Publications

Abstract Background Long Covid is associated with multiple symptoms and impairment in multiple organs. Cardiac impairment has been reported to varying degrees by varying methodologies in cross-sectional studies. Using cardiac magnetic resonance (CMR), we investigated the 12-month trajectory of cardiac impairment in individuals with Long Covid. Methods 534 individuals with Long Covid underwent baseline CMR (T1 and T2 mapping, cardiac mass, volumes, function, and strain) and multi-organ MRI at 6 months (IQR 4.3,7.3) since first post-COVID-19 symptoms and 330 were rescanned at 12.6 (IQR 11.4, 14.2) months if abnormal findings were reported at baseline. Symptoms, standardised questionnaires, and blood samples were collected at both timepoints. Cardiac impairment was defined as one or more of: low left or right ventricular ejection fraction (LVEF and RVEF), high left or right ventricular end diastolic volume (LVEDV and RVEDV), low 3D left ventricular global longitudinal strain (GLS), or elevated native T1 in ≥3 cardiac segments. A significant change over time was reported by comparison with 92 healthy controls. Results The technical success of this multiorgan assessment in non-acute settings was 99.1% at baseline, and 98.3% at follow up, with 99.6% and 98.8% for CMR respectively. Of individuals with Long Covid, 102/534 [19%] had cardiac impairment at baseline; 71/102 had complete paired data at 12 months. Of those, 58% presented with ongoing cardiac impairment at 12 months. High sensitivity cardiac troponin I and B-type natriuretic peptide were not predictive of CMR findings, symptoms, or clinical outcomes. At baseline, low LVEF, high RVEDV and low GLS were associated with cardiac impairment. Low LVEF at baseline was associated with persistent cardiac impairment at 12 months. Conclusion Cardiac impairment, other than myocarditis, is present in 1 in 5 individuals with Long Covid at 6 months, persisting in over half of those at 12 months. Cardiac-related blood biomarkers are unable to identify cardiac impairment in Long COVID. Subtypes of disease (based on symptoms, examination, and investigations) and predictive biomarkers are yet to be established. Interventional trials with pre-specified subgroup analyses are required to inform therapeutic options.

<h3>Introduction</h3> Patients with acutely decompensated heart failure (ADHF) are usually admitted to hospital for management. However, there is growing interest in delivering IV diuretic therapy at home, in the community or in hospital day-care units. The safety and effectiveness of out-patient based management (OPM) for ADHF has not been established. Accordingly, we conducted a systematic literature review and meta-analysis to investigate the safety and efficacy of OPM compared to in-patient management (IPM) of ADHF. <h3>Methods</h3> A systematic literature review and meta-analysis. Pre-specified endpoints were 30-day mortality and 30-day hospitalisation. The meta-analysis was conducted using RevMan 5.4 software. <h3>Results</h3> 29 studies of OPM were identified. Only 5 directly compared OPM with IPM -including 3 observational studies [1–3], and two randomised controlled trials (RCTs) [4–5]. In the 5 papers comparing IPM vs OPM, the mean age of the IPM cohort was 77 (compared with 75 in OPM), with a similar proportion of male patients (55.5 v 55.6%). In the study-level aggregate analysis, 30-day all-cause mortality was 9.3% (121/1303) for OPM, compared with 15.6% (320/2047) for IPM (OR 0.29[0.09,0.93] p=0.04) [Fig. 1]. Four studies reported 30-day all-cause hospitalisation; 22.0% for IPM vs 16.8% for OPM (OR 0.73 [95% CI 0.61,0.89], p=0.001) [Fig. 2] However, in the 2 RCTs, we found no difference in 30-day mortality or hospitalisation. Overall risk of bias was low in the trials [Table 1]. <h3>Conclusion</h3> In observational studies, OPM of ADHF is associated with lower 30-day re-hospitalisation and lower 30-day mortality. Such differences were not observed in two small single-centre RCTs. A substantial multicentre RCT is required to confirm the safety and efficacy of OPM for ADHF. <h3>References</h3> 1. Thomas K <i>et al.</i> Ambulatory management of patients with acute heart failure: Setting up a multi-disciplinary service. Presented in British Society of Heart Failure Meeting 2019. 2. Salmon TE <i>et al.</i> Long Term Outcomes of Ambulatory Outpatient Management of Acute decompensated Heart Failure in a Heart Failure specialist Nurse Delivered Specialist Unit Versus Inpatient Management. <i>Circ Suppl</i>. 2021; Vol 144, Issue Suppl_1 1. Ahmed FZ <i>et al</i>. Ambulatory intravenous furosemide for decompensated heart failure: safe, feasible, and effective. <i>ESC Heart Fail</i>. 2021;<b>8</b>(5):3906–16. 4. Wong K <i>et al</i>. Does outpatient based IV diuretic treatment for acute heart failure give patients hope? <i>Heart</i> 2021;<b>107</b>:A116-A117. 5. Hamo CE <i>et al</i>. OUTpatient intravenous LASix Trial in reducing hospitalization for acute decompensated heart failure (OUTLAST). <i>PLoS One</i>. 2021;<b>16</b>(6):e0253014. <h3>Conflict of Interest</h3> None

In hospitals participated in the CCC-AF project, >70% of AF patients were at a high risk of stroke. Although poor performance on guideline-recommended OAC use was found in this study, over time the CCC-AF project has made progress in stroke prevention in the Chinese AF population.Registration:ClinicalTrials.gov, NCT02309398.

In Poland drugs and lifestyle modification for secondary stroke prevention are not commonly adhered to. Educational programmes for physicians and patients should be developed to improve application of effective secondary prevention of stroke.

Primary care was not involved in the diagnosis of AF, indicating that most diagnoses occurr after a medical emergency. The frequency of blood tests was lower than the guideline recommendations of one per month which could in-part be due to the adverse impacts of the pandemic. Strengthening primary and community-based care may enable early diagnosis and improve continuity of care during and beyond future healthcare crises.

Abstract Background Dose adjustment of non-vitamin K antagonist oral anticoagulants (NOACs) is indicated in some patients with atrial fibrillation (AF), based on selected patient factors or concomitant medications. Purpose We assessed the frequency of label adherence of NOAC dosing among AF patients and the associations between off-label NOAC dosing and clinical outcomes in real-world clinical practice. Methods We evaluated 53,649 AF patients treated with a NOAC using Korean National Health Insurance Service database during the period from January 2013 to December 2016. NOAC doses were classified as either underdosed or overdosed, consistent with U.S. Food and Drug Administration labeling. Cox proportional hazards regression was performed to investigate the effectiveness and safety outcomes including stroke or systemic embolism, major bleeding, and all-cause mortality. Results Overall, 16,757 NOAC-treated patients (31.2%) were underdosed, 4,492 were overdosed (8.4%), and 32,400 (60.4%) were dosed appropriately according to drug labeling. Compared with patients with label adherence, those who were underdosed or overdosed were older (71±8 and 75±7 years of age vs. 70±9 years of age, respectively; p&lt;0.001), more likely female (39% and 53% vs. 38%, respectively; p&lt;0.001), and had higher CHA2DS2-VASc scores (4.6±1.7 and 5.3±1.7 vs. 4.5±1.8, respectively; p&lt;0.001). NOAC overdosing was associated with increased risk for stroke or systemic embolism (5.76 vs. 4.03 events/100 patient-years, p&lt;0.001), major bleeding (4.77 vs. 2.94 events/100 patient-years, p&lt;0.001), and all-cause mortality (5.43 vs. 3.05 events/100 patient-years, p&lt;0.001) compared with label-adherent use. Figure 1 Conclusion In routine clinical practice, a significant proportion (almost 2 in 5) of AF patients received NOAC doses inconsistent with drug labeling. NOAC overdosing is associated with increased risk for stroke or systemic embolism, major bleeding, and all-cause mortality in Asian patient with AF.

NCT02513316.

Abstract Background Insulin resistance (IR) is a key factor in the pathogenesis of type 2 diabetes mellitus (T2DM) and is associated with a higher risk of cardiovascular disease (CVD) and mortality. However, the association between IR and these outcomes in type 1 diabetes mellitus (T1DM) is less clear. This systematic review and meta-analysis aimed to investigate the associations between CVD outcomes and IR in T1DM. Methods PubMed, EMBASE, and the Cochrane Library databases were searched from inception to 15 March 2023 and updated on 31 October 2023. Observational studies (cohort studies or post hoc analysis of clinical trials) reporting the associations between IR measured by estimated glucose disposal rate (eGDR) level and the risk of CVD and all-cause mortality in individuals with T1DM were eligible. Data, pooled by random effects models, were presented as hazard ratios (95% confidence intervals, CI). The primary outcomes were the composite CVD outcome and all-cause mortality. Results Eight studies involving 21,930 individuals were included, of which five studies involving 19,960 T1DM individuals reported the risk of CVD. During a median follow-up of 10 years, there were 2,149 cases of incident CVD. The pooled hazard ratio for composite CVD outcome per 1-unit increase in the eGDR index was 0.83 (95% CI 0.78–0.90, I2 = 58.9%). Five studies involving 19,403 T1DM individuals reported the risk of all-cause mortality. During a median follow-up of 10 years, a total of 1,279 deaths were observed. The pooled hazard ratio for all-cause mortality per 1-unit increase in the eGDR index was 0.84 (95% CI 0.81–0.87, I2 = 0%). Conclusions IR as measured by eGDR may be an additional risk factor for cardiovascular disease and all-cause mortality in individuals with T1DM. Modification of IR by lifestyle interventions or pharmacological treatments could be a viable therapeutic target to lower the risk of CVD in T1DM.Figure 1 Literature flowchartFigure2 Forest plot

Maintenance of well-controlled risk factors may substantially lower the risk of death and ischemic stroke in patients with AF.