Patrick Campbell

While the impact of the coronavirus disease 2019 (COVID-19) on overall and 

 has been widely discussed, new research is detailing the impact of mental stress from the pandemic is having on heart health.

A retrospective analysis of data from 2 hospitals within the Cleveland Clinic health system, results of the study indicated rates of stress cardiomyopathy were more than 4 times greater than the pre-COVID-19 rates.

“The COVID-19 pandemic has brought about multiple levels of stress in people’s lives across the country and world. People are not only worried about themselves or their families becoming ill, they are dealing with economic and emotional issues, societal problems and potential loneliness and isolation,” said lead investigator Ankur Kalra, MD, a cardiologist in the Sections of Invasive and Interventional Cardiology and Regional Cardiovascular Medicine at the Cleveland Clinic, 

. “The stress can have physical effects on our bodies and our hearts, as evidenced by the increasing diagnoses of stress cardiomyopathy we are experiencing.”

By most accounts, the ongoing COVID-19 pandemic has reshaped life in the US and throughout the world for the foreseeable future. Despite less than a year elapsing since the initial outbreak began, mountains of data have been collected and disseminated related to the impact of COVID-19 on various aspects of a person’s health.

One of the most universal impacts of COVID-19, has been an increase in stress. From impact on sleep to overall psychological health, the effects of additional stress from COVID-19 has been felt by many patients and been the topic of dozens of studies since the outbreak began. Kalra and colleagues from the Cleveland Clinic hoped to add to the understanding of this impact by assessing the incidence of stress cardiomyopathy, also known as Takotsubo cardiomyopathy, during the COVID-19 pandemic compared against historical rates.

Using electronic medical record data obtained from patients admitted to either the Cleveland Clinic Main Campus or Cleveland Clinic Akron General hospitals between March 1-April 30, 2020, investigators identified a cohort of 258 patients presenting with acute coronary syndromes and without COVID-19, as confirmed by reverse transcription–polymerase chain reaction tests. For the purpose of their analysis, investigators created 4 control cohorts of patients admitted from March 1-April 30, 2018, January 1-February 28, 2019, March 1-April 30, 2019, and January 1-February 29, 2020 for comparison.

In total, the retrospective cohort study included 1914 patients presenting with acute coronary syndrome, including 1656 who presented pre-COVID-19. Of the 1656 pre-COVID-19 patients, 290 were admitted from March-April 2018, 309 were admitted from January-February 2019, 679 were admitted from March-April 2019, and 278 were admitted from January-February 2020. Investigators pointed out there were no statistically significant differences in median age (pre–COVID-19: 67 [59-74] years vs COVID-19: 67 [57-75] years; 

=.56) or sex (pre–COVID-19: 1064 [66.1%] men vs COVID-19: 175 [67.8%] men; 

During the COVID-19 period, a total of 20 (7.8%) patients presented with stress cardiomyopathy, which represents an increase compared to the pre-COVID-19 period. In comparison, incidence of stress cardiomyopathy during the pre-COVID-19 periods ranged from 5-12 patients. Based on the results of the analysis, investigators calculate the rate ratio during the COVID-19 period to be 4.58 times greater than during the pre-COVID-19 time periods (RR, 4.58; 95% CI, 4.11-5.11; 

Of note, patients presenting with stress cardiomyopathy during the pandemic had a longer median hospital length of stay than those hospitalized in pre-COVID-19 periods. Specifically, patients during the COVID-19 period had a median length of stay of 8 (IQR, 6-9) days compared to 4 (3-4) days for March-April 2018, 5 (3-6) days for January-February 2019, 4 (4-8) days for March-April 2019, and 5 (4-5) days for January-February 2020.

Investigators highlighted their analysis indicated no significant differences between the COVID-19 period and the pre-COVID-19 period in regard to mortality (1 patient [5.0%] vs 1 patient [3.6%], respectively; 

=.81) and 30-day rehospitalization rates (4 patients [22.2%] vs 6 patients [21.4%], respectively; 

“While the pandemic continues to evolve, self-care during this difficult time is critical to our heart health, and our overall health,” said senior investigator Grant Reed, MD, MSc, director of the Cleveland Clinic’s STEMI program, in the aforementioned statement. “For those who feel overwhelmed by stress, it’s important to reach out to your healthcare provider. Exercise, meditation and connecting with family and friends, while maintaining physical distance and safety measures, can also help relieve anxiety.”

Incidence of Stress Cardiomyopathy During the Coronavirus Disease 2019 Pandemic

Articles

New research from the Cleveland Clinic has uncovered a troubling trend related to stress from COVID-19 and cardiovascular health. 

Rates of Stress Cardiomyopathy Rising During COVID-19 Pandemic

A recent study from investigators at Yale University is diving deeper into the cause and impact of coronavirus disease 2019 (COVID-19)-associated coagulopathy.

Results of the study, which included patients treated in the ICU and non-ICU settings, indicate endotheliopathy is present in COVID-19 and is likely to be associated with critical illness and death

“While many forms of illness can generate blood clots, the endothelial cells that line the inside of blood vessels play a surprisingly large role in COVID-19 clotting,” said lead investigator Alfred Lee, MD, PhD, associate professor of medicine at Yale Cardiology Center, 

. “Endothelial damage is a central component in the entire spectrum of COVID-19 disease. Our study is the first to demonstrate that this process of endothelial damage is present in a wide range of COVID-19 patients, particularly as people become critically ill.”

To add to the knowledge surrounding COVID-19, investigators designed their study to assess the blood of 68 patients with COVID-19 and a group of 13 disease-free controls. Of the 68 COVID-19 patients, 48 were treated in ICUs and 20 were treated in non-ICU settings.

For the purpose of analysis, investigators sought to compare biomarkers of endothelial cell and platelet activation, including von Willebrand Factor (VWF) antigen, soluble thrombomodulin, soluble P-selectin, and soluble CD40 ligand, as well as coagulation factors, endogenous anticoagulants, and fibrinolytic enzymes between the arms.

Upon analysis, investigators found markers of endothelial cell and platelet activation were significantly elevated in patients ICU patients versus non-ICU patients—specifically, VWF antigen (mean 565% [SD, 199] vs 278% [SD, 133] ; 

 <.0001) and soluble P-selectin (mean 15.9 ng/mL [SD, 4.8] vs 11.2 ng/mL [SD, 3.1]; 

Further analysis indicated mortality appeared to be significantly correlated with VWF antigen and soluble thrombomodulin in the entire study cohort. Additionally, soluble thrombomodulin concentrations above 3.26 ng/mL were associated with lower rates of discharge and a lower likelihood of survival (HR, 5.9; 95% CI, 1.9-18.4; 

To learn more about the risks and impact of blood clots in COVID-19 patients, 

invited study investigator Hyung Chun, MD, associate professor of medicine and pathology at Yale School of Medicine and director of Translational Research in the Yale Pulmonary Vascular Disease Program, to take part in an interview discussing his study.

Endotheliopathy in COVID-19-associated coagulopathy: evidence from a single-centre, cross-sectional study

An associate professor of medicine at Yale School of Medicine discusses the results of a study aimed at assessing the potential pathophysiology of COVID-19-associated blood clots.

Hyung Chun, MD: Cause of Blood Clots in COVID-19

Results of a new analysis are shedding further light on the benefit of quitting smoking in young heart attack survivors.

An analysis of patients with myocardial infarction aged 50 years of age or younger, results indicated quitting smoking was associated with a 70% reduction in all-cause mortality and an 81% reduction in cardiovascular mortality after adjustment for risk factors and propensity score matching.

"These results are definitive: among young people who have had a heart attack, quitting smoking is associated with a substantial benefit," said corresponding author Ron Blankstein, MD, of the Division of Cardiovascular Medicine at Brigham and Women’s Hospital, 

. "In cardiology, we are always looking for ways to reduce the risk of cardiovascular events, be it in the form of new medications or other interventions. Our findings show the dramatic magnitude of the effect that quitting smoking can have for young adults.”

Despite being one of the most researched topics in medicine, investigators felt the benefits of smoking cessation in younger patients had often been overlooked by previous studies. To further investigate the potential impact of smoking cessation in this population, investigators designed their study as a retrospective analysis of patients in the Partners YOUNG-MI registry.

Incorporating electronic medical data from Brigham and Women’s Hospital and Massachusetts General Hospital from January 2000-April 2016, a cohort of 2072 patients who experienced a myocardial infarction caused by atherothrombotic coronary artery disease. Investigators pointed out patients who died within 1 year of the index hospitalization and those with known 

—defined as prior myocardial infarction or revascularization—were excluded from the analysis.

The median age of this cohort was 45 (Interquartile range [IQR], 42-48) years, 80.6% were women, and 52.5% (n=1088) were smokers at the time of index hospitalization. Of note, the median follow-up period for those with full smoking data was 10.2 (IQR 7.0-13.1) years.

Using data from these patients, investigators hoped to assess associations of smoking and smoking cessation with survival over the follow-up period. Specific outcomes of interest were all-cause and cardiovascular mortality, which were adjudicated independently by a pair of cardiologists. Investigators noted Partners YOUNG-MI registry provided data related to length of index hospital stay, diabetes status, hypertension status, peripheral vascular disease, eGFR, and P2Y12 inhibitor and β-blocker use at discharge for use as covariates in the analysis.

For the purpose of the analysis, smoking cessation was defined as abstinence from inhaled tobacco for at least 3 months immediately before their 1-year follow-up period and without any documented relapse. Of the 1088 current smokers at index hospitalization, 910 had complete follow-up data allowing placement into either group. In total, 343 (37.7%) were classified into the cessation group and 567 (62.3%) were classified into the persistent smoking group.

During the follow-up period, the rate of death among those in the persistent smoking group was more than 3 times greater than those in the cessation group—with rates of 13.2% and 4.1%, respectively (

 <.001). In total, 75 of the 567 persistent smokers died compared to 14 of the 343 individuals in the cessation group.

In unadjusted analyses, smoking cessation was associated with a 65% reduction in all-cause mortality (HR, 0.35; 95% CI, 0.19-0.63; 

 <.001). In the fully-adjusted, propensity score-matched analysis, smoking cessation was associated with a 70% reduction in all-cause mortality (HR, 0.30; 95% CI, 0.16-0.56; 

When examining cardiovascular mortality, investigators found similar trends. Among patients in the persistent smoking group, 30 of 567 experienced cardiovascular mortality compared to 6 of the 343 patients in the cessation group (

=.008). In unadjusted analyses, smoking cessation was associated with a 71% reduction in cardiovascular mortality (HR, 0.29; 95% CI, 0.11-0.79; 

=.02). In the fully-adjusted, propensity score-matched analysis, smoking cessation was associated with an 81% reduction in cardiovascular mortality (HR, 0.19; 95% CI, 0.06-0.56; 

Investigators pointed out their study has certain limitations. Limitations included the retrospective nature of the analysis, inability to assess smoking status beyond 1 year of follow-up, and the possibility of unmeasured lifestyle factors impacting results.

"These limitations notwithstanding, our findings reinforce the critical importance of smoking cessation, especially among those who experience a heart attack at a young age," added Blankstein, in the aforementioned statement. "Looking at the trajectories of young patients who quit smoking versus those who don't paints a clear picture of the magnitude of risk compared to the benefit of smoking cessation."

Association of Smoking Cessation and Survival Among Young Adults With Myocardial Infarction in the Partners YOUNG-MI Registry,

An analysis of data from a pair of major hospitals in Massachusetts is detailing the impact smoking cessation can have on survival in young patients with myocardial infarction.  

Quitting Smoking Drastically Improves Survival After Heart Attack

A new study of data from the Veterans Health Administration is seeking to fill the gap in knowledge regarding the impact of 

 on mortality and primary prevention of atherosclerotic cardiovascular disease in elderly patients.

Results of the propensity-matched study, which was retrospective in nature, indicate statin use decreased risk of all-cause mortality by 25% and risk of cardiovascular mortality by 20% compared to those not receiving statins.

“One of the most remarkable things about our results is that we found the benefit of statins held true regardless of whether a person was older or younger or had a condition such as dementia,” said lead investigator Ariela Orkaby, MD, MPH, a physician scientist at the VA Boston Health Care System and in the Division of Aging at Brigham and Women’s Hospital, 

To further explore the role of statin therapy for prevention of 

, Orkaby and a team of colleagues designed their analysis as a retrospective cohort study examining a group of 326,981 veterans aged 75 years and older, not using statins, and free of atherosclerotic cardiovascular disease at baseline. Of note, all patients included in the study had a clinical visit occur between 2002-2012 and were followed through December 31, 2016.

The exposure of interest in the analysis was any new statin prescription. The primary outcomes of interest were all-cause and cardiovascular mortality. The secondary outcome of the analysis was a composite of atherosclerotic cardiovascular disease events, including myocardial infarction, ischemic stroke, and revascularization with coronary artery bypass graft surgery or percutaneous coronary intervention.

The mean age of the study cohort was 81.1 (4.1) years, 97% were men, and 91% were white. During the study period, 17.5% (n=57,178) initiated statin therapy. Overall, 206,902 deaths occurred during the follow-up period, which lasted a mean of 6.8 (3.9) years. Of these, 53,296 were classified as cardiovascular deaths.

After the application of propensity score matching, results of the investigators’ analysis indicated statin use was associated with a significant reduction in risk of all-cause mortality (HR, 0.75; 95% CI, 0.74-76) and a significant reduction in risk of cardiovascular death (HR, 0.80; 95% CI, 0.78-0.81).

When assessing for secondary outcomes, investigators identified 24,951 instances of myocardial infarction, 35,630 instances of ischemic stroke, and 74,362 revascularization procedures. When assessing the impact of statin use on the secondary outcome, the adjusted risk associated with statin use was 8% lower than the risk among those not using statins (HR, 0.92; 95% CI, 0.91-0.94). HRs for specific events were 0.99 (95% CI, 0.97 to 1.03) for myocardial, 0.98 (95% CI, 0.96 to 1.01) for ischemic stroke, and 0.89 (95% CI, 0.88 to 0.91) for revascularizations.

 Stephen Nicholls, MBBS, PhD, of the Victorian Heart Institute at Monash University in Melbourne, Australia, and Adam Nelson, MBBS, PhD, of the Duke Clinical Research Institute in Durham, North Carolina, underscored the additional credence results of the current study add to the idea of statin use for primary prevention in elderly patients.

“The findings of the study by Orkaby et al. provide additional support for treatment guidelines that have increasingly advocated for more widespread use of statin therapy for ASCVD prevention in older individuals,” wrote Nicholls and Nelson. “While randomized trials will provide the most definitive data to support these recommendations, observational data from large cohorts have the potential to guide clinical practice in the interim.”

Association of Statin Use With All-Cause and Cardiovascular Mortality in US Veterans 75 Years and Older

New research is detailing the impact of statin use for primary prevention in elderly patients free from atherosclerotic cardiovascular disease. 

Author | Patrick Campbell

Articles

Rates of Stress Cardiomyopathy Rising During COVID-19 Pandemic

Hyung Chun, MD: Cause of Blood Clots in COVID-19

Quitting Smoking Drastically Improves Survival After Heart Attack

Statin Use in Elderly Linked to Decrease in Risk of Death, Cardiovascular Mortality