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Introduction: Cardiovascular comorbidities may predispose to adverse outcomes in hospitalized patients with coronavirus disease 2019 (COVID-19). However, across the USA, the burden of cardiovascular comorbidities varies significantly. Whether clinical outcomes of hospitalized patients with COVID-19 differ between regions has not yet been studied systematically. Here, we report differences in underlying cardiovascular comorbidities and clinical outcomes of patients hospitalized with COVID-19 in Texas and in New York state. Methods: We established a multicenter retrospective registry including patients hospitalized with COVID-19 between March 15 and July 12, 2020. Demographic and clinical data were manually retrieved from electronic medical records. We focused on the following outcomes: mortality, need for pharmacologic circulatory support, need for mechanical ventilation, and need for hemodialysis. Univariate and multivariate logistic regression analyses were performed. Results: Patients in the Texas cohort (n = 296) were younger (57 vs. 63 years, p value 2 vs. 28.5 kg/m2, p = 0.015), and they had higher rates of diabetes mellitus (41 vs. 30%; p = 0.014). In contrast, patients in the New York state cohort (n = 218) had higher rates of coronary artery disease (19 vs. 10%, p = 0.005) and atrial fibrillation (11 vs. 5%, p = 0.012). Pharmacologic circulatory support, mechanical ventilation, and hemodialysis were more frequent in the Texas cohort (21 vs. 13%, p = 0.020; 30 vs. 12%, p < 0.001; and 11 vs. 5%, p = 0.009, respectively). In-hospital mortality was similar between the 2 cohorts (16 vs. 18%, p = 0.469). After adjusting for differences in underlying comorbidities, only the use of mechanical ventilation remained significantly higher in the participating Texas hospitals (odds ratios [95% CI]: 3.88 [1.23, 12.24]). Median time to pharmacologic circulatory support was 8 days (interquartile range: 2, 13.8) in the Texas cohort compared to 1 day (0, 3) in the New York state cohort, while median time to in-hospital mortality was 16 days (10, 25.5) and 7 days (4, 14), respectively (both p < 0.001). In-hospital mortality was higher in the late versus the early study phase in the New York state cohort (24 vs. 14%, p = 0.050), while it was similar between the 2 phases in the Texas cohort (16 vs. 15%, p = 0.741). Conclusions: Geographical differences, including practice pattern variations and the impact of disease burden on provision of health care, are important for the evaluation of COVID-19 outcomes. Unadjusted data may cause bias affecting future regulatory policies and proper allocation of resources.

Introduction: We sought to produce the first nationally representative analysis of racial and income inequities by mortality and cost for patients with chronic total occlusion (CTO) of coronary arteries by the presence or absence of active cancer. Methods: Propensity score adjusted and backward propagation neural network machine learning augmented multivariable regression among patients with CTO and stratified by race and income was conducted for the above outcomes in this case-control study of the United States’ largest and most current all-payer hospitalized dataset, the 2016 National Inpatient Sample. Regression models were fully adjusted for age, geographic region, anemia, thrombocytopenia, cancer metastases, NIS-calculated mortality risk by Diagnosis Related Group (DRG), and the likelihood of undergoing PCI (in addition to length of stay [LOS] for cost). To produce nationally representative estimates, analyses were also adjusted for the complex survey design. Results: Of the 30,195,722 adult hospitalized patients, 1,159,994 (3.84%) underwent PCI (of whom 30,624 [2.64%] were in patients with active cancer), and 120,815 (0.40%) had CTO (of whom 3,068 [2.54%] had active cancer). In multivariable regression among patients with CTO, mortality was comparable across races in both PCI and cancer, but significantly increased among the lowest income quartile for patients with cancer (OR 4.09; 95%CI 1.30-12.80; p=0.016). PCI in Hispanic cancer patients unlike other races had significantly increased costs ($207,218.80; 95%CI 76,799.21-337,738.30; p=0.002) as did the lowest income quartile ($26,327.08; 95%CI 21,123.93-31,530.23; p=0.042) unlike other income groups significantly increased costs. Conclusions: This large nationally representative study suggests PCI can safely done in hospitalized patients with CTO and active cancer though its prevalence is far less than in those without cancer despite comparable risk profiles; there also appears to be significant racial and income inequities in both mortality and cost by both race and income.

BackgroundInfective endocarditis (IE) is more common in patients with cancer as compared with the general population. Due to an immunocompromised state, the need for invasive procedures, hypercoagulability and the presence of indwelling catheters, patients with cancer are particularly predisposed to the development of IE.ObjectivesLimited information exists about IE in patients with cancer. We aimed to evaluate the characteristics of patients with cancer and IE at our tertiary care centre, including a comparison of the microorganisms implicated and their association with mortality.MethodsA retrospective chart review of patients with cancer who had echocardiography for suspicion of endocarditis was conducted. A total of 56 patients with a confirmed diagnosis of cancer and endocarditis, based on the modified Duke criteria, were included in the study. Baseline demographics, risk factors for developing IE, echocardiography findings, microbiology and mortality data were analysed.ResultsFollowing the findings of vegetations by echocardiography, the median survival time was 8.5 months. Staphylococcus aureus was the most common organism identified as causing endocarditis. The mitral and aortic valves were the most commonly involved sites of endocarditis. Patients with S. aureus endocarditis (SAE) had a significantly poorer survival when compared with patients without SAE (p=0.0217) over the 12-month period from diagnosis of endocarditis.ConclusionsOverall survival of patients with cancer and endocarditis is poor, with a worse outcome in patients with SAE.

Levels of intestinal toll-like receptor 4 (TLR4) impact inflammation in the neonatal gastrointestinal tract. While surfactant protein A (SP-A) is known to regulate TLR4 in the lung, it also reduces intestinal damage, TLR4 and inflammation in an experimental model of necrotizing enterocolitis (NEC) in neonatal rats. We hypothesized that SP-A-deficient (SP-A−/−) mice have increased ileal TLR4 and inflammatory cytokine levels compared to wild type mice, impacting intestinal physiology. We found that ileal TLR4 and proinflammatory cytokine levels were significantly higher in infant SP-A−/− mice compared to wild type mice. Gavage of neonatal SP-A−/− mice with purified SP-A reduced ileal TLR4 protein levels. SP-A reduced expression of TLR4 and proinflammatory cytokines in normal human intestinal epithelial cells (FHs74int), suggesting a direct effect. However, incubation of gastrointestinal cell lines with proteasome inhibitors did not abrogate the effect of SP-A on TLR4 protein levels, suggesting that proteasomal degradation is not involved. In a mouse model of experimental NEC, SP-A−/− mice were more susceptible to intestinal stress resembling NEC, while gavage with SP-A significantly decreased ileal damage, TLR4 and proinflammatory cytokine mRNA levels. Our data suggests that SP-A has an extrapulmonary role in the intestinal health of neonatal mice by modulating TLR4 and proinflammatory cytokines mRNA expression in intestinal epithelium.

Introduction: Although primarily a respiratory illness, COVID-19 frequently involves the cardiovascular system. Hypothesis: Accordingly, we assessed whether abnormal electrocardiographic findings, including cardiac dysrhythmias, ST/T wave changes, and QTc interval prolongation, predict adverse outcomes in patients with COVID-19. Methods: A multi-center retrospective study of hospitalized patients with COVID-19 was performed across 4 hospitals in Texas and 1 in New York. Initial and subsequent ECG findings among patients with uncomplicated disease course, patients with adverse clinical outcomes (need for vasopressors, mechanical ventilation or renal replacement therapy) and patients who died were analyzed. Univariable and multivariable Cox analyses were performed. Results: We identified 297 consecutive patients with COVID-19. Of these patients, 91% had available ECGs. Median heart rate on initial ECG was 92 bpm (IQR: 27), and median QTc interval was 442 msec (IQR: 40). Longer QTc interval on initial ECG was associated with adverse clinical outcomes (443 msec, IQR: 43) and death (457 msec, IQR: 52, vs 441.5 msec, IQR: 36; p=0.033). Cardiac dysrhythmias or ST/T wave changes were noted in subsequent ECGs of 46% of patients and were associated with adverse clinical outcomes (58%) or death (68% vs 33%; HR: 2.2, 95% CI: 1.3-3.6; p=0.002). Sixty-four patients (23%) developed a QTc interval >500msec during their hospitalization. In multivariable Cox analysis, history of coronary artery disease was independently associated with development of QTc>500msec (HR 2.1, 95% CI 1.0-4.4; p=0.047) while other baseline comorbidities were not. Patients with QTc>500msec were more commonly treated with azithromycin (91% vs 77%; p=0.048); no other differences in COVID-19 treatment were identified. In-hospital mortality among patients with QTc>500msec was 37% versus 13% among patients with shorter QTc intervals (HR: 2.6, 95% CI 1.5-4.5; p=0.001). Conclusions: Prolonged QTc interval on initial ECG of COVID-19 patients predicted adverse outcomes and death. Azithromycin was associated with development of QTc>500msec. Patients with a QTc interval >500msec had a 2.6 times higher risk for in-hospital mortality compared to patients with shorter QTc intervals.

Introduction: In a time span of 6 months, COVID-19 has infected more than 7 million and cost the lives of more than 400,000 people worldwide. Cardiovascular involvement is associated with adverse clinical outcomes. Hypothesis: Increased plasma troponin and brain natriuretic peptide (BNP) or NT-proB-type natriuretic peptide (NT-proBNP) levels are associated with the presence of underlying cardiovascular disease and predict increased in-hospital mortality. Methods: Here we present a multicenter observational study of patients diagnosed with COVID-19, who were hospitalized in 5 hospitals (4 in Texas and 1 in New York) between March 16 th and May 22 nd , 2020. Demographic and clinical characteristics were abstracted after patient’s discharge or death. To address the non-standard troponin and BNP/NT-proBNP assays across institutions we used the upper 99th percentile as the cut-off for abnormal on each test. Results: We identified 297 consecutive patients hospitalized with COVID-19. Troponin levels were available in 84% and BNP/NT-proBNP levels in 47% of patients. Troponin levels were increased in 14% and BNP/NT-proBNP in 46% of patients. In multivariate Cox analysis, history of coronary artery disease was independently associated with elevated troponin levels (Hazard Ratio [HR]: 5.24; 95% confidence interval [CI]: 1.37-19.97; p=0.015), while history of congestive heart failure was independently associated with elevated BNP/NT-proBNP levels (HR: 2.58; 95% CI: 1.05 6.31; p=0.038). Older age, history of hypertension, dyslipidemia, or stroke, were associated with elevated troponin or BNP/NT-proBNP levels only in the univariate analysis. Other demographic and clinical characteristics were not significantly associated with cardiac biomarker elevation. Collectively, elevated troponin or BNP/NT-proBNP were significantly associated with in-hospital mortality (HR: 3.47 95% CI: 1.90-6.35 and HR: 3.56; 95% CI: 1.44-8.77, respectively; both p Conclusions: Increased levels of cardiac biomarkers were associated with a 3-fold increase of in-hospital mortality among patients with COVID-19. Troponin or BNP/pro-BNP testing has a prognostic value and may guide treatment.

Since the optimal management of coronary artery disease (CAD) and breast cancer is unknown, we sought to conduct the first known nationally representative study of mortality and cost effectiveness for breast cancer and percutaneous coronary interventions (PCI). Backward propagation neural network

There are no nationally representative studies of mortality and cost effectiveness for percutaneous coronary interventions (PCI) and colon cancer despite the growing prevalence of cardiovascular disease (CVD) and this cancer. Propensity score-matched analysis and backward propagation neural network