Possible Mechanism and Current Recommendation of Thromboembolism in COVID-19

The coronavirus disease (COVID-19) has become a global pandemic with a high mortality rate. There has been emerging evidence regarding the presence of thrombosis in patients with severe COVID-19 infection. In addition, prognosis of COVID patients, once they are complicated with DVT or fatal pulmonary emboli, will also significantly decline. Hence, understanding the pathomechanism and prompt treatment of thromboembolism is important in improving the outcome in COVID-19 patients. Prophylaxis anticoagulant was proposed for all hospitalized COVID-19 patients. The aim of this article is to review the current literature regarding pathomechanism, risk assessment, diagnosis, and management of VTE

High risk of ventricular repolarization abnormalities among hemodialytic end-stage renal disease patients

Introduction: Patients with chronic renal disease (CKD) are at a significantly elevated risk for ventricular arrhythmia. Several electrocardiographic (ECG) methods can be used to assess the ventricular arrhythmia risk on the standard 12-lead ECG.Aim: This study aimed to evaluate the ECG parameters of ventricular repolarization abnormalities, such as QT, QTc, Tp-e, and Tp-e/QT ratio, Tp-e/QTc ratio, and their predictors in hemodialytic end-stage renal disease (ESRD) patients.Materials and methods: Fifty-three patients with hemodialytic ESRD and 32 pre-dialytic CKD patients were enrolled in the study. ECG parameters were measured manually using calipers. The independent samples t-test was used for comparative analysis. The multivariate linear regression analysis was used to distinguish the independent predictors of each ECG parameters and variables correlating significantly in bivariate analysis.Results: Mean ages of hemodialytics and pre-dialytics were 47±11 and 51±7 years, respectively. Ventricular repolarization abnormalities in the hemodialytic compared to the pre-dialytic group were found to be significantly different [QTc (448±34 vs. 428±31 ms, p=0.007), Tp-e (81±20 vs. 71±19 ms, p=0.025), Tp-e/QT (0.23±0.06 vs. 0.20±0.05, p=0.043)]. QTc interval was positively correlated with sodium (p=0.001) and age (p=0.007). Tp-e/QT ratio was the ECG parameter correlated to most of variables including eGFR (p=0.003), creatinine (p=0.040), potassium (p=0.009), chloride (p=0.048), and glucose (p=0.041).Conclusions: Ventricular repolarization was found to be increased in patients with hemodialytic ESRD. Hence, observation ECG parameters of ventricular repolarization should be performed in the hemodialytic patients for early detection of ventricular arrhythmia

Potential biomarker of neutrophil extracellular traps in venous thromboembolism : a systematic review

Background: Neutrophil extracellular traps (NETs) are a network of extracellular DNA produced by activated neutrophils to trap and disarm microbes. NETs increase the formation of thrombus by forming a network frame that activates platelets and initiates coagulation. NETs were involved in the thrombogenic process and have been reported in various animal models. However, the evidence of NETs’ role in venous thromboembolism (VTE) development in humans is still scarce. This review aims to discover the relationship between NETs and VTE risk.Methods: We performed literature search to identify relevant available articles from PubMed, Cochrane Library, MEDLINE, EMBASE, Clinical Key between October 2009 until October 2019. The inclusion criteria were: clinical trials published in English, involving human as subjects, conducted within the past ten years, and had available and accessible full-text. In addition, Newcastle Ottawa Scale (NOS) was used to assess evidence quality.Results: Four studies with a total of 1,430 patients, i.e. three case controls and one cohort met our eligibility criteria. All four studies' quality was good. One study of cancer patients demonstrated that NETs increase VTE risk, two other studies demonstrated NETs correlate with deep vein thrombosis (DVT), and another study demonstrated there were increasing NETs in residual vein obstruction (RVO) and increased D-dimer. All four of the studies found a significant association of NETs and VTE occurrence (p=0.003; p=0.018; p<0.01; p<0.001, respectively).Conclusions: NETs are associated with an increased VTE risk. Further studies are necessary to determine the NETs’ role in VTE as a diagnostic biomarker or target of therapy.peer-reviewe

Poor Outcome of Right Bundle Branch Block Coexist with ST-Elevation Myocardial Infarction

BACKGROUND: The incidence of new-onset right bundle branch block (RBBB) coexistence with ST-elevation myocardial infarction (STEMI) has been associated with higher in-hospital mortality compared with those without RBBB.CASES: We present three cases of new-onset RBBB coexist with STEMI. Case I: a 64 years old male presented Killip I STEMI inferior-anterior with RBBB as new-onset. Rescue percutaneous coronary intervention (PCI) after failed thrombolytic was performed. New-onset atrial fibrillation (AF) with rapid ventricular response worsened his hemodynamic profile, leading to cardiogenic shock. Case II: an 80 years old male presented Killip IV late-onset anterior STEMI with new-onset RBBB. Cardiogenic shock got worsened after PCI stent. Case III: a 65 years old male presented Killip II extensive anterior STEMI with new-onset RBBB who underwent a primary PCI stent. Recurrent ventricular tachycardia (VT), worsening cardiogenic shock, and transient AV block occurred after PCI. The right bundle branch blood supply is mainly provided by a septal branch of left descending artery (LAD). Therefore, it may indicate proximal LAD occlusion and extensive infarction. Thus, catastrophic events may occur, which including acute heart failure, AV block, malignant ventricular arrhythmia, new-onset AF, and mostly cardiogenic shock, despite initiate reperfusion was performed without delay once the diagnosis is confirmed.  CONCLUSION: New RBBB suggests poor short-term prognosis due to its complication. Higher mortality is mostly linked to worsening cardiogenic shock

Relationship of D-dimer with severity and mortality in SARS-CoV-2 patients : A meta-analysis

Introduction: The novel severe acute respiratory syndrome coronavirus 2 (SARSCoV- 2) has caused a pandemic. Many studies have shown that several laboratory parameters are related to disease severity and mortality in SARS-CoV-2 cases. This meta-analysis aimed to determine the relationship of a prognostic factor, D-dimer, with disease severity, need for intensive care unit (ICU) care, and mortality in SARSCoV- 2 patients. Methods: A systematic search for all observational studies and trials involving adult patients with SARS-CoV-2 that had any data related to D-dimer on admission was conducted using PubMed, Science Direct, Scopus, ProQuest, and MedRxiv databases. We performed random-effects inverse-variance weighting analysis using mean difference (MD) of D-dimer values for outcomes such as disease severity, mortality, and need for ICU care. Results: A total of 29 studies (4,328 patients) were included in this meta-analysis, which revealed a higher mean of D-dimer levels on admission in severe patients than in nonsevere patients (MD = 0.95, [95% confidence interval (CI): 0.61-1.28], P < .05; I2 = 90%). The nonsurvivor group had a higher pooled MD of D-dimer values on admission (MD = 5.54 [95% CI: 3.40-7.67], P < .05; I2 = 90%). Patients who needed ICU admission had insignificantly higher D-dimer values than patients who did not need ICU admission (MD = 0.29, [95% CI: −0.05 to 0.63], P = .10; I2 = 71%). Conclusion: Elevated D-dimer levels on admission were associated with an increased risk of disease severity and mortality in patients with SARS-CoV-2 infectio

Treatment considerations in total anomalous pulmonary venous connection

Background Total anomalous pulmonary venous connection (TAPVC) is a rare cyanotic abnormality that accounts for about 1%–3% of congenital heart disease malformations. TAPVC is a condition in which there is no direct connection between all four pulmonary veins and the left atrium but makes abnormal connections to the right atrium or systemic venous system. TAPVC caused a high mortality rate of 80% in the first year of life, and 50% of them die within 3 months after birth without intervention. Objectives The aim of this review is to elucidate the various treatment considerations of TAPVC. Methods A literature search was conducted on PubMed, ScienceDirect and Google Scholar using various combinations of keywords related to treatment of TAPVC. The citations from all selected articles were reviewed for additional studies. Results and Conclusion TAPVC intervention, including medical and surgical, is tailored to each type of TAPVC. Catheter-based interventions are frequently used to temporize neonates and provide time to optimize patients medically prior to definite repair. Corrective surgery is required for all patients with this condition. Several latest catheter-based or surgical intervention technique modifications have also been reported

Hypertension and COVID-19: Potential use of beta-blockers and a call for Randomized Evidence

Hypertension is one of the most common morbidities in COVID-19. Previous studies demonstrated that hypertension increases composite poor outcomes in patients with COVID-19. Beta-blockers is widely used as one of the most common antihypertensive agents. Beta-blockers may hold potential benefits in COVID-19 treatment, with current evidence of the potential mechanism of beta-blockers remains scarce. However, several mechanisms were suggested, including decreasing RAAS pathway activity and lowering the ACE2 levels, reducing cytokine storms, and may be beneficial in reducing mortality in ARDS related COVID-19. Further large-scale randomized clinical trials should be conducted before a definite recommendation can be drawn

Paradoxical heart rate response after atropine sulfate administration in total atrioventricular block complicating acute myocardial infarction: A case report

Acute myocardial infarction is sometimes complicated by atrioventricular block. Advanced cardiac life support guideline for the treatment of atrioventricular block suggests early use of atropine. Atropine works as a parasympatholytic drug that enhances SA node automaticity and AV node conduction. We report a case of a male patient with inferior myocardial infarction and total atrioventricular block who showed a marked reduction in heart rate after first and second atropine administration, a paradoxical worsening of the block. Atropine has been associated with some adverse consequences, including proarrhythmic effect, worsening of the high-grade atrioventricular block, and worsening of the ischemic situation. In this case of total atrioventricular block caused by acute myocardial infarction, immediate revascularization can be the only required management. Awareness of this potential adverse reaction will help the clinician make a risk/benefit ratio consideration regarding the use of atropine for certain patients