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Severe acute respiratory syndrome coronavirus 2 infections are associated with greater risk of both arterial and venous thromboembolic events. This has been attributed to a florid pro-inflammatory state resulting in microvascular dysfunction, activation of platelets and procoagulant systems as well as possible direct endothelial injury. The associated morbidity and mortality of these events has prompted much speculation and varied anticoagulation and fibrinolytic strategies based on multiple criteria including disease severity and biomarkers. No clear definitive benefit has been established with these approaches, which have frequently led to greater bleeding complications without significant mortality benefit. In this review, we outline the burden of these thromboembolic events in coronavirus disease-2019 (COVID-19) as well as the hypothesized contributory biological mechanisms. Finally, we provide a brief overview of the major clinical studies on the topic, and end with a summary of major societal guideline recommendations on anticoagulation in COVID-19.

Introduction Asthma is one of the most common chronic diseases worldwide. As a disease of the respiratory tract, the site of entry for the SARS-CoV-2 virus, there may be an important interplay between asthma and COVID-19 disease. Areas covered We report asthma prevalence among hospitalized cohorts with COVID-19. Those with non-allergic and severe asthma may be at increased risk of a worsened clinical outcome from COVID-19 infection. We explore the epidemiology of asthma as a risk factor for the severity of COVID-19 infection. We then consider the role COVID-19 may play in leading to exacerbations of asthma. The impact of asthma endotype on outcome is discussed. Lastly, we address the safety of common asthma therapeutics. A literature search was performed with relevant terms for each of the sections of the review using PubMed, Google Scholar, and Medline. Expert opinion Asthma diagnosis may be a risk factor for severe COVID-19 especially for those with severe disease or nonallergic phenotypes. COVID-19 does not appear to provoke asthma exacerbations and asthma therapeutics should be continued for patients with exposure to COVID-19. Clearly much regarding this topic remains unknown and we identify some key questions that may be of interest for future researchers.[Figure: see text].

Objectives This study sought to identify electrocardiographic (ECG) and clinical predictors of sudden cardiac arrest (SCA) in sarcoidosis. Background Sudden cardiac death (SCD) is the leading cause of death in cardiac sarcoidosis (CS) and may be the earliest manifestation of disease. Widespread or repeated advanced imaging is a challenging solution to this problem. ECG is an affordable and widely accessible modality that could help guide diagnostic approaches and risk stratification. Methods Data were obtained from the National Inpatient Sample (2005–2017) using International Classification of Diseases-9th Revision and -10th Revision-Clinical Modification. The primary outcome was to identify predictors of SCA, whereas predictors of SCA in young individuals and those with normal ventricular function served as secondary measures. Furthermore, temporal trends in sarcoidosis as well as SCA were also analyzed. Logistic regression analysis was used to calculate odds ratios, following which a multivariable regression was used to adjust for potential confounders. Results Electrocardiographic markers of AV node dysfunction or bundle branch block are associated with substantially increased risk of SCA in a limited proportion of patients (8.6%). This association is also observed among younger patients ( Conclusions ECG evidence of AV nodal dysfunction or distal conduction disease should raise suspicion for cardiac involvement in patients with sarcoidosis and are associated with increased risk of SCA. ECG markers could help identify patients who would benefit from advanced imaging. The sensitivity of ECGs is, however, limited and presence of a normal ECG does not reflect a low risk of SCA.

Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in patients with heart failure. These benefits of MRAs vary in different heart failure populations based on left ventricular ejection fraction and associated comorbidities.We define the pharmacologic properties of MRAs and the pathophysiological rationale for their utility in heart failure. We outline the current literature on the use of MRAs in different heart failure populations, including reduced and preserved ejection fraction (HFrEF/HFpEF) and acute heart failure decompensation. Finally, we describe the limitations of currently available data and propose future directions of study.While there is strong evidence supporting the use of MRAs in HFrEF, evidence in patients with HFpEF or acute heart failure is less definitive. Comorbidities such as obesity or atrial fibrillation could be clinical modifiers of the response to MRAs and potentially alter the risk/benefit ratio in these subpopulations. Emerging evidence for new non-steroidal MRAs reveal promising preliminary results that, if confirmed in large randomized clinical trials, could favor a change in clinical practice.

Postural orthostatic tachycardia syndrome (POTS) is an increasingly well-recognized condition encountered in clinical practice. Diagnosis and treatment remain extremely challenging. The limited success of currently available therapies has laid the foundation for a number of experimental therapies.In this review, we will briefly outline the pathophysiology and clinical features of this syndrome, before moving on to its management, with a specific focus on experimental pharmacological therapies. Finally, we briefly discuss POTS related to the SARS CoV-2 (COVID-19) pandemic.Despite tremendous advances, the diagnosis and management of POTS remains extremely challenging. The multitude of contributory mechanisms, which predominate to varying degrees in different patients further complicates management. Improved characterization of pathophysiological phenotypes is essential to individualize management. Lifestyle measures form the first line of therapy, followed by beta-blockers, ivabradine, fludrocortisone, and midodrine. Supplemental therapies such as iron, vitamin D and α lipoic acid are quite safe and a trial of their use is reasonable. The use of erythropoietin, IVIG, desmopressin, etc., are more specialized and nuanced alternatives. In recent years, interest has grown in the use of cardiac neuromodulation. Though preliminary, some of these therapies are quite promising.

BACKGROUND: The impact of asthma diagnosis and asthma endotype on outcomes from coronavirus disease 2019 (COVID-19) infection remains unclear. OBJECTIVE: To describe the association between asthma diagnosis and endotype and clinical outcomes among patients diagnosed as having COVID-19 infection. METHODS: Retrospective multicenter cohort study of outpatients and inpatients presenting to 6 hospitals in the Mount Sinai Health System New York metropolitan region between March 7, 2020, and June 7, 2020, with COVID-19 infection, with and without a history of asthma. The primary outcome evaluated was in-hospital mortality. Secondary outcomes included hospitalization, intensive care unit admission, mechanical ventilation, and hospital length of stay. The outcomes were compared in patients with or without asthma using a multivariate Cox regression model. The outcomes stratified by blood eosinophilia count were also evaluated. RESULTS: Of 10,523 patients diagnosed as having COVID-19 infection, 4902 were hospitalized and 468 had a diagnosis of asthma (4.4%). When adjusted for COVID-19 disease severity, comorbidities, and concurrent therapies, patients with asthma had a lower mortality (adjusted odds ratio [OR], 0.64 (0.53-0.77); P < .001) and a lower rate of hospitalization and intensive care unit admission (OR, 0.43 (0.28-0.64); P < .001 and OR, 0.51 (0.41-0.64); P < .001, respectively). Those with blood eosinophils greater than or equal to 200 cells/µL, both with and without asthma, had lower mortality. CONCLUSION: Patients with asthma may be at a reduced risk of poor outcomes from COVID-19 infection. Eosinophilia, both in those with and without asthma, may be associated with reduced mortality risk.

Studies evaluating fish consumption and cardiovascular disease events have shown inconsistent results. We performed a systematic review of peer-reviewed publications from an extensive query of Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Scopus, and Web of Science from database inception to September 2020 for observational studies that reported the association between fish consumption and cardiovascular disease events. We identified and reviewed 24 studies related to fish consumption and the effect on cardiovascular outcomes. The study population included a total of 714,526 individuals and multiple cohorts from several countries. We found that nonfried fish consumption is probably associated with a reduced risk of overall cardiovascular disease events and myocardial infarction risk. In contrast, fried fish consumption is probably associated with an increased risk of overall cardiovascular disease events and myocardial infarction risk. No studies to date have shown any significant association between fish consumption and stroke. Our analysis suggests that fish consumption may reduce cardiovascular disease events, but fried fish consumption was associated with an increased risk of cardiovascular events.

Background Catheter ablation is increasingly employed in the management of atrial fibrillation (AF). Data regarding safety of ablation of AF is largely derived from controlled clinical trials. Objectives The aim of this study was to analyze safety and complications of AF ablation performed in a "real world" setting outside of clinical trials, and obtain insights on predictors of complications. Methods We utilized the National Inpatient Sample database, to identify all patients who underwent AF ablations between 2015 and 2017 using International Classification of Disease-Tenth revision codes. Complications were defined as per the Agency for Health Care Research and Quality Guidelines. Statistical tests including multivariate logistic regression were performed to determine predictors of complications. Results Among 14,875 cases of AF ablation between 2015 and 2017, a total of 1884 complications were identified among 1080 (7.2%) patients. Patients with complications were likely to be older and female with a higher burden of comorbidities. A 27% increase in complications was observed from 2015 to 2017, driven by an increase in pericardial complications. Multivariate regression analysis revealed that pulmonary hypertension (adjusted odds ratio [aOR]: 1.99, p = .041) and chronic kidney disease (CKD; aOR: 1.67, p = .024), were independent predictors of complications. Centers with higher procedural volumes were associated with lower complication rates. Conclusions Complication rates related to AF ablations remain substantially high. Presence of pulmonary hypertension and CKD are predictive of higher procedural complications. Furthermore, hospital procedure volume is an important factor that correlates with complication rates.

There are limited data to guide the most effective anticoagulation strategy in patients with a bioprosthetic heart valve and concomitant atrial fibrillation (AF). The use of vitamin-K antagonists (...

Introduction: Heart failure is a major public health concern that is expected to increase over the decades to come. Despite significant advances, fluid overload and congestion remain a major therapeutic challenge. Vascular congestion and neurohormonal activation are intricately linked and the goal of therapy fundamentally aims to reduce both.Areas covered: The authors briefly review a number of core concepts that elucidate the link between fluid overload and neuro-hormonal activation. This is followed by a review of heart-kidney interactions and the impact of diuresis in this setting. Following an in-depth review of currently available pharmacological agents, the rationale and evidence behind their use, the authors end with a brief note on novel agents/approaches to aid volume management in HF.Expert opinion: A number of non-pharmacological advances in the management of volume overload in heart failure, though promising - are associated with a number of shortcomings. Pharmacological therapy remains the cornerstone of volume management. A number of novel approaches, utilizing existing therapies as well as the emergence of new agents over the past decade bode well for the vulnerable HF population.

Data on long-term outcomes of catheter ablation (CA) for atrial fibrillation (AF) in outside of clinical trials settings are sparse.We aimed to assess outcomes and readmissions at 1 year following admission for CA for AF.Utilizing the Nationwide Readmissions Database (2016-2018), we identified patients with CA among all patients with a primary admission diagnosis of AF, and a control group by propensity score match adjusted for age, sex, comorbidities, CHA₂DS₂-VASc scores, and the hospital characteristics. The primary outcome was a composite of unplanned heart failure (HF), AF and stroke-related readmissions, and death at 1 year, and secondary outcomes were hospital outcomes and all-cause readmission rates.The study cohort consisted of 29,771 patients undergoing CA and 63,988 controls. Patients undergoing CA were younger with lower CHA₂DS₂-VASc scores and less comorbidities. Over a follow-up of 170 ±1.1 days, the primary outcome occurred in 5.2% in CA group and 6.0% of controls (hazard ratio [HR] and 95% confidence interval [CI]: 0.86 [0.76-0.94], p = .002). CA affected AF and stroke related readmission, but showed no effect on HF and mortality outcome. Male sex (HR: 0.83 [0.74-0.94], p = .03), younger age (HR: 0.71 [0.61-0.83], p .001], and lower CHA₂DS₂-VASc scores (HR: 0.68 [0.55-0.84], p .001) were associated with lower risk of primary outcome with CA.In this study, CA for AF was associated with significantly lower AF and stroke-related admissions, but not to HF or all-cause readmission. Better outcomes were seen among males, younger patients, and in patients with less comorbidities and low CHA₂DS₂-VASc scores.

Cardiogenic shock is associated with high short-term mortality. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a mechanical circulatory support strategy for patients with refractory cardiogenic shock. A drawback of this hemodynamic support strategy is increased left ventricular (LV) afterload, which is mitigated by concomitant use of Impella (extracorporeal membrane oxygenation with Impella [ECPELLA]). However, data regarding the benefits of this approach are limited. We conducted a systematic search of Medline, EMBASE, and Cochrane databases to identify studies including patients with cardiogenic shock reporting clinical outcomes with Impella plus VA-ECMO compared with VA-ECMO alone. Primary outcome was short-term all-cause mortality (in-hospital or 30-day mortality). Secondary outcomes included major bleeding, hemolysis, continuous renal replacement therapy, weaning from mechanical circulatory support, limb ischemia, and transition to destination therapy with LV assist device (LVAD) or cardiac transplant. Of 2,790 citations, 7 observational studies were included. Of 1,054 patients with cardiogenic shock, 391 were supported with ECPELLA (37%). Compared with patients on only VA-ECMO support, patients with ECPELLA had a lower risk of short-term mortality (risk ratio [RR] 0.89 [0.80 to 0.99], Isup2/sup = 0%, p = 0.04) and were significantly more likely to receive a heart transplant/LVAD (RR 2.03 [1.44 to 2.87], Isup2/sup = 0%, plt;0.01). However, patients with ECPELLA had a higher risk of hemolysis (RR 2.03 [1.60 to 2.57], Isup2/sup = 0%, plt;0.001), renal failure requiring continuous renal replacement therapy (RR 1.46 [1.23 to 174], Isup2/sup = 11%, plt;0.0001), and limb ischemia (RR 1.67 [1.15 to 2.43], Isup2/sup = 0%, p = 0.01). In conclusion, among patients with cardiogenic shock requiring VA-ECMO support, concurrent LV unloading with Impella had a lower likelihood of short-term mortality and a higher likelihood of progression to durable LVAD or heart transplant. However, patients supported with ECPELLA had higher rates of hemolysis, limb ischemia, and renal failure requiring continuous renal replacement therapy. Future prospective randomized are needed to define the optimal treatment strategy in this high-risk cohort.

The role of electromechanical dyssynchrony in heart failure gained prominence in literature with the results of trials of cardiac resynchronization therapy (CRT). CRT has shown to significantly decrease heart failure hospitalization and mortality in heart failure patients with dyssynchrony. Current guidelines recommend the use of electrical dyssynchrony based on a QRS150 ms and a left bundle branch block pattern on surface electrocardiogram to identify dyssynchrony in patients who will benefit from CRT implantation. However, predicting response to CRT remains a challenge with nearly one-third of patients gaining no benefit from the device. Multiple echocardiographic measures of mechanical dyssynchrony have been studied over the past two decade. However, trials where mechanical dyssynchrony used as an additional or lone criteria for CRT failed to show any benefit in the response to CRT. This shows that a deeper understanding of cardiac mechanics should be applied in the assessment of dyssynchrony. This review discusses the evolving role of imaging techniques in assessing cardiac dyssynchrony and their application in patients considered for device therapy.

The 2017 American Heart Association Scientific Statement on meditation and cardiovascular risk suggested that meditation may be considered as an adjunct to guideline-directed cardiovascular risk-reduction interventions. Meditation could potentially increase physical and mental relaxation, leading to improved outcomes after a major cardiovascular event. We hypothesized that meditation is associated with lower cardiovascular risk in the US general population. Using data from the 2012 and 2017 National Health Interview Survey, we identified all patients with hypercholesterolemia, systemic hypertension (SH), diabetes mellitus (DM), stroke, and coronary artery disease (CAD), as well as those who reported that they meditate. Multivariable logistic regression analyses were performed to evaluate the association between meditation and risk of hypercholesterolemia, SH, DM, stroke, and CAD, adjusting for potential confounders. Of 61,267 the National Health Interview Survey participants, 5,851 (9.6%) participated in some form of meditation. After adjusting for age, gender, body mass index, race, marital status, cigarette smoking, sleeping duration, and depression, meditation was independently associated with a lower prevalence of hypercholesterolemia (odds ratio [OR] 0.65; 95% confidence interval [CI] 0.54 to 0.79; p = 0.001), SH (OR 0.86; 95% CI 0.75 to 0.99; p = 0.04), diabetes (OR 0.70; 95% CI 0.59 to 0.84; p = 0.0001), stroke (OR 0.76; 95% CI 0.58 to 0.99; p = 0.04), or CAD (OR 0.51; 95% CI 0.39 to 0.66; p0.001), compared with those who did not meditate. In conclusion, using a large national database, we found that meditation is associated with a lower prevalence of cardiovascular risks factors and disease.

Predictive models for key outcomes of coronavirus disease 2019 (COVID-19) can optimize resource utilization and patient outcome. We aimed to design and internally validate a web-based calculator predictive of hospitalization and length of stay (LOS) in a large cohort of COVID-19-positive patients presenting to the Emergency Department (ED) in a New York City health system. The study cohort consisted of consecutive adult ( 18 years) patients presenting to the ED of Mount Sinai Health System hospitals between March 2020 and April 2020, diagnosed with COVID-19. Logistic regression was utilized to construct predictive models for hospitalization and prolonged ( 3 days) LOS. Discrimination was evaluated using area under the receiver operating curve (AUC). Internal validation with bootstrapping was performed, and a web-based calculator was implemented. From 5859 patients, 65% were hospitalized. Independent predictors of hospitalization and extended LOS included older age, chronic kidney disease, elevated maximum temperature, and low minimum oxygen saturation (p 0.001). Additional predictors of hospitalization included male sex, chronic obstructive pulmonary disease, hypertension, and diabetes. AUCs of 0.881 and 0.770 were achieved for hospitalization and LOS, respectively. Elevated levels of CRP, creatinine, and ferritin were key determinants of hospitalization and LOS (p 0.05). A calculator was made available under the following URL: https://covid19-outcome-prediction.shinyapps.io/COVID19_Hospitalization_Calculator/ . This study yielded internally validated models that predict hospitalization risk in COVID-19-positive patients, which can be used to optimize resource allocation. Predictors of hospitalization and extended LOS included older age, CKD, fever, oxygen desaturation, elevated C-reactive protein, creatinine, and ferritin.

Background Despite advances in resuscitation medicine, the burden of in‐hospital cardiac arrest (IHCA) remains substantial. The impact of these advances and changes in resuscitation guidelines on IHCA survival remains poorly defined. To better characterize evolving patient characteristics and temporal trends in the nature and outcomes of IHCA, we undertook a 20‐year analysis of a national database. Methods and Results We analyzed the National Inpatient Sample (1999–2018) using International Classification of Diseases , Ninth Revision and Tenth Revision, Clinical Modification ( ICD‐9‐CM and ICD‐10‐CM ) codes to identify all adult patients suffering IHCA. Subgroup analysis was performed based on the type of cardiac arrest (ie, ventricular tachycardia/ventricular fibrillation or pulseless electrical activity‐asystole). An age‐ and sex‐adjusted model and a multivariable risk‐adjusted model were used to adjust for potential confounders. Over the 20‐year study period, a steady increase in rates of IHCA was observed, predominantly driven by pulseless electrical activity‐asystole arrest. Overall, survival rates increased by over 10% after adjusting for risk factors. In recent years (2014–2018), a similar trend toward improved survival is noted, though this only achieved statistical significance in the pulseless electrical activity‐asystole cohort. Conclusions Though the ideal quality metric in IHCA is meaningful neurological recovery, survival is the first step toward this. As overall IHCA rates rise, overall survival rates are improving in tandem. However, in more recent years, these improvements have plateaued, especially in the realm of ventricular tachycardia/ventricular fibrillation‐related survival. Future work is needed to better identify characteristics of IHCA nonsurvivors to improve resource allocation and health care policy in this area.

INTRODUCTION Despite tremendous advances, the shortcomings of current therapies for coronary disease are evidenced by the fact that it remains the leading cause of death in many parts of the world. There is hence a drive to develop novel therapies to tackle this disease. Therapeutic approaches to coronary angiogenesis have long been an area of interest in lieu of its incredible, albeit unrealized potential. AREAS COVERED This paper offers an overview of mechanisms of native angiogenesis and a description of angiogenic growth factors. It progresses to outline the advances in gene and stem cell therapy and provides a brief description of other investigational approaches to promote angiogenesis. Finally, the hurdles and limitations unique to this particular area of study are discussed. EXPERT OPINION An effective, sustained, and safe therapeutic option for angiogenesis truly could be the paradigm shift for cardiovascular medicine. Unfortunately, clinically meaningful therapeutic options remain elusive because promising animal studies have not been replicated in human trials. The sheer complexity of this process means that numerous major hurdles remain before therapeutic angiogenesis truly makes its way from the bench to the bedside.

Gas hydrates are ice-like crystalline minerals with high energy concentrations, which generally occur in deepwater environments, at low temperature and high pressure, usually close to the seafloor. Gas hydrate research wells are normally drilled riser-less, with multiple wells being drilled in rapid succession. Logging-while-drilling (LWD) is the preferred logging method as the borehole condition in such shallow formations deteriorates very rapidly after drilling. LWD helps minimize the time between drilling and logging. The LWD sonic measurement is key in such projects and is used typically for geomechanics and formation evaluation purposes. The water-bearing sedimentary section within the shallow gas hydrate stability zone is often shale-rich, unconsolidated and the measured acoustic wave slowness is “extremely slow”, with shear slowness above 1400 μs/ft and bulk density of around 1.7 gm/cc. Quadrupole measurements are commonly used in the industry to log shear slowness with LWD tools in slow formations, where the shear slowness is slower than the borehole fluid slowness. However, it is very challenging to log shear slownesses with LWD sonic tool in these extremely slow formations, even with a quadrupole measurement. This paper details the challenges related to borehole acoustics logging in gas hydrate research wells, outlines the key technological enablers and gives an overview of the performance of LWD sonic tools during the National Gas Hydrate Program Expedition 02 (NGHP-02) in the offshore of India. It will spotlight the innovative approach followed to modify the LWD sonic acquisition and processing to adapt to the extremely slow acoustic wave speeds, which facilitated recording LWD shear slowness up to approximately 1400 μs/ft.

The thromboembolic complications of Atrial fibrillation remain a major problem in contemporary clinical practice. Despite advances and developments in anticoagulation strategies, therapy is complicated by the high risk of bleeding complications and need for meticulous medicationcompliance. Over the past few decades, the left atrial appendage has emerged as a promising therapeutic target to prevent thromboembolic events while mitigating bleeding complications and compliance issues. Emerging data indicates that it is a safe, effective and feasible alternative to systemic anticoagulation in patients with non-valvular atrial fibrillation. A number of devices have been developed for endocardial or epicardial based isolation of the left atrial appendage. Increasing experience has improved overall procedural safety and ease while simultaneously reducing device related complication rates. Furthermore, increasing recognition of the non-mechanical advantages of this procedure has led to further interest in its utility for further indications beyond the prevention of thromboembolic complications. In this review, we present a comprehensive overview of the evolution of left atrial appendage occlusion, commercially available devices and the role of this modality in the current management of atrial fibrillation. We also provide a brief outline of the landmark trials supporting this approach as well as the ongoing research and future prospects of left atrial appendage occlusion This article is protected by copyright. All rights reserved.

BackgroundCoronavirus disease 2019 (COVID-19) has evolved into a true global pandemic infecting more than 30 million people worldwide. Predictive models for key outcomes have the potential to optimize resource utilization and patient outcome as outbreaks continue to occur worldwide. We aimed to design and internally validate a web-based calculator predictive of hospitalization and length of stay (LOS) in a large cohort of COVID-19 positive patients presenting to the Emergency Department (ED) in a New York City health system.MethodsThe study cohort consisted of consecutive adult (>18 years) patients presenting to the ED of one of the Mount Sinai Health System hospitals between March, 2020 and April, 2020 who were diagnosed with COVID-19. Logistic regression was utilized to construct predictive models for hospitalization and prolonged (>3 days) LOS. Discrimination was evaluated using area under the receiver operating curve (AUC). Internal validation with bootstrapping was performed, and a web-based calculator was implemented.ResultsThe cohort consisted of 5859 patients with a hospitalization rate of 65% and a prolonged LOS rate of 75% among hospitalized patients. Independent predictors of hospitalization included older age (OR=6.29; 95% CI [1.83-2.63], >65 vs. 18-44), male sex (OR=1.35 [1.17-1.55]), chronic obstructive pulmonary disease (OR=1.74; [1.00-3.03]), hypertension (OR=1.39; [1.13-1.70]), diabetes (OR=1.45; [1.16-1.81]), chronic kidney disease (OR=1.69; [1.23-2.32]), elevated maximum temperature (OR=4.98; [4.28-5.79]), and low minimum oxygen saturation (OR=13.40; [10.59-16.96]). Predictors of extended LOS included older age (OR=1.03 [1.02-1.04], per year), chronic kidney disease (OR=1.91 [1.35-2.71]), elevated maximum temperature (OR=2.91 [2.40- 3.53]), and low minimum percent oxygen saturation (OR=3.89 [3.16-4.79]). AUCs of 0.881 and 0.770 were achieved for hospitalization and LOS, respectively. A calculator was made available under the following URL: https://covid19-outcome-prediction.shinyapps.io/COVID19_Hospitalization_Calculator/ConclusionThe prediction tool derived from this study can be used to optimize resource allocation, guide quality of care, and assist in designing future studies on the triage and management of patients with COVID-19.

Background Many advanced heart failure patients have both a left ventricular assist device (LVAD) and an implantable cardioverter-defibrillator (ICD). This study examines incidence, clinical impact, and management of LVAD-related EMI. Methods We performed a three-center retrospective analysis of transvenous ICD implanted patients with LVAD implanted between January 1, 2005 and December 31, 2020. The primary outcome was EMI after LVAD implantation, categorized as LVAD-related noise or telemetry interference. Results The rate of LVAD-related EMI among the 737 patients (mean age 58.6 ± 12.8 years) studied was 5.0%. Telemetry interference (1.5%) compromised ICD interrogation in all patients. This was resolved successfully with use of a metal shield, encased wand, radiofrequency tower, different ICD programmer or by increasing distance between ICD programmer and LVAD (n = 6). ICD replacement was required to reestablish successful communication in three patients. LVAD-related noise (3.5%) led to oversensing (n = 4), inappropriate mode switches (n = 4), noise reversion (n = 3), inhibition of pacing (n = 2), inappropriate detection as atrial fibrillation (AF) (n = 2) and inappropriate detection as ventricular tachycardia (VT) and/or ventricular fibrillation (VF) (n = 2). This noise interference persisted (n = 3), resolved spontaneously (n = 16), resolved with programming change (n = 6) or required lead revision (n = 1). Conclusions EMI from LVAD impacts ICD function, although, the incidence rate is low. Physicians implanting both, LVAD in patients with ICD (more common) or ICD in patients with LVAD, should be aware of possible interferences. Telemetry failure not resolved by metal shielding was overcome by ICD generator replacement to a different manufacturer. In most cases, LVAD-related noise resolves spontaneously.

Background Intranasal high flow of dehumidified (dry) air results in evaporative cooling of nasal passages. In this randomized clinical trial, we investigated the effect of dry gas induced nasal cooling on migraine headaches. Methods In this single-blind study, acute migraineurs were randomized to either nasal high-flow dry oxygen, dry air, humidified oxygen or humidified air (control) at 15 L/min for 15 min. All gases were delivered at 37°C. Severity of headache and other migraine associated symptoms (International Classification for Headache Disorders, 3rd edition criteria) were recorded before and after therapy. The primary endpoint was change in pain scores, while changes in nausea, photosensitivity and sound sensitivity scores served as secondary endpoints. A linear regression model was employed to estimate the impact of individual treatment components and their individual interactions. Results Fifty-one patients (48 ± 15 years of age, 82% women) were enrolled. When compared to the control arm (humidified air), all therapeutic arms showed a significantly greater reduction in pain scores (primary endpoint) at 2 h of therapy with dry oxygen (−1.6 [95% CI −2.3, −0.9]), dry air (−1.7 [95% CI −2.6, −0.7)]), and humidified oxygen (−2.3 [95% CI −3.5, −1.1]). A significantly greater reduction in 2-h photosensitivity scores was also noted in all therapeutic arms (−1.8 [95% CI −3.2, −0.4], dry oxygen; −1.7 [95% CI −2.9, −0.4], dry air; (−2.1 [95% CI −3.6, −0.6], humidified oxygen) as compared to controls. The presence of oxygen and dryness were independently associated with significant reductions in pain and photosensitivity scores. No adverse events were reported. Conclusion Trans-nasal high-flow dry gas therapy may have a role in reducing migraine associated pain. Clinical Trial registration: NCT04129567

Subcutaneous loop recorders (SCRMs) are subcutaneous electronic devices which have revolutionized the field of arrhythmia detection. They have become increasingly appealing due to advances such as miniaturization of device, longer battery life, bluetooth capabilities and relatively simple implantation technique without the need for complex surgical suites. They can be implanted in the office, patient bedside without the need to go to the operating room. One of the most common indications for their implantation is detection of atrial fibrillation (AF) after a cryptogenic stroke. They have also been utilized for assessing the success of rhythm control strategies such post pulmonary venous isolation. More recently studies have assessed the utility of SCRMs for detecting silent AF in at risk populations such as patients with sleep apnea or those on hemodialysis. In this paper, we review the evolution of SCRMs, the clinical studies assessing their value for different indications, their role incurrent clinical practice and future avenues in the era of smart wearable devices like apple watch etc.

Response to cardiac resynchronization therapy (CRT) in patients with heart failure with reduced ejection fraction (HFrEF) depends on the degree of correction of interventricular (VV) electromechanical dyssynchrony between the left and right ventricles (LV, RV). Wide ( 130 ms [ms]) QRS interval is used as a qualifying ECG parameter for CRT device implantation. In this study, we aimed to evaluate myocardial strain (S) and myocardial strain patterns (SP) and strain rate (SR) by speckle tracking echocardiography (STE) and mechanical characteristics at different VV intervals in acute settings and long-term outcome from "sequential LV-RV" pacing programming in patients with narrow ( 130 ms) and wide ( 130 ms) QRS complexes as a basis for extending CRT in select patients with narrow QRS.From a previously established cohort of patients who had undergone CRT device implantation, we identified patients with narrow ( 130 ms) and wide ( 130 ms) QRS complexes, groups A and B respectively. In all patients, we assessed myocardial SP and SR by STE, and mechanical characteristics at VV intervals: "LV Off," "VV0," "VV60," and "RV Off" to provide "RV-only," "simultaneous BiV," "sequential LV-RV," and "LV-only" pacing in the acute settings, and subsequently long-term clinical outcomes with CRT devices programmed to VV60. We compared acute STE characteristics and long-term clinical outcomes between the groups.The study cohort comprised 271 patients (age 69.2 ± 10.3 years [mean ± SD], male-60%). Group A (n = 69) and group B (n = 202) were well matched for the clinical variables, including distribution of patients with ischemic versus non-ischemic cardiomyopathies. QRS width and left ventricular ejection fraction (LVEF) in groups A and B were 120.1 ± 12.3 ms and 152.1 ± 12.9 ms (p 0.05), and 22.3 ± 9.4%, and 23.3 ± 10.2% (p = not significant [NS]). With VV0, VV60, and LV-only timings, corresponding LVEF rates in the acute settings were 31.45 ± 10.9%, 40.08 ± 8.3%, and 44.32 ± 7.98% (p 0.01) in group A, and 38.94 ± 8.5%, 46.91 ± 7.33%, and 49.9 ± 8.94% (p 0.01) in group B, and accounted for similar incremental percentage increase in LVEF compared to baseline in group A (43.2 ± 51.7%, 80.9 ± 61.4%, and 93.4 ± 65.6% respectively) and group B (67.3 ± 82.0%, 100.6 ± 94.3%, and 112.9 ± 95.7% respectively) (p = NS). Abnormal SP and SR were consistently observed with RV pacing that improved with VV60 and LV-only pacing in both groups. Strain scores at different VV timings were similar between the groups (p = NS). At 1-year follow-up, LVEF improved from 22.4 ± 8.0% to 39.8 ± 11.5% (p ≤ 0.001) for the total cohort with similar increments observed in both groups (p = NS). There were fewer NYHA III-IV class patients at 1 year in both groups.Comparable myocardial SP and SR characteristics and LVEF improvement with VV60 and LV-only pacing in the acute setting and long-term outcome of CRT by "sequential LV-RV" pacing seen in patients with both narrow and wide QRS duration suggest that CRT device implantation may be justified in select patients with HFrEF and narrow QRS duration ( 130 ms) who have demonstrable dyssynchrony and abnormal myocardial SP and SR characteristics.

Introduction: Despite advances in surgical and anesthetic techniques, perioperative cardiovascular complications are a major cause of 30-day perioperative mortality. Major cardiovascular complicati...

Introduction: ST-segment changes during exercise stress testing are diagnostic of myocardial ischemia in patients with suspected coronary artery disease (CAD). Recent studies have shown that exercise-induced ST-elevation in aVR is associated with significant stenosis of the left main (LM) and proximal left anterior descending (pLAD) arteries Methods: Search of electronic databases (Embase, Medline, and Web of Science) using MeSH terms and keywords for exercise stress test, lead aVR and CAD was performed from inception through December 2019. 2 reviewers independently screened results in 2 stages: title/abstract followed by full text. Included studies had adult patients who underwent exercise stress testing and reported the performance of ST-elevation >1 mm in lead aVR for diagnosing significant LM or pLAD disease. Significant disease was defined as luminal narrowing >50% and >70% for LM and pLAD respectively. Pooled sensitivity, specificity, likelihood ratios (LR) and diagnostic odds ratios were calculated using a bivariate model, and a summary receiver operator curve (SROC) was constructed. Results: We included 6 studies with 1128 patients. The pooled sensitivity was 0.8 (95% CI 0.36-0.97; I 2 =94.7) and pooled specificity was 0.78 (95% CI 0.56-0.90; I 2 =97.8). Overall calculated positive LR was 3.56 (95% CI 2.34-5.4) and negative LR was 0.26 (95% CI 0.07-1.01). The pooled diagnostic odds ratio was 13.5 (95% CI 4.8-38.5). Hierarchical SROC curve showed an area under the curve of 0.84 (95% CI 0.81-0.87) (Figure 1). Conclusions: Our analysis showed moderate sensitivity and specificity of exercise-induced aVR ST-elevation for diagnosing significant LM or pLAD disease. The heterogeneity among studies was high, likely due to differences in patient selection. In conclusion, ST-elevation in aVR during exercise stress test increases the likelihood of having LM or pLAD disease. Large studies are needed to substantiate this finding.

Background The obesity paradox – indicating improved short term mortality in obese individuals has been widely explored in a number of cardiovascular conditions. However, its validity in an elderly population and the possible physiological impact of aging on this phenomenon in Acute Coronary syndrome (ACS) remain unclear. In this study, we aim to determine the relationship between obesity and in-hospital mortality, morbidity, and health care resource utilization in this cohort of patients. Methods A retrospective study was conducted using the AHRQ-HCUP National Inpatient Sample for the year 2014. Elderly adults (≥65 years) with a principal diagnosis of ACS and a secondary diagnosis of obesity were identified using ICD-9 diagnosis codes as described in the literature. The primary outcome of in-hospital mortality and secondary outcomes like length of hospital stay (LOS), and total hospitalization costs were analyzed. Propensity score (PS) using the next neighbor method without replacement with 1:1 matching was utilized to adjust for confounders. Independent risk factors for mortality were identified using a multivariate logistic regression model. Results In total, 1,137,108 hospital admissions with a primary diagnosis of ACS were identified, of which 7.46% were obese. In-hospital morality during the index admission was lower among obese patients with ACS compared to non-obese patients (4.62 vs 6.87%, p Conclusion In this study, obese elderly patients admitted with ACS were found to have significantly reduced in-hospital mortality and 30-day readmission rates when compared to non-obese patients - reinforcing the obesity paradox independent of patient age. Funding Acknowledgement Type of funding source: None

Background Mitral valve prolapse (MVP) is the most commonly encountered valvular pathology seen in 2–3% of the general population. Though traditionally regarded as a benign pathology, recent literature suggests that sudden cardiac death is significantly more common in these patients with estimates of 0.2–0.4%/year. The exact underlying mechanism of these higher rates of SCD remain poorly understood. In this study, we aim to identify predictors of sudden cardiac arrest (SCA) in an adolescent population. Methods We conducted a retrospective study using the AHRQ-HCUP National Inpatient Sample 2016-2017 for the years 2016-17. All patients (≤18 years) admitted with Mitral valve prolapse were identified using ICD-10 codes and further sub stratified based on presence or absence of sudden cardiac arrest (SCA). Baseline characteristics were obtained and multivariate regression analysis was utilized to identify potential predictors of SCA. Independent risk factors for in-hospital mortality were identified using a proportional hazards model. Complications were defined as per the Agency for Health Care Research and Quality guideline. Results We screened a total of 71,473,874 admissions in the NIS database to identify a total of 1,372 adolescent patients admitted with MVP in the years 2016–17. These patients were then sub-categorized based on presence or absence of SCA during the hospitalization. Our findings revealed that patients with SCA were generally slightly older (15y vs 13y, p=0.036, OR-1.1, p=0.007) and more likely female (83.3% vs 13%, p=0.227, OR – 3.55, p=0.57)). Interestingly, patients in the SCA cohort were noted to have almost 4 fold higher rates of Mitral regurgitation (66.6% vs 18.35%, p=0.008, OR-8.89, p=0.005) as well as family history of SCD (16.7% vs 4.1%, p=0.145, OR-4.65, p=0.14). Conclusions Presence of Mitral regurgitation and a family history of sudden cardiac death are associated with significantly higher rates of SCA in adolescent patients with mitral valve prolapse. Predictors of SCA in Adolescent MVP Funding Acknowledgement Type of funding source: None

Introduction Atrial fibrillation (AF) ablation and Atrioventricular Node (AVN) ablation are both important non-pharmacological therapy of AF. In spite of increased availability of AF ablation data, that of AVN ablation per se is limited. Method AF ablation was identified using ICD-9 procedure code with principle diagnosis of AF from United States National Inpatient Sample database 2005–2014. From procedure and diagnosis codes of pacemaker insertion followed by ablation, the cohort who underwent AVN ablation was identified. Patients hospitalization with any diagnosis of other type of arrythmia or epicardial ablation were excluded. Complications were defined as per the Agency for Health Care Research and Quality guideline. Results Total AF ablation was noted to increase from 2005- 2011, and declined steadily from 2011–2014. In contrast, the number of AVN ablations increased from 4505 cases to 5175 (Figure 1). AVN ablation were mainly performed in elderly patient (mean age 72), and increasingly in patient with higher Charlson Commobidity index (0.9 to 1.7)and higher CHA2DS2-VASc score (2.8 to 3.7) (Table 1). An increasing trend in procedure complications but no significant change in mortalitywere observed with AVN ablation. Progressive increase in the length of stay and the hospitalization cost were also observed over the years with AVN ablation. Conclusion AVN ablation is being performed at a steady volume, and increasingly in patients with multiple comorbidities. This trend although was not associated with increased mortality, it was associated with increased hospital complications. Funding Acknowledgement Type of funding source: None

Background Atrial fibrillation (AF) is commonly encountered in patients with Hypertrophic Cardiomyopathy (HCM). Presence of AF in this high risk population is detrimental due to its effect on hemodynamics, diastolic function and potential induction of ventricular tachyarrhythmias. For these reasons a rhythm control strategy is highly desirable, and yet catheter ablation of AF is consistently inefficacious with poorer overall outcomes. We hypothesize that in HCM presence of outflow tract obstruction by virtue of its effect on left atrial hemodynamics, altered circulatory flow patterns in the pulmonary veins, and stretch related triggered activities would create an arrhythmogenic substrate, and have significant impact on the outcomes of catheter ablation of AF. In this study, we aimed to evaluate AF ablation outcomes based on the presence or absence of outflow tract obstructions in patients with HCM. Methods We conducted a retrospective study using the AHRQ-HCUP National Readmission Database for the years 2016–17. All adults (≥18 years) with HCM undergoing AF ablation procedures were identified using ICD-9 codes. The cohort was divided into two groups; Obstructive HCM (Group A) and Non-Obstructive HCM (Group B) Multivariate regression analysis was utilized to adjust for confounders. Independent risk factors for in-hospital mortality were identified using a proportional hazards model. Complications were defined as per the Agency for Health Care Research and Quality guideline. Results From a total of 71,451,419 patients in the NRD registry, 97 patients with HCM were identified and formed the study cohort. When divided based on the presence or absence of outflow tract obstruction, there were 25 patients with Obstructive HCM and 72 patients with Non-obstructive HCM. Both groups were similar in clinical characteristics including CHADVASc scores and Charlson Comobidity indices as outlined in Table 1. Procedural outcome analysis revealed higher 30-day cardiac readmissions in the Obstructive HCM group compared to Non-obstructive HCM (25.2% vs 7.97%, p=0.049). The Obstructive HCM group had higher rates of atrial arrhythmias, 57.97%, compared to 32.44% in the non-obstructive HCM group, and heart failure exacerbations, 41.27% vs 25.82%. However, both indices did not reach statistical significance. The procedural complications rates tended to be higher in the non-obstructive HCM group, 10.8% vs. 5.6% in the Obstructive HCM group (p=0.54). Conclusions Presence of an obstructive component to HCM is associated with significantly increased short term cardiac readmissions predominantly driven by recurrent atrial arrhythmias and heart failure. These findings suggest negative influence of altered cardiac hemodynamics related to outflow tract obstruction on atrial arrhythmias. The arrhythmogenic substrate of HCM may therefore be different and less amenable to catheter ablation. HCM ablation outcomes Funding Acknowledgement Type of funding source: None