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The population of elderly adults is increasing globally. It has been projected that the population of adults aged 65 years will increase by approximately 80% by 2050 in the United States. Similarly, the elderly population is rising in other countries; a notable example being Japan where approximately 30% of the population are aged above 65 years. The pathophysiology and management of heart failure (HF) in this age group tend to have more intricacies than in younger age groups owing to the presence of multiple comorbidities. The normal aging biology includes progressive disruption at cellular and genetic levels and changes in molecular signaling and mechanical activities that contribute to myocardial abnormalities. Older adults with HF secondary to ischemic or valvular heart disease may benefit from surgical therapy, valve replacement or repair for valvular heart disease and coronary artery bypass grafting for coronary artery disease. While referring these patients for surgery, patient and family expectations and life expectations should be taken into account. In this review, we will cover the pathophysiology and the management of HF in the elderly, specifically discussing important geriatric domains such as frailty, cognitive impairment, delirium, polypharmacy, and multimorbidity.

Heart transplant (HT) recipients represent a unique and vulnerable population in whom medium and long-term outcomes are significantly affected by the risk of arrhythmias and sudden cardiac death. The use of implantable cardioverter-defibrillators (ICDs) in this population remains debated. A retrospective analysis of the National Inpatient Sample data between 2009 and 2018 was conducted. Hospitalization data on patients who underwent HT, or who had a preexisting HT, and who received a new ICD were included (excluding the preexisting ICD). Outcomes assessed included inpatient mortality, length of stay, and inflation-adjusted costs. We explored temporal trends in ICD placement and mean length of stay, and predictors of ICD placement. Between 2009 and 2018, 22,673 hospitalizations were recorded for HT, during which patients either received a concurrent new ICD placement (n = 70 [0.31%]) or no new ICD placement (n = 22,603 [99.7%]). During the same period, 146,555 admissions were recorded in patients with a history of HT. ICD placement in patients with a preexisting HT was associated with significantly higher inflation-adjusted costs ($55,680.7 vs $17,219.2; p 0.001). Predictors of ICD placement in preexisting patients with HT included cardiac arrest during hospitalization (odds ratio [OR]:14.3 [3.5 to 58.6]), drug abuse (OR:6.0 [1.3 to 27.1]), and previous PCI (OR:6.0 [2.1 to 17.3]). In conclusion, ICD placement in patients with HT history was associated with significantly higher inflation-adjusted costs. In patients with HT history, factors predicting ICD placement included cardiac arrest at hospitalization, previous PCI, and drug abuse.

Huzefa Bhopalwala,1 Nakeya Dewaswala,2 Sandhya Kolagatla,1 Lauren Wisnieski,3 Jonathan Piercy,1 Adnan Bhopalwala,1 Nagabhishek Moka1 1Department of Internal Medicine, Appalachian Regional Healthcare, Whitesburg, KY, USA; 2Department of Cardiovascular Disease, University of Kentucky, Lexington, KY, USA; 3Department of Public Health and Research, Lincoln Memorial University, Harrogate, TN, USACorrespondence: Nakeya Dewaswala, Department of Cardiovascular Disease, University of Kentucky, 900 South Limestone Street, Charles T. Wethington Building Rm. 326, Lexington, KY, 40536-0200, USA, Tel +1 4252136401, Email nakeya52@gmail.comBackground: The prevalence and outcome of coronavirus disease 2019 (COVID-19) in rural areas is unknown.Methods: This is a multi-center retrospective cohort study of hospitalized patients diagnosed with COVID-19 from April 5, 2020 to December 31, 2020. The data were extracted from 13 facilities in the Appalachian Regional Healthcare system that share the same electronic health record using ICD-10-CM codes.Results: The number of patients diagnosed with COVID-19 per facility ranged from 5 to 535 with a median of 106 patients. Total mortality was 11.4% and ranged from 0% to 22.6% by facility (median: 9.0%). Non-survivors had a greater prevalence of congestive heart failure (CHF), hypertension, type 2 diabetes mellitus, stroke, transient ischemic attack (TIA), and pulmonary embolism. Patients who died were also more likely to have had chronic obstructive pulmonary disease (COPD), acute respiratory failure (ARF), liver cirrhosis, chronic kidney disease (CKD), dementia, cancer, anemia, and opiate dependence.Conclusion: The aging population, multiple co-morbidities, and health-related behaviors make rural patients vulnerable to COVID-19. A better understanding of the disease in rural areas is crucial, given its heightened vulnerability to adverse outcomes.Keywords: coronavirus, COVID-19, SARS-CoV-2, cohort, mortality, survival

OBJECTIVE To evaluate the epidemiology and outcomes of non-ST-segment-elevation myocardial infarction-cardiogenic shock (NSTEMI-CS) in the United States. METHODS Adult (>18 years) NSTEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011 and 2012-2017). Outcomes of interest included temporal trends of prevalence and in-hospital mortality, use of cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. RESULTS In over 7.3 million NSTEMI admissions, CS was noted in 189,155 (2.6%). NSTEMI-CS increased from 1.5% in 2000 to 3.6% in 2017 (adjusted odds ratio [aOR] 2.03 [95% confidence interval {CI} 1.97-2.09]; p

Background A subset of patients with hypertrophic cardiomyopathy (HCM) is at high risk of sudden cardiac death (SCD). Practice guidelines endorse use of a risk calculator, which requires entry of left atrial (LA) diameter. However, American Society of Echocardiography (ASE) guidelines recommend the use of LA volume index (LAVI) for routine quantification of LA size. The aims of this study were to (a) develop a model to estimate LA diameter from LAVI and (b) evaluate whether substitution of measured LA diameter by estimated LA diameter derived from LAVI reclassifies HCM‐SCD risk. Methods The study cohort was comprised of 500 randomly selected HCM patients who underwent transthoracic echocardiography (TTE). LA diameter and LAVI were measured offline using digital clips from TTE. Linear regression models were developed to estimate LA diameter from LAVI. A European Society of Cardiology endorsed equation estimated SCD risk, which was measured using LA diameter and estimated LA diameter derived from LAVI. Results The mean LAVI was 48.5 ± 18.8 mL/m2. The derived LA diameter was 45.1 mm (SD: 5.5 mm), similar to the measured LA diameter (45.1 mm, SD: 7.1 mm). Median SCD risk at 5 years estimated by measured LA diameter was 2.22% (interquartile range (IQR): 1.39, 3.56), while median risk calculated by estimated LA diameter was 2.18% (IQR: 1.44, 3.52). 476/500 (95%) patients maintained the same risk classification regardless of whether the measured or estimated LA diameter was used. Conclusions Substitution of measured LA diameter by estimated LA diameter in the HCM‐SCD calculator did not reclassify risk.

The Southeastern rural areas of the USA have a higher prevalence of heart failure (HF). Coronavirus disease 2019 (COVID-19) infection is associated with poor outcomes in patients with HF. Our study aimed to compare the outcomes of hospitalized HF patients with and without COVID-19 infection specifically in rural parts of the USA.We conducted a retrospective cohort study of HF patients with and without COVID-19 hospitalized in Southeastern rural parts of the USA by using the Appalachian Regional Healthcare System. Analyses were stratified by waves from April 1, 2020 to May 31, 2021, and from June 1, 2021 to October 19, 2021.Of the 14,379 patients hospitalized with HF, 6% had concomitant COVID-19 infection. We found that HF patients with COVID-19 had higher mortality rate compared to those without COVID-19 (21.8% versus 3.8%, respectively, P0.01). Additionally, hospital resource utilization was significantly higher in HF patients with COVID-19 compared to HF patients without COVID-19 with intensive care unit (ICU) utilization of 21.6% versus 13.8%, P0.01, mechanical ventilation use of 17.3% versus 6.2%, P0.01, and vasopressor/inotrope use of 16.8% versus 7.9%, P0.01. A lower percentage of those with COVID-19 were discharged home compared to those without a COVID-19 diagnosis (63.4% versus 72.0%, respectively). There was a six-fold greater odds of dying in the first wave and seven-fold greater odds of dying in the second wave.Our study confirms previous findings of poor outcome in HF patients with COVID-19. There is a need for review of healthcare resources in rural hospitals which already face numerous healthcare challenges.

Background: The number of fatalities due to coronavirus disease 2019 (COVID-19) is escalating with more than 800,000 deaths globally. The scientific community remains in urgent need of prognostic tools to determine the probability of survival in patients with COVID-19 and to determine the need for hospitalization. Methods: This is a retrospective cohort study of patients with a diagnosis of COVID-19 admitted to a tertiary center between March 2020 and July 2020. Patients age 18 years and older were stratified into two groups based on their troponin-I level in the first 24 h of admission (groups: elevated vs. normal). The aim of the study is to explore the utility of cardiac troponin-I level for early prognostication of patients with COVID-19. Results: This cohort of 257 patients included 122/257 (47%) women with a mean age of 63 ± 17 years. Patients with an elevated troponin-I level were more likely to be older (77 ± 13 vs. 58 ± 16 years, P < 0.0001), have a history of hypertension (P < 0.0001), diabetes mellitus (P = 0.0019), atrial fibrillation or flutter (P = 0.0009), coronary artery disease (P < 0.0001), and chronic heart failure (P = 0.0011). Patients with an elevated troponin-I level in the first 24 h of admission were more likely to have higher in-hospital mortality (52% vs. 10%, P < 0.0001). Troponin-I level in the first 24 h of admission had a negative predictive value of 89.7% and a positive predictive value of 51.9% for all-cause in-hospital mortality. Conclusions: Troponin-I elevation is commonly seen in patients with COVID-19 and is significantly associated with fatal outcomes. However, a normal troponin-I level in the first 24 h of admission had a high negative predictive value for all-cause in-hospital mortality, thereby predicting favorable survival at the time of discharge. Cardiol Res. 2020;11(6):398-404 doi: https://doi.org/10.14740/cr1159

There are limited data on the temporal trends, incidence, and outcomes of ST-segment-elevation myocardial infarction-cardiogenic shock (STEMI-CS).Adult (18 years) STEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011, 2012-2017). Outcomes of interest included temporal trends, acute organ failure, cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay.In ∼4.3 million STEMI admissions, CS was noted in 368,820 (8.5%). STEMI-CS incidence increased from 5.8% in 2000 to 13.0% in 2017 (patient and hospital characteristics adjusted odds ratio [aOR] 2.45 [95% confidence interval {CI} 2.40-2.49]; P 0.001). Multiorgan failure increased from 55.5% (2000-2005) to 74.3% (2012-2017). Between 2000 and 2017, coronary angiography and percutaneous coronary intervention use increased from 58.8% to 80.1% and 38.6% to 70.6%, whereas coronary artery bypass grafting decreased from 14.9% to 10.4% (all P 0.001). Over the study period, the use of intra-aortic balloon pump (40.6%-37.6%) decreased, and both percutaneous left ventricular assist devices (0%-12.9%) and extra-corporeal membrane oxygenation (0%-2.8%) increased (all P 0.001). In hospital mortality decreased from 49.6% in 2000 to 32.7% in 2017 (aOR 0.29 [95% CI 0.28-0.31]; P 0.001). During the 18-year period, hospital lengths of stay decreased, hospitalization costs increased and use of durable left ventricular assist device /cardiac transplantation remained stable (P 0.05).In the United States, incidence of CS in STEMI has increased 2.5-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and PCI increased during the study period.

INTRODUCTION: Acute pancreatitis (AP) and acute aortic dissection (AAD) are medical emergencies that must be promptly recognized to avoid the development of life-threatening complications. Both of these diseases can present with chest or epigastric pain which can radiate to the back, thus, early suspicion based on clinical presentation and risk factors is essential. We present the case of a 56-year-old patient initially diagnosed with AP who was later found to have an AAD. CLINICAL FINDINGS: A 56-year-old man with a history of alcohol abuse presented with 1 day of diffuse abdominal pain, nausea and vomiting. His lipase was 3,909 U/L and creatinine was 2.19 mg/dL and he was diagnosed with acute alcoholic pancreatitis with acute kidney injury. A non-contrast computed tomography (NCCT) scan of the abdomen showed aortic calcifications. He received 3.8 liters of fluids after which he developed acute respiratory distress requiring intubation. A workup for extracorporeal membrane oxygenation (ECMO) was initiated, given the suspicion of acute respiratory distress syndrome (ARDS) due to pancreatitis. This revealed an AAD with severe aortic regurgitation on transthoracic echocardiography (TTE). CT angiogram showed type A AAD involving the aortic root, ascending aorta, descending aorta, suprarenal and infrarenal abdominal aorta. The celiac axis, superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) were patent. OUTCOMES: The patient underwent type A AAD repair with mechanical aortic valve replacement and survived the acute event. His AP resolved and he was discharged home with appropriate follow up. CONCLUSION: We hypothesize that if our patient was not assessed for ECMO, the finding of AAD would have been a diagnostic challenge. AP secondary to AAD is rare but a high index of suspicion is required for diagnosis.

Early during the Coronavirus disease 2019 (Covid-19) pandemic, concerns were raised regarding potential adverse outcomes in patients taking angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs). These concerns were based on animal studies showing increased ACE-2 expression in mice treated with ACEI/ARB. This is a single-center, retrospective, cohort study of 289 patients diagnosed with 2019 Novel Coronavirus (SARS-CoV-2) hospitalized between March of 2020 and June of 2020. The study was intended to investigate the impact of ACEIs and/or ARBs on in-hospital mortality, intensive care unit (ICU) admission, postadmission hemodialysis requirement, and the need for mechanical ventilation in patients with COVID-19. This cohort of 289 patients included 139 of 289 women (48%) with a mean age of 61 ± 19 years. Patients using ACEIs/ARBs were older (69.68 vs. 57.9 years; P0.0001), more likely to have a history of hypertension (97% vs. 36%; P0.0001), diabetes mellitus (48% vs. 20.9%; P0.0001), chronic heart failure (11.39% vs. 4.29%; P0.0512), coronary artery disease (20.25% vs. 7.14%; P0.0025), stroke/Transient Ischemic Attack (7.59% vs. 2.38%; P0.0761), chronic kidney disease (11.39% vs. 3.33%; P0.0167), atrial fibrillation/flutter (18.99% vs. 7.14%; P0.0080), and dementia (22.7% vs. 11.4%; P0.0233) compared with the nonuser group. There was significantly higher in-hospital mortality in patients using ACEIs/ARBs than nonusers, respectively (32.9% vs. 15.2%; P0.0015). However, a multivariate logistics regression analysis performed to adjust for common confounders demonstrated no significant difference in all-cause in-patient mortality (P 0.7141). Admission to ICU, postadmission hemodialysis requirement, and mechanical ventilation showed no significant differences between the 2 groups (P = NS). This study suggests that the use of ACEIs and ARBs in patients with COVID-19 was not found to significantly increase all-cause in-hospital mortality, ICU admissions, and hemodialysis and mechanical ventilation requirements.

Background Limited data is available for reliable and accurate predictors of in-hospital mortality in patients diagnosed with COVID-19. Methods This scientific study is a retrospective cohort study of patients without a known history of liver diseases who were hospitalized with COVID-19 viral infection. Patients were stratified into low score groups (Model of End-Stage Liver Disease [MELD] score

Recent studies focusing on the prevalence, characteristics, and outcomes of primary heart failure (HF) with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF) in non-alcoholic fatty liver disease (NAFLD) are sparse. We sought to assess these using a nationally-representative population. We used the 2016-2018 National Inpatient Sample database to study the prevalence, characteristics, clinical risk profiles, morbidity, mortality, cost, and resource utilization among primary HFpEF and HFrEF hospitalizations with and without NAFLD. In the period from January 1, 2016, to December 31, 2018, there were 3,522,459 admissions of patients aged ≥18 years with a diagnosis of primary HF. Of these, 82,585 (2.3%) hospitalizations had secondary diagnosis of NAFLD. Admissions with NAFLD and HFrEF were associated with higher rates of in-hospital mortality (aOR 1.84, CI 1.66-2.04, P0.001) compared to admissions of HFrEF without NAFLD. Similarly, hospitalizations with HFpEF-NAFLD were associated with higher rates of in hospital mortality (aOR 1.65 CI 1.43-1.9, P0.001) compared to HFpEF admissions without NAFLD. Pressors use, cardiogenic shock, AKI with or without dialysis use, cardiac arrest, LOS and hospitalization cost were higher in admissions of HFrEF and HFpEF with NAFLD compared to those without NAFLD. In-hospital mortality, was higher in primary HFrEF and HFpEF admissions with NAFLD compared to without NAFLD. Physicians must be aware of the worse clinical outcomes of HFrEF and HFpEF in patients with NAFLD. Further clinical research is needed to address the knowledge gap and treatment options available for the patients with HF and NAFLD.

Introduction: On March 11, 2020, the World Health Organization (WHO) declared SARS-CoV-19 a pandemic with about 114 countries affected. Many studies and metanalyses have investigated the risk factors associated with poor outcomes from COVID-19 infection. Different clinical as well as laboratory parameters have been shown to correlate with disease severity, including age, male gender, smoking history, presence of one or more co-morbidities, heart disease, hypertension, diabetes, obesity, and chronic lung disease. Among these risk factors, several studies suggest that a decreased platelet count is associated with more severe disease course. A lower platelets count was also observed to be associated with a poor prognosis. On the contrary, not all reports seem to show the same association. Objective: Our study is aimed at investigating the prognostic impact of the platelet count in patients admitted with COVID-19 infection and understanding its association with disease severity and mortality. Methodology: All patients admitted to JFK Medical center in Atlantis, Florida and diagnosed with COVID-19 from March 2020 to May 2020 were identified and included in this retrospective cohort. Certain demographic and clinical data were collected for each patient, including age, gender, comorbidities, complete blood count and blood chemistry values on admission. The following data was calculated: quick Sequential Organ Failure Assessment (qSOFA), the ratio of oxygen saturation to the fraction of inspired oxygen ratio (SpO2/FiO2) were calculated, presence or absence of adult respiratory distress syndrome (ARDS), and the outcome in terms of mortality. Data regarding the radiographic findings on chest X-ray (CXR) were determined to be normal, mild, moderate, or severe by a radiologist. Patients were identified as having severe disease if they met the following criteria: Admission to the intensive care unit (ICU) during hospitalization or met criteria for ARDS. Results: A total of 175 patients were identified. The mean age was 62.97 years(SD 17.9years), 97 patients (55.4%) were males, 36 (20.6%) had an ICU admission during their hospitalization, 18 (10.3%) met the criteria for ARDS, 131 (74.9%) had qSOFA of 0 with only 3 (1.7%) having qSOFA of 2. The majority of CXR findings were mild 66 out of valid 155 cases (37.7%) while 19.4% read as severe infiltrate. The mean platelets count on admission was 227.71 x 109/L (SD 104 x 109/L). 43 patients (24.6%) died in the hospital. Patients with severe disease versus non-severe disease did not differ significantly in the platelet count at admission. Platelet counts were also not associated with in-hospital mortality. No significant correlation was found between the platelets count and the qSOFA scale, the SpO2/FiO2 and the CXR findings (table 2). Conclusion: In our retrospective Cohort study, no significant association was found between the platelet count on admission and disease severity or mortality. Studies examining the risk factors for severe COVID-19 infection and mortality showed that thrombocytopenia is a significant risk factor.(13) Other studies showed that patients with significantly elevated platelets (> 300 x 109/L) during treatment had longer average hospitalization days.(12). Finding practical and actionable indicators of disease severity can help clinicians guide patients with potentially worse outcomes to aggressive therapies that may lead to better outcomes when instituted earlier. More work should be done to clarify the role platelet counts can play in the prognostication of patients with COVID-19 infection. Our Study will be followed by further investigation of the correlation between day 3 platelet count and COVID-19 severity. We are also examining the validation of a scoring system involving the platelet count among other parameters to use as a predictor for disease course and outcome. Disclosures No relevant conflicts of interest to declare.

Background: Concerns exist that angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs) increase susceptibility to coronavirus SARS CoV-2 (the virus that causes the disease COVID-19) and the likelihood of severe COVID-19 illness. Methods: This is a single-center retrospective cohort study of 172 patients diagnosed with 2019 Novel Coronavirus (SARS-CoV-2) between March of 2020 and May of 2020. Our study aimed to investigate the impact of ACEI and/or ARBs on the in-hospital mortality, intensive care unit (ICU) admission, hospital length of stay (LOS), and ICU LOS of patients with COVID-19. Results: This cohort of 172 patients included 88 (51%) women with a mean age of 58±17 years. Patients who had a history of using ACEI/ARBs were older 68±14 vs. 54±17 (P Outcomes: There was significantly higher in-hospital mortality in patients who used ACEI/ARBs than non-users (33% vs. 13%, p=0.0039, respectively). To evaluate the effect of ACEI/ARBs on mortality after controlling for confounding factors, multivariable logistic regression (MLR) was performed based on age (p=0.0003), obesity (p=0.3394), hypertension (p=0.4159), diabetes mellitus (p=0.0144), and chronic kidney disease (0.3189). The MLR showed no significant differences in mortality between patients who used ACEI/ARBs and non-users (p= 0.8372). Admission to ICU was more likely in patients who used ACEI/ARBs than non-users (28% vs. 13%, p=0.0384 respectively), while hospital LOS (6±9 vs. 4±6, p=0.1240 respectively), and ICU LOS (12±12 vs. 8±5, p= 0.3253 respectively) were similar between the two groups. Conclusion: This study suggests that the use of ACEI/ARBs associated with higher mortality in patients with COVID-19. This is likely attributed to the fact that patients who use these medications are older and are more likely to have diabetes mellitus and hypertension.

Description Ventricular septal rupture (VSR) is a rare complication after acute myocardial infarction (MI). The case presents an apical four chamber echocardiogram showing mid-septal discontinuity with lateral to medial movement of the transected ventricular septum during systole and diastole. Color Doppler demonstrates flow across the septum with extensive anatomic destruction of the ventricular septum.