Signs And Symptoms In Cardiology By Horowitz And Groves Pdf
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Coronavirus disease COVID has affected patients across all age groups, with a wide range of illness severity from asymptomatic carriers to severe multi-organ dysfunction and death. Although early reports have shown that younger age groups experience less severe disease than older adults, our understanding of this phenomenon is in continuous evolution.
Since the beginning of the pandemic, coronavirus disease COVID in children has shown milder cases and a better prognosis than adults. Although the respiratory tract is the primary target for severe acute respiratory syndrome coronavirus 2 SARS-CoV-2 , cardiovascular involvement is emerging as one of the most significant and life-threatening complications of SARS-CoV-2 infection in adults.
To summarize the current knowledge about the potential cardiovascular involvement in pediatric COVID in order to give a perspective on how to take care of them during the current pandemic emergency. The websites of World Health Organization, Centers for Disease control and Prevention, and the Johns Hopkins Coronavirus Resource Center were reviewed to provide up to date numbers and infection control recommendations.
Reference lists from the articles were reviewed to identify additional pertinent articles. Retrieved manuscripts concerning the subject were reviewed by the authors, and the data were extracted using a standardized collection tool. Data were subsequently analyzed with descriptive statistics. For Pediatric multisystemic inflammatory syndrome temporally associated with COVID PMIS , multiple meta-analyses were conducted to summarize the pooled mean proportion of different cardiovascular variables in this population in pseudo-cohorts of observed patients.
A total of articles were included. Most publications used in this review were single case reports, small case series, and observational small-sized studies or literature reviews. Out of PMIS cases we identified 10 articles reporting sporadic cases of myocarditis, pulmonary hypertension and cardiac arrythmias in previously healthy children.
We also found another 10 studies reporting patients with pre-existing heart diseases. Most cases consisted in children with severe COVID infection with full recovery after intensive care support, but cases of death were also identified. The management of different cardiac conditions are provided based on current guidelines and expert panel recommendations. Based on our review, children previously healthy or with pre-existing heart disease with acute COVID requiring hospital admission should undergo a cardiac workup and close cardiovascular monitoring to identify and treat timely life-threatening cardiac complications.
Core Tip: Cardiovascular involvement has emerged as a remarkable risk-factor for poor outcomes of primary respiratory diseases such as coronavirus disease COVID Nevertheless, the body of evidence of cardiac complications in pediatric COVID is still scarce to extract definitive conclusions about the adequate management for these patients.
This review establishes a perspective on how COVID impacts on the heart of both previously healthy children and those with pre-existing heart diseases, and how to take care of them during the current pandemic emergency. The coronavirus disease COVID was first discovered in a cluster of patients with severe respiratory symptoms in Hubei Province, China, in December [ 1 , 2 ]. By early January , analysis of bronchoalveolar lavage BAL fluid from infected patients revealed that COVID is caused by the novel coronavirus strain, named the severe acute respiratory syndrome coronavirus 2 SARS-CoV-2 [ 3 ] , a single-stranded RNA virus belonging to the beta genus coronavirus in the coronaviridae family.
COVID rapidly swept China and spread worldwide, becoming a global pandemic causing significant mortality and morbidity [ 4 ]. At the time of this review July 31, , COVID has caused more than 18 million cases and an estimate of more than associated deaths [ 5 ].
Since the beginning of the pandemic, COVID in children has shown milder cases and a better prognosis than adults [ 6 ].
Epidemiological studies have consistently demonstrated across the world that children are at a lower risk of developing severe symptoms or critical illness compared with adults. Dong et al [ 16 ] reported, in the most extensive pediatric study in China, that only 5.
At the time of this publication, there had been relatively few reported cases of pediatric deaths attributed to COVID Only four children died case-fatality rate 0. The mechanism by which children seem less susceptible to severe infection caused by SARS-CoV-2 has yet to be elucidated Table 1 [ 26 - 31 ]. Most commonly, children presented with a mild flu-like state that can progress to potentially lethal acute respiratory distress syndrome, fulminant pneumonia, and multi-organ failure [ 10 , 32 - 35 ].
Although the respiratory tract is the primary target for SARS-CoV-2, the virus may interact with the cardiovascular system producing myocardial injury through different mechanisms Table 2 [ 36 - 40 ] , increasing morbidity in both, previously healthy patients and those with underlying cardiovascular conditions.
Thus, cardiovascular involvement is emerging as one of the most significant and life-threatening complications of SARS-CoV-2 infection in adults [ 41 , 42 ]. Besides, there is a suggestion that, as with other viral illnesses such as respiratory syncytial virus or influenza, children with underlying cardiac conditions are also at greater risk of cardiac complications or develop a more severe SARS-CoV-2 infection [ 21 ].
Furthermore, from April , increasing cases of previously healthy children showing a hyper-inflammatory state and features similar to Kawasaki-Shock disease are being reported in Europe and America [ 44 - 49 ].
Remarkably, initial reports suggest many of these patients have myocardial dysfunction and coronary artery involvement with high requirements of PICU admission, hemodynamic, and respiratory support. All the above brings out that cardiovascular involvement could be a significant risk factor for severe COVID in children. In this article, we aimed to summarize the current knowledge about the potential cardiovascular involvement in pediatric COVID to give a perspective on how to take care of them during the current pandemic emergency.
Also, the websites of the health organizations including World Health Organization and CDC and the website of the Johns Hopkins Coronavirus Resource Center were reviewed to provide up to date numbers and infection control recommendations. Multiple searches were performed during the writing of this article, as the COVID pandemic is still evolving. Reference lists of the articles identified by this search strategy were reviewed to capture additional studies.
No randomized trials neither interventional studies were available at the time this article was written; hence, observational studies, long-term prospective cohort studies, case-control, cross-sectional studies, case series, or case reports were also included in this review.
Few additional articles before our search time period were included if they were referenced in existing articles and included pertinent essential data for this present article. Only articles published in the English language were included in this review. After the initial search, the authors separately screened all abstracts based on the eligibility criteria. Any abstracts or articles for which there was disagreement or uncertainty were reviewed again and discussed until consensus was reached.
We finally included articles. The included studies were categorized by whether the study involved previously healthy patients or patients with pre-existing cardiac conditions.
As the vast majority of cases reported of pediatric cardiovascular involvement are patients with pediatric multisystemic inflammatory syndrome temporally PMIS associated with COVID, multiple meta-analyses were conducted to summarize the pooled mean proportion of different cardiovascular variables in this population. The management of the different cardiac conditions was extracted from the correspondent clinical guidelines or expert panel recommendations.
Since April , various alerts were issued in Italy, United Kingdom, and Spain about a local increase in the number of these cases [ 44 - 46 ]. After these reports, the first cases in North America were reported in May [ 47 , 48 ]. Centers for Disease Control and Prevention and the U. Taking into account that on July 29th there were 4. The case definition is nonspecific, and confirmatory laboratory testing does not exist.
Therefore, it might be challenging to distinguish PMIS from other conditions with overlapping clinical manifestations such as severe acute COVID and Kawasaki disease KD , making challenging to know the exact incidence of the disease.
As the COVID pandemic has evolved, case reports have appeared describing school-aged children and adolescents presenting with persistent high fever and systemic hyper-inflammation, reflected in a constellation of symptoms involving multiple organ systems [ 54 - 89 ]. They frequently manifested abdominal pain and gastrointestinal symptoms, KD-like features, myocardial dysfunction, coronary artery dilation, and cardiogenic shock.
Almost all of these children wholly recovered in a few days, although rare deaths have been reported. Of note, there are striking similarities between the overall clinical picture of children affected by PMIS and the late phase of adult COVID infection, characterized by cytokine storm, hyper-inflammation, and multi-organ damage [ 96 - 98 ]. Thus, they had laboratory findings associated with the cytokine storm described in adults, including high serum C-reactive protein CRP , erythrocyte sedimentation rate ESR , procalcitonin, ferritin, Dimer-D, interleukin IL -6, Troponin and pro B-type natriuretic peptide proBNP levels.
These findings suggest similar pathogenesis and a spectrum of illness from children to adults, leading to the hypothesis that PMIS is due to a post-infectious inflammatory state that occurs several weeks after a primary infection with SARS-CoV Proposed mechanisms include direct triggering of auto-inflammatory response and deregulation of immune responses after COVID infection, which could result in other environmental insults triggering a hyper-inflammatory pathology in predisposed patients [ 89 - 98 ].
One hypothesis for the marked cytokine storm experienced by children with PMIS derives from the ability of coronaviruses to block type I and type III interferon responses, which can lead to an uncontrolled viral replication in those with initially high SARS-CoV-2 viral load [ 99 ]. Myocarditis has been demonstrated by late gadolinium enhancement on cardiac magnetic resonance imaging in various children with PMIS [ 77 ].
This finding points out that SARS-CoV-2 could also produce a direct myocyte injury similar to other viral myocarditis as the mechanism of myocardial injury and heart failure during the PMIS course. Both the virus-induced damage and the local inflammatory response to cell injury could lead to necrosis of cardiomyocytes. The finding of viral particles in neutrophils within the myocardium supports the idea of local virus-induced inflammation.
Of note, infection of endothelial cells in the endocardium could result in the hematogenous spread of SARS-CoV-2 to other organs and tissues, facilitating the typical multisystem failure. Currently, available data so far suggests that PMIS shares a common pathophysiological pathway and overlapping symptoms with that described in KD [ - ]. However, clinical, laboratory, and epidemiological characteristics of PMIS appear to be different from those of KD, raising the question if they are the same entities.
For this review we selected only those studies that included at least 10 patients with PMIS and with complete data about cardiovascular involvement cardiogenic shock, cardiac biomarkers, ECG, echocardiography , treatment inotropes, mechanical ventilation, ECMO support, anti-inflammatory and immunomodulatory and outcomes [ 45 - 48 , 54 , 56 , 60 - 62 , 65 , 66 , 68 , 70 , 76 , 78 , 86 ]. We excluded those articles with suspected overlapping of patients due to multiple communications of the same patients in different papers.
In our review, we found a total of PMIS cases Of note, the vast majority of patients were previously healthy Since the first cases were reported, it was noticed that PMIS could be a severe acute condition, especially focusing on the cardiovascular system. ECG alterations were not infrequent However, there have also been reported cases of sustained arrhythmias leading to hemodynamic collapse and the need for ECMO support.
Although infrequent, most of the cases of PMIS require hospitalization and intense clinical management because of the severity of the disease. In our review, we found that a PICU admission rate of Almost all patients However, to resolve this severe inflammatory state associated is challenging, as these patients exhibit an increased resistance rate to these anti-inflammatory therapies regarding those rates reported for KD.
Hence, biologic therapy blocking IL-1 anakinra and IL-6 tocilizumab receptors have been used in up to COVID prothrombotic effects are concerning in adults [ - ] , increased use of anticoagulation Children with PMIS are at risk of thrombotic complications from multiple causes, including hypercoagulable state, possible endothelial injury, stasis from immobilization, ventricular dysfunction, and coronary artery aneurysms [ ]. Therefore, antiplatelet and anticoagulation are recommended [ , ].
Cardiac sequelae in the form of mild myocardial dysfunction or coronary artery alterations were present in up to 5. Thus, we found a mortality rate of 1. As the prognosis is excellent after treatment, the early diagnosis of PMIS and prompt initiation of anti-inflammatory therapy is crucial for a successful, rapid, and full recovery and preventing end-organ damage and mortality.
For this purpose, a high index of clinical suspicion is needed. As cardiovascular involvement is present in any form in almost patients with PMIS, the screening of cardiac alterations through cardiac biomarkers, ECG, or echocardiography could be useful for the early identification of PMIS cases. Data from this review indicate that PMIS cases have similar manifestations and outcomes from different studies across the world.
As fundamental aspects of PIMS remain unknown, future studies will improve prospects for the prevention and treatment of this severe pediatric condition. Until them, a close multidisciplinary collaboration among various disciplines including pediatrics, intensive care, rheumatology, cardiology, and immunology is warranted for the adequate management of these patients.
Cardiovascular involvement in previously healthy children out of PMIS: There is also evidence of cardiac manifestation in previously healthy children out of the setting of PMIS in children. Since the beginning of the pandemic, a few cases have been reported with cardiovascular involvement similar to adults, in the form of myocarditis, pericarditis, heart failure, cardiogenic shock, cardiac arrhythmia, and pulmonary hypertension PH Table 6 [ - ].
Although infrequent, these cases are usually reported as severe or critically ill patients, pointing out the relevance of the cardiac involvement also in previously healthy children with COVID Myocardial dysfunction and heart failure: Myocarditis is an inflammatory disease of the myocardium, diagnosed by established histological, immunological, and immune-histochemical criteria, caused mostly by infectious, immune-mediated or toxic agents [ ].
Acute myocardial injury by SARS-CoV-2 may be due to the coincidence of various mechanisms including a direct viral myocardial injury, a secondary inflammatory response in the form of cytokine storm, the severe hypoxemia due to pneumonia, and the side-effects of therapy against SARS-CoV-2 infection Table 1 and 2 [ - ].
To date, sporadic cases of myocarditis have been reported in pediatric COVID patients as the first clinical presentation of the disease, alone or in the clinical context of pneumonia.
Dong et al [ 16 ] found myocardial injury and heart failure occurring in up to 0.
Signs and Symptoms in Cardiology
Since the beginning of the pandemic, coronavirus disease COVID in children has shown milder cases and a better prognosis than adults. Although the respiratory tract is the primary target for severe acute respiratory syndrome coronavirus 2 SARS-CoV-2 , cardiovascular involvement is emerging as one of the most significant and life-threatening complications of SARS-CoV-2 infection in adults. To summarize the current knowledge about the potential cardiovascular involvement in pediatric COVID in order to give a perspective on how to take care of them during the current pandemic emergency. The websites of World Health Organization, Centers for Disease control and Prevention, and the Johns Hopkins Coronavirus Resource Center were reviewed to provide up to date numbers and infection control recommendations. Reference lists from the articles were reviewed to identify additional pertinent articles.
ESC entities having participated in the development of this document:. No commercial use is authorized. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC. Disclaimer: The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their publication. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient's case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional's responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. Bax, Michael A.
Global travel patterns: an overview. World Tourism Organization , Accessed June 1, Roth GA Global, regional, and national burden of cardiovascular diseases for 10 causes, to J Am Coll Cardiol 70 : 1 — J Travel Med 19 : 96 —
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Directrices para autores. Acceso: 12 junio Myocardial infarction redefined. Eur Heart J ; Risk of subsequent cardiac events in stable convalescing patients after first non-Q-wave and Q-wave myocardial infarction. Coron Artery Dis ;
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