Right atrial thrombus, junctional tachycardia, and critical lower limb ischemia: three rare complications of severe acute respiratory syndrome coronavirus 2 infection

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can engender multi-system inflammatory syndrome. Its main symptoms are cardiovascular and thromboembolic problems that can develop into severe complications. The present case is about a 55-year-old patient who was admitted for critical ischemia of the right lower limb and necrosis of the right forefoot. The patient was infected with coronavirus disease 2019 (COVID-19) one month before her admission. The patient also has cardiovascular risks including type 2 diabetes and hypertension. The performance of ultrasounds revealed a thrombus in the right atrium and the pulmonary artery, and arteriography detected an occlusion of the right popliteal joint for which she had an endovascular recanalization and amputation of the right forefoot. This case highlights that SARS-CoV-2 infection could be considered a serious cardiovascular disease requiring cardiovascular explorations to initiate hospital management and avoid severe complications

Association between body mass index and outcomes after percutaneous coronary intervention in multi-ethnic south east Asian population: A retrospective analysis of the Malaysian National Cardiovascular Disease Database - percutaneous coronary intervention (NCVD-PCI) registry / Zaid Azhari

Objective: The state of being obese has been generally associated with worse outcomes in many clinical conditions. However, it has been shown in certain settings that obesity might be protective and had better outcomes, and this phenomenon is called "obesity paradox". This study was conducted to examine the relationship between body mass index (BMI) and outcomes after percutaneous coronary intervention (PCI) in a multi-ethnic South East Asian population. Methods: This is a retrospective study of anonymized data obtained from the Malaysian National Cardiovascular Disease Database - Percutaneous Coronary Intervention (NCVD-PCI) registry. 28,742 patients from the NCYD-PCl registry who had their first PCI between January 2007 and December 2014 were included. Those without their body mass index (BMI) recorded or BMI less than 11 kg/m2 or more than 70 kg/m2 were excluded. The patients were divided according to their BMI group , and their baseline characteristics, angiographic profiles and medications upon disharge were compared. In-hospital death, major adverse cardiovascular events (MACE), and vascular complication between different BMI groups were also calculated. Results: The patients were divided into four groups; underweight (BMI 23 kg/m2), overweight (BMI 23 to 27.5 kg/m2). Comparison of their baseline characteristics showed that the obese group was younger, had lower prevalence of smoking but higher prevalence of diabetes, hypertension, and dyslipidemia.Obese patients were more likely to have multi-vessel disease, but lesser involvement of the Left Anterior Descending (LAD) artery. There was no difference found in terms of in-hospital death, MACE and vascular complications after PCI. multivariable Cox proportional hazard regression analysis showed that compared to normal BMI group, the underweight group had a non-significant difference (HR: 1.02, p=0.952), while the overweight group had significantly lower risk of 1-year mortality (HR:0.71, p=0.005). The obese group also showed lower HR but this was non-significant (HR: 0.78, P=0.056). Conclusion: Using Asian specific BMI cut-off points, the overweight group in our study population was independently associated with lower risk of 1-year mortality afler PCI compared to the normal BMI group

Outcomes of STEMI patients with chronic kidney disease treated with percutaneous coronary intervention: the Malaysian National Cardiovascular Disease Database – Percutaneous Coronary Intervention (NCVD-PCI) registry data from 2007 to 2014

Abstract Background Patients with renal impairment often left out from most major clinical trials assessing the optimal treatment for ST-elevation myocardial infarction (STEMI). Large body of evidence from various cardiovascular registries reflecting more ‘real-world’ experience might contribute to the knowledge on how best to treat this special cohort. We aim to analyze the outcomes of Malaysian STEMI patients with renal impairment treated with coronary angioplasty. Methods Utilizing the Malaysian National Cardiovascular Disease Database-Percutaneous Coronary Intervention (NCVD-PCI) registry data from 2007 to 2014, STEMI patients treated with percutaneous coronary intervention (PCI) were stratified into presence (GFR < 60 mls/min/1.73m2) or absence (GFR ≥ 60 mls/min/1.73m2) of chronic kidney disease (CKD). Patient’s demographics, extent of coronary artery disease, procedural data, discharge medications, short (in-hospital) and long (1 year) term outcomes were critically assessed. Results A total of 6563 patients were included in the final analysis. STEMI CKD cohort was predominantly male (80%) with mean age of 61.02 ± 9.95 years. They had higher cardiovascular risk factors namely diabetes mellitus (54.6%), hypertension (79.2%) and dyslipidemia (68.8%) in contrast to those without CKD. There were notably higher percentage of CKD patients presented with Killip class 3 and 4; 24.9 vs 8.7%. Thrombolytic therapy remained the most commonly instituted treatment regardless the status of kidney function. Furthermore, our STEMI CKD cohort also was more likely to receive less of evidence-based treatment upon discharge. In terms of outcomes, patients with CKD were more likely to develop in-hospital death (OR: 4.55, 95% CI 3.11–6.65), MACE (OR: 3.42, 95% CI 2.39–4.90) and vascular complications (OR: 1.88, 95% CI 0.95–3.7) compared to the non-CKD patients. The risk of death at 1-year post PCI in STEMI CKD patients was also reported to be high (HR: 3.79, 95% CI 2.84–5.07). Conclusion STEMI and CKD is a deadly combination, proven in our cohort, adding on to the current evidence in the literature. We noted that our STEMI CKD patients tend to be younger than the Caucasian with extremely high prevalence of diabetes mellitus. The poor outcome mainly driven by immediate or short term adverse events peri-procedural, therefore suggesting that more efficient treatment in this special group is imperative

Empagliflozin in Patients with Chronic Kidney Disease

Background The effects of empagliflozin in patients with chronic kidney disease who are at risk for disease progression are not well understood. The EMPA-KIDNEY trial was designed to assess the effects of treatment with empagliflozin in a broad range of such patients. Methods We enrolled patients with chronic kidney disease who had an estimated glomerular filtration rate (eGFR) of at least 20 but less than 45 ml per minute per 1.73 m(2) of body-surface area, or who had an eGFR of at least 45 but less than 90 ml per minute per 1.73 m(2) with a urinary albumin-to-creatinine ratio (with albumin measured in milligrams and creatinine measured in grams) of at least 200. Patients were randomly assigned to receive empagliflozin (10 mg once daily) or matching placebo. The primary outcome was a composite of progression of kidney disease (defined as end-stage kidney disease, a sustained decrease in eGFR to &lt; 10 ml per minute per 1.73 m(2), a sustained decrease in eGFR of &amp; GE;40% from baseline, or death from renal causes) or death from cardiovascular causes. Results A total of 6609 patients underwent randomization. During a median of 2.0 years of follow-up, progression of kidney disease or death from cardiovascular causes occurred in 432 of 3304 patients (13.1%) in the empagliflozin group and in 558 of 3305 patients (16.9%) in the placebo group (hazard ratio, 0.72; 95% confidence interval [CI], 0.64 to 0.82; P &lt; 0.001). Results were consistent among patients with or without diabetes and across subgroups defined according to eGFR ranges. The rate of hospitalization from any cause was lower in the empagliflozin group than in the placebo group (hazard ratio, 0.86; 95% CI, 0.78 to 0.95; P=0.003), but there were no significant between-group differences with respect to the composite outcome of hospitalization for heart failure or death from cardiovascular causes (which occurred in 4.0% in the empagliflozin group and 4.6% in the placebo group) or death from any cause (in 4.5% and 5.1%, respectively). The rates of serious adverse events were similar in the two groups. Conclusions Among a wide range of patients with chronic kidney disease who were at risk for disease progression, empagliflozin therapy led to a lower risk of progression of kidney disease or death from cardiovascular causes than placebo