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Patients with cardiovascular disease (CVD) have an increased mortality risk with COVID-19 infection yet several studies have shown fewer hospital-based CVD diagnoses and procedures during the COVID-19 pandemic. In this issue of Heart, Wu and colleagues1 show that despite a decrease in the number of patients presenting with an acute CVD event there was an 8% excess of CVD deaths in England between March and June 2020 (during the COVID-19 pandemic), compared with the previous 6 years (figure 1). About ½ of these deaths occurred outside the hospital with the most frequent causes of CVD death being stroke (35.6%), acute coronary syndrome (24.5%), heart failure (23.4%) pulmonary embolism (9.3%) and cardiac arrest (4.6%). Most of these deaths were not related to a known COVID-19 infection, suggesting they were most likely due to delays in seeking medical care or undiagnosed COVID-19 infection.
As Singh and Newby2 emphasise in an editorial: ‘the evidence presented by Wu and colleagues1 provides us with an important message to our patients and society: it is important to seek emergency medical attention for symptoms indicative of serious life-threatening cardiovascular disease even during the height of the pandemic. Here, the risk of fatal stroke and myocardial infarction outweighs the COVID-19 risk to the patient, and the healthcare system had capacity within acute specialities outside of the intensive care and dedicated COVID-19 units to provide life-saving treatments. This ultimately begs the question: is the fear of disease worse than the disease itself?’
Another important study in this issue of heart describes a 12-year cohort study of 419 patients with infective endocarditis in South Korea.3 Overall, hospital mortality was 14.6% with risk factors for mortality including aortic valve infection, Staphylococcus aureus, neurological complications multi-organ failure, and an increased number of comorbidities. Surgical intervention was associated with a markedly lower risk of in-hospital mortality (OR 0.25, p<0.001) and improved long-term outcomes (figure 2).
‘We could (and should) do better’ in preventing and treating infective endocarditis plead Scully et al.4 They conclude that: ‘As the present data from South Korea demonstrate, IE remains associated with poor outcomes and its incidence is increasing in many countries around the world. Greater public health awareness is warranted alongside renewed emphasis on education of patients at risk (with particular regard to prompt symptom reporting and maintenance of good oral and cutaneous hygiene), early diagnosis, timely referral and specialist care. Once suspected or diagnosed, early involvement of a dedicated Endocarditis Team is essential in managing these patients combined with early, appropriate antibiotic therapy and decisions regarding the need for surgery and its timing.’
Another interesting paper in this issue of Heart by Onishi and colleagues5 describes the diagnosis and outcomes of triglyceride deposit cardiomyovasculopathy (TGCV) which is seen in about 20% of haemodialysis patients with suspected coronary artery disease. At median follow-up of 4.7 years, the composite primary endpoint of CVD death, non-fatal myocardial infarction and non-fatal stroke occurred in 52.3% of the definite TGCV patients compared with 27.3% in those with probable TGCV and 9.1% of the non-TGCV patients. In the accompanying editorial, Nakajima6 explains the causes of TGCV and discusses the diagnostic approach. In brief, ‘The principal disorder in TGCV is defective intracellular lipolysis, which causes excessive triglyceride accumulation in the myocardium and coronary artery vascular smooth muscle cells, leading to heart failure and coronary artery disease with a poor prognosis.’ Diagnosis is based on the presence of impaired long-chain fatty acid metabolism or triglyceride deposition in the myocardium in combination with clinical major and minor criteria and supportive items.
The Education in Heart article in this issue7 reviews the prevalence and predictors of neurocognitive and psychosocial impairment among adults with congenital heart disease followed by a discussion of how these issues can be mitigated over the patient’s lifespan.
Readers will also want look at the review article8 on the emerging mechanistic models that link atrial fibrosis, atrial fibrillation and stroke given the implications of these models for new approaches to prevention of adverse clinical events (figure 3). Boyle et al outline ‘a vision of a future paradigm integrating simulations in formulating personalised treatment plans for each patient.’
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.
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