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The association between COVID-19 infection and the cardiovascular system necessitates the use of an echocardiogram in this setting. Information on the utilization, safety, and quality of point-of-care cardiac and lung ultrasound using a hand-held device in these patients is scarce.To investigate the safety, technical aspects, quality indices, and interpretive accuracy of a hand-held echocardiogram in patients with COVID-19.From April-28 through July-27, 2020, consecutive patients with COVID-19 underwent hand-held echocardiogram and lung ultrasound evaluation (Vscan Extend™; GE Healthcare) within 48-h of admission. The operators recorded a series of technical parameters and graded individual experiences. The examinations were further analyzed by a blinded fellowship-trained echocardiographer for general quality, proper acquisition, and right ventricular (RV) demonstration.Among 103 patients, 66 (64.1%) were male. Twenty-nine (28.2%) patients could not turn on their left side and 23 (22.3%) could not maintain effective communication. The mean length of each echocardiogram study was 8.5 ± 2.9 min, battery usage was 14 ± 5%, and mean operator-to-patient proximity was 59 ± 11 cm. Ninety-five (92.2%) examinations were graded as fair/good quality. A fair agreement was demonstrated between the operator and the echocardiographer for general ultrasound quality (Kappa = 0.329, p0.001). A fair-good correlation (r = 0.679, p0.001) and substantial agreement (Kappa = 0.612, p0.001) were demonstrated between the operator and echocardiographer for left ventricular ejection fraction (LVEF), whereas a fair agreement was demonstrated for RV systolic function (Kappa = 0.308, p = 0.002). LVEF agreement was also assessed using the Bland-Altman analysis revealing a mean bias of -0.96 (95% limits of agreement 9.43 to -11.35; p = 0.075).Among patients with COVID-19, echocardiography with a hand-held ultrasound is a safe and reasonable alternative for a complete formal study (10% poor-quality indices). Echocardiogram assessment by the operators during the exam acquisition is reliable for LVEF, while RV systolic function should be subsequently offline reassessed.

Background Strict isolation precautions limit formal echocardiogram use in the setting of COVID-19 infection. Information on the importance of the utilization of a hand-held focused ultrasound for cardiac evaluation in these patients is scarce. This study investigated the utility of a hand-held echocardiogram device in COVID-19 hospitalized patients in diagnosing cardiac pathologies and predicting the composite endpoint of in-hospital death, mechanical ventilation, shock, and acute decompensated heart failure. Methods From April 28th through July 27th, 2020, consecutive patients diagnosed with COVID-19 underwent evaluation using a hand-held ultrasound (Vscan Extend™ with Dual Probe; GE Healthcare) within 48-h of admission. The patients were divided into two groups: 'Normal' and 'Abnormal' (as defined by biventricular systolic dysfunction/enlargement, or moderate/severe valvular regurgitation/stenosis) echocardiogram study. Results Among 102 patients, 26 (25.5%) had an abnormal study. They were older, with more co-morbidities, and more severe presenting symptoms, as compared to the group with a normal echocardiogram. The prevalence of the composite outcome among low- and high-risk patients (oxygen saturation

Background Heart failure with preserved ejection fraction (HFpEF) is common in elderly people and is increasing in prevalence. No specific treatment for this condition exists. Coenzyme Q10 (CoQ10) is an essential cofactor for energy production, with reduced levels being noted in HF. Previous studies have suggested a possible role for CoQ10 in the treatment of HF. This study examined the effect of CoQ10 supplementation on diastolic function in HFpEF patients. Methods We conducted a prospective, randomized, double-blind, placebo-controlled trial including patients aged > 55 years presenting with New York Heart Association class II-IV heart failure symptoms and left ventricular ejection fraction > 50%, with impaired diastolic function. Echocardiography and levels of serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) were performed at baseline and following 4 months of CoQ10 or placebo supplementation. Results A total of 39 patients were enrolled-19 in the CoQ10 group and 20 in the placebo group. Baseline clinical characteristics were similar between groups, while compliance was high and also similar between the CoQ10 and placebo groups. There was no significant effect of treatment on indices of diastolic function (difference in the lateral E/e' ratio: -0.86 ± 6.57 in the CoQ10 group, +0.18 ± 3.76 in the placebo group; p = 0.561) or on serum NT-proBNP levels (- 72 pg/mL vs. - 42 pg/mL; p = 0.195). Conclusions In this pilot trial in elderly patients with HFpEF, treatment with CoQ10 did not significantly affect echocardiographic indices of diastolic function and serum NT-proBNP levels. Trial registration This trial was registered in the US National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier: NCT02779634).

Incorporating artificial intelligence (AI) into echocardiography operated by clinicians working in the emergency department to accurately assess left-ventricular ejection fraction (LVEF) may lead to better diagnostic decisions. This randomized controlled pilot study aimed to evaluate AI use as a didactic tool to improve noncardiologist clinicians' assessment of LVEF from the apical 4-chamber (A4ch) view.This prospective randomized controlled pilot study tested the feasibility and acceptability of the incorporation of AI as a didactic tool by comparing the ability of 16 clinicians who work in the emergency department to assess LVEF before and after the introduction of an AI-based ultrasound application. Following a brief didactic course, participants were randomly equally divided into an intervention and a control group. In each of the first and second sessions, both groups were shown 10 echocardiography A4ch clips and asked to assess LVEF. Following each clip assessment, only the intervention group was shown the results of the AI-based tool. For the final session, both groups were presented with a new set of 40 clips and asked to evaluate the LVEF.In the "normal-abnormal" category evaluation, as related to own baseline accuracy assessment, the intervention group had an improvement in accuracy on 50 consecutive clip assessments compared with a decline in the control group (0.10 vs. -0.12, respectively,A study involving AI incorporation as a didactic tool for clinicians working in the emergency department appears feasible and acceptable. The introduction of an AI-based tool to clinicians working in the emergency department improved the assessment accuracy of LVEF as compared to the control group.

The role of point-of-care ultrasound (POCUS) in patient management has been established in recent years as an important tool. It is increasingly used by multiple medical disciplines in numerous clinical settings, for different applications and diagnostic purposes and in the guidance of procedures. The introduction of small-sized and inexpensive hand-held ultrasound devices (HUDs) has addressed some of the POCUS-related challenges and has thus extended POCUS’ applicability. HUD utilization is even more relevant in the COVID-19 setting given the operators’ infection risk, excessive workload concerns and general equipment contamination. This review focuses on the available technology, usefulness, feasibility and clinical applications of HUD for echocardiogram assessment in patients with COVID-19.

Patients with ST-elevation myocardial infarction (STEMI) can present with angiographically significant coronary artery disease (CAD) of non-infarct-related artery (IRA) or with IRA-only CAD. This study aimed to evaluate the prevalence, predictors, and outcome of patients with STEMI and angiographically significant CAD of non-IRA. All consecutive patients with STEMI who underwent primary percutaneous coronary intervention between 2000 and 2020 were included. Angiographically significant CAD was defined as50% stenosis of the left main coronary artery and/or90% stenosis for all other coronary arteries. A total of 2,663 patients had IRA-only CAD (80.2%) and 657 had angiographically significant non-IRA CAD (19.8%). Independent predictors for non-IRA CAD were male gender (odds ratio [OR] 1.34, 95% confidence interval [CI] 1.05 to 1.70, p = 0.021), age50 years (OR 1.45, 95% CI 1.11 to 1.91, p = 0.007), and diabetes mellitus (OR 1.56, 95% CI 1.29 to 1.9, p0.001), whereas smoking (OR 0.83, 95% CI 0.68 to 0.99, p = 0.004) and family history of CAD (OR 0.78, 95% CI 0.62 to 0.98, p = 0.032) were found to be negatively associated with non-IRA CAD. In-hospital 30-day and 1- and 5-year all-cause mortality were higher in patients with non-IRA CAD compared with IRA-only CAD (5.8% vs 2.5%, 8.5% vs 3.3%, 18.4% vs 7.6% and 36.3% vs 20.3%, respectively; p for all0.001). In conclusion, 20% of patients with STEMI had angiographically significant non-IRA CAD. Older age, male gender, and diabetes mellitus were independent predictors for non-IRA CAD, whereas smoking and family history of CAD predicted IRA-only CAD. The presence of non-IRA CAD was associated with higher short- and long-term all-cause mortality rates.

Background ST-Segment elevation MI (STEMI) is one of the leading cause of mortality in the western world. The coronavirus disease-2019 (COVID-19) pandemic might have implications of the treatment of STEMI patients. Our aim was to evaluate the treatment of STEMI patients during 2 months of the COVID-19 pandemic as compared with the year before. Methods Data of 90 STEMI patients treated at the Shaare Zedek Medical Center intensive coronary care unit (ICCU) Between March-April 2019 and March-April 2020 were collected. Patients were divided into 2 groups: The pre COVID-19 group and the COVID-19 era group. Data regarding complications upon arrival and during hospitalization, door to balloon time and echocardiographic exams. Results Fifty one (56%) patients were admitted with STEMI in the pre COVID-19 group and only 39 (44%) in the COVID-19 era group. Of them 13.7% vs. 20.5% were female, p=0.392 with a mean age of 62.1 (±13.5) vs. 63.4 (±11) years old, p=0.635 in the pre vs. post COVID-19 era group, respectively. Interestingly, more Jewish vs. non-Jewish were admitted with STEMI in the COVID-19 era group. There were no differences regarding baseline characteristics, catheterization access, culprit vessel and percutaneous coronary intervention rate. Door to balloon time was also similar in both pre and post COVID-19 era groups 35.4 (±32) vs. 30.5 (±29.1) minutes (p=0.896). Moreover, there was no difference regarding infarct size. Complications including acute renal failure, cardiogenic shock, and the use of intra-aortic balloon pump were similar in both groups. 30-day mortality rate was low and similar in both pre and post COVID-19 era groups (5.9% vs. 2.6%, respectively, p=0.426). Conclusions During the beginning of COVID-19 era there was a reduction in STEMI admission rate, while no significant difference was found regarding baseline characteristics, door to balloon time, infarct size and mortality rate Funding Acknowledgement Type of funding sources: None.

Introduction D-dimer is a small protein fragment and is a product of fibrinolysis. A high levels of D-dimer have been suggested as a prognostic factor in cancerous and other critically ill patients. We aimed to evaluate D-dimer levels and outcomes of critically ill patients admitted to a tertiary care intensive coronary care unit (ICCU). Material and method All patients admitted to the ICCU at our Medical Center between January 1, 2020 and December 31, 2020 were included in the study. Patients were divided into 2 groups according to their D-dimer level on admission. Low D-dimer level Results and discussion Overall 1,082 consecutive patients were included, mean age was 67 (±16), 70% were males. Of them 296 (27.4%) had low D-dimer level and 663 (61.3%) had high D-dimer level. Patients with high D-dimer level were older as compared to patients with low D-dimer level (mean age 70.4±15 and 59±13 years respectively, p=0.004), had significantly higher rate of female gender (35.9% vs 15.9% respectively, p A multivariate Cox proportional hazards analysis for mortality, adjusted for age, gender, risk factors for cardiovascular disease, ejection fraction Conclusion Elevated D-dimer levels on admission in ICCU patients is a poor prognostic factor of in-hospital morbidity and mortality in the first year following hospitalization. Funding Acknowledgement Type of funding sources: None. Cumulative survival according to d-Dimer

Background The association between COVID-19 infection and the cardiovascular system has been well described. Strict precautions limit the use of formal echocardiography in this setting. Information on the importance of the utilization of a hand-held point-of-care cardiac ultrasound (POCCUS) for cardiac evaluation in these patients is scarce. Objective To investigate the utilization of hand-held echocardiography in COVID-19 hospitalized patients and the association between cardiac pathologies and outcomes. Methods Consecutive patients diagnosed with COVID-19 underwent POCCUS evaluation using a hand-held ultrasound within 24 hours of admission at our institute, throughout March-May 2020. According to the POCCUS results, the patients were divided into two groups: 'Normal' and 'Abnormal' (including left or right ventricular dysfunction or enlargement, or moderate/severe valvular regurgitation/stenosis). Results Among 102 patients, 26 (25.5%) had an abnormal POCCUS study. They were older, with more co-morbidities, cardiovascular disease history, chronic medical therapy, and more severe presenting symptoms, as compared to the group with a normal echocardiography exam. Individual and composite endpoints (advanced ventilatory support, acute decompensated heart failure, shock, or death) are presented in Table 1. Multivariate logistic regression analysis adjusting for pertinent variables revealed that abnormal echocardiography at presentation was independently associated with the composite endpoint OR=4.63 (95% CI 1.51–14.15, p=0.007). Conclusions Abnormal echocardiography results in COVID-19 infection settings are associated with a higher burden of medical comorbidities and independently predict major adverse endpoints. Hand-held POCCUS at presentation can be utilized as an important tool for risk stratification for hospitalized COVID-19 patients. Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): SZMC Scientific

Background: Heart failure with preserved ejection fraction (HFpEF) is the most common form of heart failure (HF) in the elderly and is increasing in prevalence. No specific treatment for this condition appears to be effective. Coenzyme Q10 (CoQ10) is an essential cofactor for energy production and reduced levels have been noted in HF. Previous studies have suggested a possible role for CoQ10 in the treatment of HF in particular in the elderly. Aim: To evaluate the effect of CoQ10 supplementation on diastolic function in patients with HFpEF. Methods: A prospective, randomized, double-blind, placebo-controlled trial. Inclusion criteria were age > 50 years, New York Heart Association class II-IV, ejection fraction > 50%, and evidence of impaired diastolic function defined as lateral e' < 0.09 cm/sec, average E/e' > 13 or average E/e' > 8 with additional markers of impaired diastolic function such as delayed relaxation (E/A < 0.5), elevated left atrial volume index (> 40ml / m 2 ) elevated left ventricular mass index ( > 122 gr/ m 2 ♀ or 149 gr/ m 2 ♂) or pulmonary hypertension. Patients with other forms of cardiomyopathies or treated with chronic renal replacement therapy were excluded. Echocardiographic studies and levels of N-terminal pro-B type natriuretic peptide (NT-proBNP) were completed at baseline and following 4 months of CoQ10 (300 mg daily) or placebo supplementation. Results: A total of 39 patients were enrolled, 19 patients in the CoQ10 and 20 patients in the placebo group. Groups were similar in baseline clinical characteristics. Compliance was high and similar between groups (average 208 ± 108 mg/day for the CoQ10 versus 212 ± 95 mg/day for the placebo group). No significant effect was observed on indices of diastolic function or NT-proBNP levels following 4 months of CoQ10 use. Conclusions: Treatment with CoQ10 did not affect indices of diastolic function or NT-proBNP levels in patients with HFpEF. Our study does not support the routine use of CoQ10 in patients with HFpEF.

Background ST-elevation myocardial infarction (STEMI) mostly occurs as a result of vulnerable coronary artery plaque rupture. Constituting hypolipidemic and pleiotropic effects, statins stabilize coronary artery plaque and may prevent STEMI events. Purpose To determine the association between statin pre-treatment and its intensity, low-density-lipoprotein cholesterol (LDL-C) levels and presentation of patients with an ACS (STEMI vs. NSTEMI/unstable angina [UAP]). Methods Data was drawn from the Acute Coronary Syndrome Israeli Survey (ACSIS), a biennial prospective survey of ACS patients hospitalized in all CCU/Cardiology departments during 2008–2018. The rate of STEMI vs NSTEMI/UAP at the time of presentation was calculated by LDL-C levels on admission, stratified to 5 subgroups (130 mg/dl) and the use of statins, including statin intensity prior to the index ACS event. Results Among 5,103 patients, 875 (17%) were pre-treated with high intensity statin (HIST), 1,389 (27%) with low intensity statin (LIST), and 2,839 (56%) were statin naive patients. Statin-pre-treated patients were older, more likely to suffer from co-morbidities and cardiovascular diseases and were more often pre-treated with anti-platelets. The proportion of patients presenting with STEMI vs. NSTEMI/UAP was significantly lower among HIST vs. LIST vs. statin naive patients (31.0%, 37.8%, 54.0%, respectively, p for trend Conclusions Among patients admitted with ACS, pre-treatment with high intensity statin but not LDL-C level, was independently associated with a lower probability of presenting with STEMI. Funding Acknowledgement Type of funding source: None

Emergency medical services (EMS) provides a critical role in the rapid treatment, stabilization, and transfer of patients in the prehospital setting. The national EMS provider for Israel has developed a robust and unique organization of volunteers with advanced telecommunication strategies to activate and direct them in order to improve these processes. The volunteers include local high school students, international college students, emergency medical technicians, on-call volunteers, motorcyclists, and Life Guardian first responders. The telecommunication strategies include pagers, push-to-talk over cellular, and sophisticated smartphone-based software applications. These are monitored and directed via a central command and control station. Such processes, both on an organizational as well as technical level, can be adapted to improve prehospital emergency care.

Objective To assess the role of the computerized tomography (CT) scanner in cross-transmission of carbapenem-resistant Acinetobacter baumannii between hospitalized patients undergoing CT scan. Methods A single-centre retrospective observational analysis of inpatients undergoing CT scans. Patient-unique CT scans were defined as ‘index cases’ (patients undergoing CT scan with carbapenem-resistant Acinetobacter baumannii (CRAB) colonization documented during the previous 60 days), ‘incident cases’ (patients found colonized with CRAB within 14 days following CT scan), and ‘negative cases’ (negative for CRAB before and after CT scan). CRAB acquisition was analysed by time interval between CT scan and CT scan of the prior index-case patient. Results Amongst 73 047 CT scans performed over 5 years, 4834 scans were performed within 12 hours of an index case. CRAB acquisition was detected in 20 patients (incident cases), including 16/2725 (5.8/1000 scans) who underwent CT scan within 6 hours of an index-case CT scan and 4/2109 (1.9/1000 scans) who had their CT scan 7–12 hours after the CT scan of an index-case patient (p 0.033, risk ratio 3.1, 95%CI 1.03–9.25). Patient characteristics for the two time periods were similar. While not the only significant predictor of CRAB acquisition (others included age and length of hospital stay prior to the CT scan), the time elapsed from an index case remained a significant predictor for CRAB acquisition on multivariate analysis (OR 0.84, 95%CI 0.74–0.95, p 0.007). Conclusions Performing a CT scan within 6 hours of a CT scan performed in a CRAB-positive patient was an independent predictor of CRAB acquisition, approximately tripling the risk. This probably reflects poor infection control practice in the CT suite.

Point-of-care ultrasound (POCUS) is becoming universal in the hands of physicians as well as medical students. However, the results are often binary or general rather than achieving the specificity of an experienced cardiologist. Artificial intelligence (AI) is now used by non-experts (NE) in

Multi-casualty incidents (MCIs) continue to occur throughout the world, whether they be mass shootings or natural disasters. Prehospital emergency services have done a professional job at stabilizing and transporting the victims to local hospitals. When there are multiple casualties, there may not be enough professional responders to care for the injured. Bystanders and organized volunteer first responders have often helped in extricating the victims, stopping the bleeding, and aiding in the evacuation of the victims. Magen David Adom (MDA translated as “Red Shield of David”), the national Emergency Medical Services (EMS) provider for Israel, has successfully introduced a program for volunteer first responders that includes both a mobile-phone-based application and appropriate life-saving equipment. Most of the responders, known as Life Guardians, are already medical professionals such as physicians, nurses, or off-duty medics. They are notified by a global positioning system application if there is a nearby life-threatening incident such as respiratory or cardiac arrest, major trauma, or an MCI. They are given a kit that includes a bag-valve mask device, oropharyngeal airways, tourniquets, and bandages. There are currently 17,000 Life Guardians, and in the first-half of 2017, they responded to 253 events.The Life Guardians are essentially an out-of-hospital manpower multiplier using a simple crowdsourcing application who have the necessary skills and equipment to treat those in cardiopulmonary arrest, or victims of trauma, including MCIs. Such a model can be integrated into other systems throughout the world to save lives.JaffeE, DadonZ, AlpertEA. Wisdom of the crowd in saving lives: the Life Guardians app. Prehosp Disaster Med. 2018;33(5):550–552.

Background Streptococcus gordonii is an infrequent cause of infective endocarditis (IE); associated spondylodiskitis has not yet been described in the literature. Purpose We describe 2 patients who presented with new-onset, severe back pain; blood cultures revealed S. gordonii bacteremia, which led to the diagnosis of spondylodiskitis and IE. We review our 2-decade experience with S. gordonii bacteremia to describe the clinical and epidemiological characteristics of these patients. Results In our hospital over the last 20 years (1998–2017), a total of 15 patients with S. gordonii bacteremia were diagnosed, including 11 men and 4 women, and the mean age was 65 ± 22 (range 23–95). The most common diagnosis was IE (9 patients), spondylodiskitis (the presented 2 patients, who in addition were diagnosed with endocarditis), necrotizing fasciitis (1), sternitis (1), septic arthritis (1) and pneumonia (1). The 11 patients with IE were treated with penicillin ± gentamicin, or ceftriaxone for 6 weeks, 5 required valve surgery and 10/11 (91%) attained complete cure. The 2 patients with diskitis required 2–3 months of intravenous antibiotics to achieve complete cure. Conclusion Spondylodiskitis was the presenting symptom of 2/11 (18%) patients with S. gordonii endocarditis. Spondylodiskitis should probably be looked for in patients diagnosed with S. gordonii endocarditis and back pain as duration of antibiotic treatment to achieve complete cure may be considerably longer.