Aims Healthcare services worldwide have been significantly impacted by the COVID-19 pandemic. Recent reports have shown a decline in hospitalization for emergency cardiac conditions. The impact of the COVID-19 pandemic on hospitalization and particularly mortality due to acute heart failure has not been thoroughly described. Methods and results In this single-centre observational study, we examined referrals to the acute heart failure team over a period of 16 weeks (7 January to 27 April 2020) spanning the ongoing COVID-19 pandemic; 283 patients referred to our acute heart failure services over the study period were included on the basis of typical symptoms, raised BNP, and echocardiogram. There was a substantial but statistically non-significant drop in referrals with 164 referred in the 8 weeks before the first UK death due to COVID-19 on 2 March 2020 (BC), compared with 119 referred after (AC) in the subsequent 8 weeks, representing a 27% reduction overall (P = 0.06). The 30 day case fatality rate was increased from 11% in the BC group compared with 21% in the AC group (risk ratio = 1.9, 95% confidence interval 1.09-3.3). Age, gender, length of stay, left ventricular ejection fraction, and N-terminal pro-brain natriuretic peptide were similar between the groups. Admission creatinine, age, and AC cohort status were found to be univariable predictors of mortality. On multivariate Cox regression analysis, only age (hazard ratio 1.04, P = 0.03) and AC cohort status (hazard ratio 2.1, P = 0.017) remained significant predictors of mortality. On sensitivity analysis, this increased mortality was driven by COVID-19 positive status. Conclusions There was a reduction in referral of patients with acute heart failure with significant increase in mortality in the 8 weeks following the first reported UK death due to COVID-19. The observation of increased mortality does not appear related to a change in population in terms of demographics, left ventricular ejection fraction, or N-terminal pro-brain natriuretic peptide. The observed increased mortality appears to be related to the coexistence of COVID19 infection with acute heart failure. The study highlights the need for widespread preventative and shielding measures particularly in this group of patients especially in the light of the second wave. Longer follow-up with inclusion of data from other centres and community heart failure services will be needed.

A 57-year-old man presented for an elective pacemaker upgrade, complicated by the discovery of device infection. He had a background of complex congenital heart disease, including replacement of heart valves, and was treated for presumed infective endocarditis that was later confirmed by echocardiography. Antibiotic treatment, with intravenous vancomycin, was given as per the tissue sample sensitivities. On day 24 of treatment he deteriorated clinically, with the evolution of recurrent fever, epigastric pain, diarrhoea, widespread pruritic rash, lymphadenopathy and severe hypoxia over the subsequent 7–10 days. Blood tests revealed development of a marked eosinophilia, transaminitis and rising inflammatory markers. Further radiological imaging was non-diagnostic. On the basis of these clinical and biochemical features a diagnosis of drug reaction with eosinophilia and systemic symptoms syndrome was made. This led to the cessation of vancomycin, the offending agent and the referral for specialist immunology advice. He was subsequently treated with oral prednisolone and made a full recovery.

Recent NICE guidance has highlighted the importance of appropriate and safe intravenous fluid use. We aimed to improve the quality of out of hours fluid prescription in a Bristol hospital by ensuring that indications and cautions for fluid therapy were clearly documented at the time of initiation.Time-pressured on-call doctors need quick access to information regarding patients' care. A documented “fluid plan” allows doctors to undertake a more informed assessment of the patient's fluid balance, leading to safer prescriptions.Our ideal was for 100% of out of hours intravenous fluid prescriptions to be appropriate. Our process measures included the proportion of patients on intravenous fluids who had a documented fluid plan in the medical notes or on the prescription chart on Friday, prior to the weekend on call period. This was defined as mention of indications and/or cautions to fluid therapy.The introduction of a sticker to prompt fluid plan documentation did marginally improve use of fluid plans. It was notable that 96% of these were followed where plans were documented (n=23). Initiation of IV fluid with an accompanying plan is likely to make subsequent fluid prescriptions safer.Rapid turnover of staff and stationary proved significant barriers to consistent implementation of the sticker. Despite these challenges we demonstrated a “proof of concept”, suggesting system modification to include fluid plans is safe and effective.

Background Spontaneous coronary artery dissection (SCAD) is an increasingly recognized and important cause of acute myocardial infarction, particularly in women under 50, often with minimal risk factors. Many patients have underlying arteriopathy, most commonly in the form of fibromuscular dysplasia. Case summary A 38-year-old woman presented to the hospital with chest pain and elevated high-sensitivity Troponin. Invasive coronary angiography demonstrated SCAD of the left anterior descending artery. The same day the patient developed a severe progressive headache and subsequent imaging revealed a left vertebral artery dissection. She was managed conservatively with optimal medical therapy and was successfully discharged from hospital on Day 7. Discussion To our knowledge, this is the first case report of simultaneous spontaneous coronary and vertebral artery dissections not related to pregnancy. It highlights not only the importance of recognizing and accurately diagnosing SCAD, but also of appreciating the possibility of underlying arteriopathy: this is paramount to ensuring appropriate investigations, follow-up and assessment of any unexplained symptoms in this patient group.

Funding Acknowledgements Type of funding sources: None. Background Acute decompensated heart failure carries a poor prognosis and places a significant burden on healthcare resources. Our ability to predict patients at high risk of deterioration is limited. The Rockwood Clinical Frailty Scale (CFS) is an established frailty screening tool that stratifies patients on a nine-point scale ranging from 1 (very well) to 9 (terminally ill) providing a useful measure of physiological reserve. CFS is used extensively for general prognostication in geriatric populations, yet its impact on mortality specifically in patients admitted with acute heart failure remains sparsely investigated. Purpose We performed a retrospective cohort study to investigate the prognostic role for CFS for short term mortality in patients admitted with acute heart failure. Methods Over a period of 16 weeks (7th January – 27th April 2020), 283 consecutive patients presenting to our hospital with signs and symptoms of acute heart failure were identified. Discharge summaries, electronic notes and shared care networks were manually searched for each patient to determine frailty score, baseline demographics, admission bloods and co-morbidity indices. Short term mortality at 30 days was recorded from electronic hospital and GP records. Univariate and multivariate Cox regression analysis was performed to identify clinical and biochemical predictors of mortality. Results In total, 283 patients were admitted with acute heart failure over the study period (mean age 81+/-10 years, 46% female. The mean CFS score was 5+/-1 and mean Charlson Comorbidity Index score 8+/-3. 15% of patients died within 30 days. On univariate analysis age, creatinine, Charlson Comorbidity Index and CFS were associated with prognosis. On multivariate analysis, only CFS was found to be an independent predictor of mortality (hazard ratio 1.36, p = 0.029). Conclusion This study demonstrates a clear relationship between increasing frailty score and short-term mortality in acute heart failure. The CFS is a rapid and easily accessible screening tool used widely throughout the UK. This work highlights its potential for use alongside other parameters in prognostication of patients presenting with acute decompensated heart failure. Further work is needed to explore the impact on longer term mortality and to determine practical implementation in this setting. Abstract Figure.