalization rate of 2.5% compared to 26.1% in the NL-C group (p &lt; 0.001). Completing exercise training was associated with reclassification to low-risk, associated with a better outcome. This easy-to-calculate risk score offers robust prognostic information. No-exercise groups were independently associated with the worst outcomes. Exercise-based CR program changed RS, improving classification and prognosis

The natural history of QTc interval and its clinical impact in coronavirus disease 2019 survivors after 1 year

Background and objective: Prolonged QTc interval on admission and a higher risk of death in SARS-CoV-2 patients have been reported. The long-term clinical impact of prolonged QTc interval is unknown. This study examined the relationship in COVID-19 survivors of a prolonged QTc on admission with long-term adverse events, changes in QTc duration and its impact on 1-year prognosis, and factors associated with a prolonged QTc at follow-up. Methods: We conducted a single-center prospective cohort study of 523 SARS-CoV-2-positive patients who were alive on discharge. An electrocardiogram was taken on these patients within the first 48 h after diagnosis and before the administration of any medication with a known effect on QT interval and repeated in 421 patients 7 months after discharge. Mortality, hospital readmission, and new arrhythmia rates 1 year after discharge were reviewed. Results: Thirty-one (6.3%) survivors had a baseline prolonged QTc. They were older, had more cardiovascular risk factors, cardiac disease, and comorbidities, and higher levels of terminal pro-brain natriuretic peptide. There was no relationship between prolonged QTc on admission and the 1-year endpoint (9.8% vs. 5.5%, p = 0.212). In 84% of survivors with prolonged baseline QTc, it normalized at 7.9 ± 2.2 months. Of the survivors, 2.4% had prolonged QTc at follow-up, and this was independently associated with obesity, ischemic cardiomyopathy, chronic obstructive pulmonary disease, and cancer. Prolonged baseline QTc was not independently associated with the composite adverse event at 1 year.Conclusions: Prolonged QTc in the acute phase normalized in most COVID-19 survivors and had no clinical long-term impact. Prolonged QTc at follow-up was related to the presence of obesity and previously acquired chronic diseases and was not related to 1-year prognosis

Additional file 1 of Baseline NT-proBNP levels as a predictor of short-and long-term prognosis in COVID-19 patients: a prospective observational study

Supplementary Material

An intensive, structured, mobile devices-based healthcare intervention to optimize the lipid-lowering therapy improves lipid control after an acute coronary syndrome

Aims: despite the evidence, lipid-lowering treatment (LLT) in secondary prevention remains insufficient, and a low percentage of patients achieve the recommended LDL cholesterol (LDLc) levels by the guidelines. We aimed to evaluate the efficacy of an intensive, mobile devices-based healthcare lipid-lowering intervention after hospital discharge in patients hospitalized for acute coronary syndrome (ACS). Methods and results: ambiespective register in which a mobile devices-based healthcare intervention including periodic follow-up, serial lipid level controls, and optimization of lipid-lowering therapy, if appropriate, was assessed in terms of serum lipid-level control at 12 weeks after discharge. A total of 497 patients, of which 462 (93%) correctly adhered to the optimization protocol, were included in the analysis. At the end of the optimization period, 327 (70.7%) patients had LDLc levels ≤ 70 mg/dL. 40% of patients in the LDLc ≤ 70 mg/dL group were upgraded to very-high intensity lipid-lowering ability therapy vs. 60.7% in the LDLc > 70 mg/dL group, p < 0.001. Overall, 38.5% of patients had at least a change in their LLT. Side effects were relatively infrequent (10.7%). At 1-year follow-up, LDLc levels were measured by the primary care physician in 342 (68.8%) of the whole cohort of 497 patients. In this group, 71.1% of patients had LDLc levels ≤ 70 mg/dL. Conclusion: an intensive, structured, mobile devices-based healthcare intervention after an ACS is associated with more than 70% of patients reaching the LDLc levels recommended by the clinical guidelines. In patients with LDLc measured at 1-year follow-up, 71.1% had LDLc levels ≤ 70 mg/dL

Myocardial injury as a prognostic factor in mid- and long-term follow-up of COVID-19 survivors

Myocardial injury, which is present in >20% of patients hospitalized for COVID-19, is associated with increased short-term mortality, but little is known about its mid- and long-term consequences. We evaluated the association between myocardial injury with one-year mortality and readmission in 172 COVID-19 patients discharged alive. Patients were grouped according to the presence or absence of myocardial injury (defined by hs-cTn levels) on admission and matched by age and sex. We report mortality and hospital readmission at one year after admission in all patients and echocardiographic, laboratory and clinical data at six months in a subset of 86 patients. Patients with myocardial injury had a higher prevalence of hypertension (73.3% vs. 50.0%, p = 0.003), chronic kidney disease (10.5% vs. 2.35%, p = 0.06) and chronic heart failure (9.3% vs. 1.16%, p = 0.03) on admission. They also had higher mortality or hospital readmissions at one year (11.6% vs. 1.16%, p = 0.01). Additionally, echocardiograms showed thicker walls in these patients (10 mm vs. 8 mm, p = 0.002) but without functional disorder. Myocardial injury in COVID-19 survivors is associated with poor clinical prognosis at one year, independent of age and sex, but not with echocardiographic functional abnormalities at six months