Practical Cardiology Editorial Staff 

An all-female panel of American Heart Association experts will be available to answer questions on the COVID-19 pandemic and the changes it has made to resuscitation and patient care.

The event will take place on Reddit in a Reddit Ask Me Anything event.

The AHA panel will focus on how the COVID-19 pandemic has led to fewer 911 calls, and why hospitals are still the safest place to be if a medical emergency such as a heart attack or stroke occurs. Drs. Sasson and Topjian will be available to answer questions on specific ways medical experts are addressing patients’ health during the pandemic, or questions about COVID-19 and emergency cardiovascular care. 
	
	What:             Ask Me Anything Q&A Session on Reddit
	
	When:            Friday, June 12, 1:00-2:00 p.m. CT
	
	Where:          

  
	
	Who:               Comilla Sasson, M.D., Ph.D., FAHA, FACEP, is vice president of emergency cardiovascular care science and innovation for the American Heart Association and an associate clinical professor of emergency medicine at the University of Colorado, Denver, where she is a practicing ER physician. She worked for one month on the front lines in New York City caring for patients with COVID-19.
	
	                        Alexis Topjian, M.D., M.S.C.E., FAHA, is a pediatric critical care medicine physician at Children's Hospital of Philadelphia and an assistant professor in the department of anesthesia, critical care and pediatrics at Perelman School of Medicine at the University of Pennsylvania.

Articles

American Heart Association Experts Will Answer Questions About COVID-19 and Emergency Cardiovascular Care 

A 40-year-old woman went to the doctor after petechia and palpable purpura appeared on the palms of her hands, fingers, and toes. She appeared chronically ill and had significant weight loss. Her doctor also noted the presences of Osler nodes. She did not have any recent injuries or skin punctures and reported she had been in good health until the last few weeks.  Based on these clues, how would you diagnose this patient?

A. Leukocytoclastic vasculitis
	B. Subacute bacterial endocarditis
	C. Candida sepsis
	D. Thrombotic thrombocytopenic pupura (TTP)

Not sure? Use the Differential Builder in 

To learn more about this diagnosis, visit the 

Image IQ: Petechia and Palpable Purpura on the Palms of Hands, Fingers, and Toes

In the face of the worldwide coronavirus (COVID-19) pandemic, 4 of the largest cardiology organizations are advising patients receiving treatment with ACE inhibitors (ACE-i) and angiotensin receptor blockers (ARBs) they should not be discontinuing treatment unless it is recommended by their physician.

The European Society of Cardiology (ESC) Council on Hypertension announced their stance in a positioning statement on March 13, and the American College of Cardiology (ACC), American Heart Association (AHA), and Heart Failure Society of America (HFSA) published a joint statement days later on March 17-a move which showed solidarity in opinion between cardiologists, whose patient populations are among the most vulnerable during the outbreak.

“We understand the concern-as it has become clear that people with cardiovascular disease are at much higher risk of serious complications including death from COVID-19," AHA president Robert A. Harrington, MD, said in a statement. "However, we have reviewed the latest research-the evidence does not confirm the need to discontinue ACE-i or ARBs, and we strongly recommend all physicians to consider the individual needs of each patient before making any changes to ACE-i or ARB treatment regimens."

While research surrounding the topic is still limited, the discussion on whether ACE-i and ARBs should be discontinued as part of therapy has mostly been waged by cardiologists on social media. With evidence angiotensin-converting enzyme 2 identified as a functional receptor for SARS-CoV-2, which leads to COVID-19, many have raised the question as to whether it is appropriate to discontinue the aforementioned therapies.

The statement from the ESC Council on Hypertension, which was penned by Giovanni de Simone, MD, Chair of the ESC Council on Hypertension, references the debate taking place on social media and notes the concern this can cause for patients who may read it. The statement goes on to discredit the speculation, citing work in animal studies that suggests these medications might have benefit for preserving lung function.

“This speculation about the safety of ACE-i or ARB treatment in relation to COVID-19 does not have a sound scientific basis or evidence to support it,” Simone and colleagues wrote. “Indeed, there is evidence from studies in animals suggesting that these medications might be rather protective against serious lung complications in patients with COVID-19 infection, but to date there is no data in humans.”

In the event a clinician has a patient with cardiovascular conditions that contracts COVID-19, the joint HFSA/ACC/AHA statement recommends delaying changes in treatment until after a full evaluation is complete. The statement also recommends shared-decision making with the rest of the patient’s care team before going forward with changes to treatment.

“While the primary symptoms of COVID-19 include respiratory symptoms, the latest evidence demonstrates some patients with COVID-19 may also have severe cardiovascular damage," said Biykem Bozkurt, MD, PhD, HFSA president, in the joint statement. "We must ensure we fully evaluate and treat patients with cardiovascular disease."

HFSA/ACC/AHA statement addresses concerns re: using RAAS antagonists in COVID-19

,” was published online in the AHA Newsroom.

Position Statement of the ESC Council on Hypertension on ACE-Inhibitors and Angiotensin Receptor Blockers

,” was published online in the Council of Hypertension News.
	 

Cardiology Organizations Advise on ACE Inhibitors, ARBs Use During COVID-19

A 42-year-old man went to the ED complaining of acute onset of dizziness, heart palpitations, and a racing heartbeat. He's been working overtime at two jobs and has been drinking multiple energy drinks with high amounts of caffeine to stay awake. He reported multiple episodes of faintness over a short period of time and sought treatment. An ECG showed a wide QRS complex.

A. Ventricular tachycardia
	B. Vasovagal syncope
	C. Generalized anxiety disorder
	D. Myocardial ischemia

The correct answer is (A) ventricular tachycardia.

A cardiac arrhythmia originating from the ventricles. May be asymptomatic or may present with dizziness, palpitations, chest pain, shortness of breath, syncope, or sudden cardiac arrest. Characterized by a wide QRS complex (duration >120 msec), although supraventricular tachyarrhythmias may also exhibit a wide QRS complex when abnormal intracardiac conduction (aberrancy) is present. Distinction between these arrhythmias may be helpful for long-term treatment, although it may not be necessary for treatment of an unstable patient.

Ventricular tachycardia (VT) may be classified as:

Sustained or nonsustained – Sustained VT is defined as persistence for ≥30 seconds. Nonsustained VT is defined as duration of >3 beats but spontaneous termination within 30 seconds.

Monomorphic or polymorphic – Morphology of all QRS complexes is the same in monomorphic VT, whereas beat-to-beat variation in QRS morphology is seen in polymorphic VT.

VT is most commonly observed in patients with underlying structural cardiac abnormalities (including coronary artery disease, hypertrophic cardiomyopathy, dilated cardiomyopathy, and ion channel mutations such as Brugada syndrome and long QT syndrome), although some patients will present with idiopathic VT, which is defined by occurrence of VT in a structurally normal heart.

Treatment varies depending on the presenting symptoms and hemodynamic stability. Options may include cardiopulmonary resuscitation, electrical defibrillation, or use of antiarrhythmic drugs (eg, amiodarone). Patients with a history of life-threatening or recurrent VT will often undergo radiofrequency catheter ablation and/or placement of an implantable cardioverter defibrillator.

To learn more about this diagnosis and for ICD10 codes, visit 

A 42-year-old man visited the ED complaining of acute onset of dizziness, heart palpitations, and a racing heartbeat. He's been working overtime and drinking caffeinated energy drinks to stay awake. He said he had multiple episodes of faintness over a short period of time. Can you diagnose this patient?

Image IQ: 42-year-old man with dizziness and racing heartbeat

A study presented today at the 2020 International Stroke Conference in Los Angeles finds that the long-term use of low-dose aspirin in ischemic stroke patients who have a glucose-6-phosphate dehydrogenase (G6PD) deficiency, may have higher risks of moderate-to-severe bleeding and all-cause death.

The study was featured in a poster presentation today by Yicong Chen, et al., of Sun Yat-sen University in China.

G6PD is an inherited condition in which red blood cells break down in response to certain triggers, such as infection, stress, certain drugs or specific foods, such as fava beans. It can lead to fever, dark urine, abdominal and back pain, fatigue, and pale skin.

In this study, researchers evaluated the use of aspirin in G6PD patients who had a stroke and received aspirin, which is a common antiplatelet therapy to prevent secondary stroke. Their question:  Does aspirin increase the risk of hemolysis, bleeding or death in patients with G6PD deficiency?

RELATED:  11 Percent Change of Stroke Recurrence in AFib Patients

In this prospective, multicenter, observational study, they compared the safety and efficacy of long-term low-dose aspirin in ischemic stroke patients with and without G6PD deficiency.

Patients with and without G6PD deficiency were given low-dose aspirin of 100 mg/daily for three months. G6PD levels were examined after stroke occurrence.

Of 1,121 patients, 130 (11.6%) were G6PD-deficient and 991 (88.4%) were G6PD-normal. 81 G6PD-deficient patients and 576 G6PD-normal patients received low-dose aspirin for three months.

One G6PD-deficient patient experienced acute hemolysis, but in none of the G6PD-normal patients. Moderate-to-severe bleeding occurred in 2.5% of deficient patients and 0.3% normal patients. And, the all-cause death rate as 6.2% in deficient patients and 1.4% in normal patients. Stroke affected 2.5% of deficient patients and 1.7% of normal patients.G6PD deficiency was associated with increased moderate-to-severe bleeding (P = 0.048) and all-cause death during aspirin use (P = 0.008).

The researchers concluded that G6PD deficient stroke patients treated with low-dose aspirin were at higher risk of moderate to severe bleeding, but also all-cause death. However, stroke recurrence rates were similar among the two groups.

Yicong Chen, Jinsheng Zeng. "Safety and Efficacy of Long-term Low-dose Aspirin in Ischemic Stroke Patients With Glucose-6-phosphate Dehydrogenase Deficiency." International Stroke Conference. Feb. 19, 2020. Abstract: LBP19

Aspirin for G6PD Deficient Patients May Deserve a Second Look 

The chances of having an acute ischemic stroke (AIS) due to atrial fibrillation 14 days post stroke or transient ischemic attack (TIA) is high, according to a study presented today during the start of the 2020 International Stroke Conference being held in Los Angeles this week.

In this study, which was a poster presentation by Xiyan Yi, et al., and colleagues from the University of South Florida, Tampa, analyzed a subgroup of the AREST study (Apixaban for Early Prevention of Recurrent Embolic Stroke and Hemorrhagic Transformation). AREST was a multi-center, randomized controlled trial of early apixaban treatment compared to patients with atrial fibrillation who were treated with warfarin one week post-TIA or two weeks post-AIS.

Due to an increased risk of embolic stroke, chronic oral anticoagulation is recommended for most atrial fibrillation patients. But once a stroke occurs, anticoagulation is generally delayed due to the possibility of hemorrhagic transformation. But the question is:  What are the chances of having an ischemic stroke in these cases? Well, as much as 11 percent according to the authors of this study.

RELATED:  Aspirin for G6PD Deficient Patients May Deserve a Second Look

This study is based on the evaluation of brain magnetic resonance imaging scans to determine stroke occurrence in this group of 91 patients from the AREST study who were treated with warfarin. Of these, 47 were assigned to warfarin and 28 had brain MRI scans 14 days after the initial stroke. Prior to the MRI, 10 patients were receiving an anticoagulation, four developed recurrent AIS and two had hemorrhagic transformation. Of 18 patients who did receive anticoagulation therapy or low dose therapy, one had a TIA, two had recurrent AIS, and two had hemorrhagic transformation.

While 11 percent of patients had recurrent AIS, 11 percent had hemorrhagic transformation of the prior stroke which is higher than the 4.9% and .5% rates previously reported for stroke and hemorrhage. But those numbers, the authors say, were clinically reported and most likely low. The MRI-diagnosed cases suggest a more realistic occurrence rate.

"Although AREST was a small study, it suggests that tools designed for annual risk estimation may not accurately reflect the full aggregate of recurrent stroke or bleeding during the subacute phase, especially if asymptomatic. Improved surveillance may help provide safer decisions on timing of anticoagulation for stroke patients with AF," the authors wrote.

Nhi Tran, M.S. "Atrial Fibrillation and Recurrent Stroke on Brain Mri: The "natural History" of 14 Days Without Therapeutic Anticoagulation." International Stroke Conference. Feb. 19, 2020. Abstract: LBP20