Objectives To identify predictors of poor prognosis in previously healthy young individuals admitted with COVID-19. Methods We studied a cohort of patients hospitalized with COVID-19 disease. All patients without comorbidities, no usual treatments and ≤65 years old were selected from an international registry (HOPE-COVID-19, NCT04334291). We focused on baseline variables-symptoms and signs at admission-to analyze risk factors for poor prognosis. The primary endpoint was a composite of major adverse clinical events during hospitalization including mortality, mechanical ventilation, high flow nasal oxygen therapy, prone, sepsis , SIRS, and embolic events. Results Overall, 773 healthy young patients were included. The primary composite endpoint was observed in 29% (225/773) and the overall mortality rate was 3.6% (28/773). In the combined event group, 75% (168/225) of patients were men and the mean age was 49 (±11) years, whereas in the non-combined event group, the prevalence of male gender was 43% (238/548) and the mean age was 42 (±13) years; p<0.001 for both. On admission, respiratory insufficiency and cough were described in 51.4% (114/222), and 76% (170/223) of patients, respectively, in the combined event group, vs. 7.9% (42/533) and 56% (302/543) of patients in the other group; p<0.001 for both. The strongest independent predictor for the combined endpoint was desaturation (SpO2<92%) (OR: 5.40; CI95% 3.34-8.75; p<0.001), followed by tachypnea (OR: 3.17; CI95% 1.93-5.21; p<0.001), male gender (OR: 3.01; CI95% 1.96-4.61; p<0.001), and pulmonary infiltrates on chest X ray at admission (OR: 2.21; CI95% 1.18-4.16; p: 0.014). Conclusions Major adverse clinical events were unexpectedly high considering the baseline characteristics of the cohort. Signs of respiratory compromise at admission, and male gender, were predictive for poor prognosis among young healthy patients hospitalized with COVID-19.

This article presents a case of displacement of the ventricular electrode of a DDD pacemaker occurring 3 years after implantation following a session of respiratory therapy. The incident provoked the loss of the ventricular pacing and left pectoral stimulation. The different techniques for achieving airway patency that can be used in respiratory therapy of patients with permanent pacemakers are discussed.

Transient myocardial ischaemia in the absence of chest pain ('silent ischaemia') commonly occurs in patients with coronary artery disease (CAD) and has important prognostic implications. However, doubts exist as to whether and how silent ischaemia should be managed. In the present article we review current knowledge regarding silent ischaemia and the role of recently developed drugs that may be effective to control its occurrence. Since the description in the 1770s of the syndrome of 'angina pectoris' by William Heberden, the importance of chest pain for the diagnosis of CAD has remained un-abated. However, several decades ago it became apparent that both myocardial infarctions and transient episodes of myocardial ischaemia could occur in the absence of chest pain. Indeed, a large proportion of patients with CAD have both silent and painful myocardial ischaemia as a manifestation of CAD. Whether the presence of asymptomatic ischaemic electrocardiographic changes in patients with CAD has prognostic importance and whether it needs medical or surgical treatment has been a matter of speculation for several decades.

Background Many specific prognostic risk scores have been validated for myocardial infarction (MI), such as the Global Registry of Acute Coronary Events (GRACE) 2.0. Other general risk scores are used in intensive care units (ICUs), such as the Acute Physiologic and Chronic Health Evaluation (APACHE) II and the Simplified Acute Physiology Score (SAPS) II. Purpose Compare the ability of GRACE 2.0, APACHE II and SAPS II risk scores to estimate in-hospital, 3- and 12-month mortality after primary angioplasty (PA) for ST-segment elevation MI (STEMI). Methods Retrospective cohort of 427 consecutive STEMI patients (64 years [55–75]; 78% men) admitted to a general ICU between November-2013 and February-2017. We used Area under the Receiver Operating Characteristic (ROC) curve (AUC) analysis to asses performance of risk scores, and the Hosmer-Lemeshow (HL) goodness of fit test and the Standardized Mortality Ratio (SMR) to assess calibration. Results All risk scores were associated with in-hospital, 3- and 12-month mortality (P<0.001). SAPS II had the highest sensitivity for short-term mortality and the highest AUC for in-hospital, 3- and 12-month mortality (Figure). SAPS II had the highest calibration and the less underestimation of mortality in all follow-up periods analysed (Table). Performance of prognostic risk scores Youden index (J) Sensitivity (%) Specificity (%) AUC (95% CI) H-L (P value) SMR In-Hospital mortality (5.4%)   SAPS II 32 87.0 89.4 0.938 (0.887–0.988) 1.826 (0.969) 1.64   GRACE 2.0 150 86.9 83.7 0.922 (0.865–0.979) 8.111 (0.423) 1.77   APACHE II 17 82.6 93.8 0.896 (0.841–0.986) 11.941 (0.154) 1.92 3-month mortality (5.6%)   SAPS II 32 79.2 89.1 0.913 (0.854–0.973) 3.635 (0.821) 1.85   GRACE 2.0 150 79.1 85.4 0.902 (0.842–0.962) 5.149 (0.742) 2.0   APACHE II 17 79.1 93.8 0.882 (0.792–0.971) 9.244 (0.322) 2.0 12-month mortality (7.0%)   SAPS II 32 73.3 89.7 0.880 (0.809–0.951) 1.994 (0.960) 1.58   GRACE 2.0 150 76.7 84.1 0.878 (0.816–0.941) 4.073 (0.850) 2.31   APACHE II 17 70.0 92.4 0.824 (0.722–0.927) 7.464 (0.487) 2.14 AUC: Area under the curve; H-L: Hosmer-Lemeshow; SMR: Standardized Mortality Ratio. Area under the ROC curves (AUC) Conclusions SAPS II represents the best model to estimate mortality in this cohort of STEMI patients, with an appropriate calibration and less underestimation of mortality. Underestimation of mortality showed by all risk scores suggests the need of creating new risk prediction models that improve identification of high risk STEMI patients.

Background Frailty is characterized by decline in physiologic reserve and function leading to increased vulnerability. Sarcopenia, one of its features, has been associated with cardiac dysfunction. Purpose Assess frailty-based mortality in ST-segment elevation myocardial infarction (STEMI) patients following primary angioplasty. Methods Retrospective cohort of 427 consecutive STEMI patients (64 years [55–75]; 78% men) admitted to a general ICU between November-2013 and February-2017. We assessed frailty with the Clinical Frailty Scale (CFS). We used Kaplan-Meier and Cox regression models for survival analysis, stratified by CFS score categories (Figure). For clinical relevance, patients were dichotomized in robust (CFS 1–3) and vulnerable (CFS ≥4). Results Vulnerable patients were older, had more comorbidities and a higher GRACE 2.0. They had lower CK and albumin levels and higher BNP levels, despite the lack of frailty-based differences in LVEF and MI size and location. One-year mortality rate was higher in vulnerable patients (Table). After Cox regression analysis, vulnerable patients (CFS ≥4) showed a 3.37-fold higher risk of one-year mortality than robust ones (95% CI, 1.59–7.15; P=0.002), independently of age, gender, GRACE 2.0 or LVEF. Baseline characteristics Vulnerable (CFS ≥4) Robust (CFS 1–3) P value (n=60) (n=367) One-year mortality, n (%) 15 (25) 14 (4.1) <0.001 Age (years) 78 [67–85] 61 [54–72] <0.001 Gender (women), n (%) 28 (46.7) 65 (17.7) <0.001 Hypertension, n (%) 47 (78.3) 156 (42.5) <0.001 Diabetes mellitus, n (%) 31 (51.7) 79 (21.5) <0.001 GRACE 2.0 150 [129–170.8] 112 [93–136] <0.001 Left ventricular ejection fraction (%) 52 [40–60] 55 [45–60] 0.151 MI location (anterior), n (%) 26 (43.3) 168 (45.8) 0.781 Creatin-phosphokinase (UI/L) 921 [286.8–2072] 1496 [607–2786] 0.011 High-sensitivity troponin I (pg/mL) 3699.5 [38–47968.1] 8789.8 [65.8–61970] 0.537 B-natriuretic peptide (pg/mL) 267.9 [117.3–901.6] 104.3 [29.5–268.7] <0.001 Albumin (g/L) 34.9 [32.8–37.4] 38.4 [35.7–40.4] <0.001 Kaplan-Meier and Cox survival curves. Conclusions Frailty is an independent predictor of one-year mortality in STEMI patients, independently of age, clinical severity and ventricular function. Frailty assessment should be routinely included in the clinical examination and decision-making process of STEMI patients.