Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : FC06 - FC10 Full Version

Clinical and Therapeutic Aspects of Cardiovascular Complications in COVID-19 Patients: A Cross-sectional Study


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/55071.16505
K Brinda Angel, M Kulandaiammal, K Thamayanthi, M Mohanalakshmi

1. Postgraduate Resident, Department of Pharmacology, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India. 2. Professor and Head, Department of Pharmacology, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India. 3. Assistant Professor, Department of Pharmacology, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India. 4. Assistant Professor, Department of Pharmacology, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India.

Correspondence Address :
Dr. M Kulandaiammal,
Professor and Head, Department of Pharmacology, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India.
E-mail: drkulandpharma@gmail.com

Abstract

Introduction: Less is known regarding the Cardiovascular (CV) manifestations in Coronavirus Disease 2019 (COVID-19) patients. Among the complications, in patients with COVID-19 with pre-existing cardiovascular disease, there seem to be worse outcomes with an increased risk of mortality despite treatment. Several therapeutics are still under investigation for COVID-19 patients with cardiovascular impairment, but none of them has shown proven clinical efficacy to date.

Aim: To associate clinical and therapeutic aspects of cardiovascular complications in COVID-19 patients at a tertiary care hospital.

Materials and Methods: The data used for this single-centre cross-sectional study were collected from all the case sheets of COVID-19 positive patients with cardiovascular complications from the Medical Records Department of a Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India, between May 2020 and December 2020. Parameters like demographic details, co-morbid conditions, time of presentation, clinical presentation, complications, therapy and the outcome of the treatment in terms of mortality rate, Intensive Care Unit (ICU) admission and duration of stay in the hospital were obtained. Chi-square test or Odds Ratio (OR) was used to analyse the data for 97 patients.

Results: The mean age of total 97 patients in the study was 58.48 ± 13.1 years and 30.9% were female. The most common cardiovascular complications include acute coronary syndrome (46.4%), conduction abnormalities (21.6%), cardiac failure (18.6%) and accelerated hypertension (11.3%). Remdesivir use significantly reduced the duration of ICU stay in COVID-19 patients (OR: 8.18; 95%CI: 2.9-22.9). There was no effect found with remdesivir on cardiovascular complications like acute coronary syndrome, conduction abnormalities, cardiac failure and accelerated hypertension. Cardiac drug use significantly reduced the duration of ICU stay in COVID-19 patients (OR: 3.3, 95% CI: 2.4-4.48). There was a significant reduction in cardiovascular complications like thromboembolism and conduction abnormalities with the use of cardiac drugs. In contrast, the use of steroids had no impact on the duration of ICU stay and other cardiovascular complications except for conduction abnormalities (OR: 5.2; 95%CI: 1.1-24.1).

Conclusion: COVID-19 patients presenting with cardiovascular complications were associated predominantly with pre-existing hypertension. The use of remdesivir and cardiac drugs significantly reduced the duration of ICU stay in COVID-19 patients. There was a significant reduction of cardiovascular complications like thromboembolism and conduction abnormalities only with the use of cardiac drugs.

Keywords

Coronavirus disease, Hypertension, Intensive care unit, Remdesivir

The outbreak of Coronavirus Disease 2019 (COVID-19), an infectious disease with the severe acute respiratory syndrome, has now become a worldwide pandemic (1),(2),(3). Coronavirus disease 2019 (COVID-19) presents either asymptomatic or pneumonia-like symptoms (cough, fever, dyspnoea) (4). The COVID-19 patients with other co-morbidities like diabetes, hypertension, Chronic Obstructive Pulmonary Disease (COPD), Cardiovascular Diseases (CVD), Human Immunodeficiency Virus (HIV), and malignancies, can develop life-threatening complications (5).

Despite the respiratory complication, COVID-19 is also associated with significant multiple organ dysfunction, including severe cardiac impairment. Emerging evidence reveals a direct interplay between COVID-19 and dire cardiovascular complications, including myocardial injury, heart failure, heart attack, myocarditis, arrhythmias as well as blood clots, which are accompanied by elevated risk and adverse outcomes among infected patients, even sudden death (6),(7).

Among the complications, in COVID-19 patients with pre-existing cardiovascular disease, there seem to be worse outcomes with an increased risk of mortality (8). Acute cardiac injury is the most commonly reported cardiac abnormality in COVID-19 that occurs in approximately 8-12% of all patients and there will be a significant elevation of cardiac troponins (9). COVID-19 itself can induce arrhythmia, myocardial injury, acute coronary syndrome and venous thromboembolism (8).

Pre-existing CVD appears to be linked with adverse outcomes and also increased risk of mortality in COVID-19 patients (8). The mechanisms of cardiac impairment were due to the invasion of coronavirus through angiotensin-converting enzyme-2 into cardiovascular tissue, which leads to endothelial dysfunction, atherosclerotic plaques destabilization, diminished oxygen supply leading to cardiac stress, myocardial tissue damage, myocardial infarction and stent thrombosis (10). Several therapeutics are still under investigation for COVID-19 patients with cardiovascular impairment, but none of them has shown proven clinical efficacy to date (7),(11). Less is known regarding the CV manifestations in COVID-19 patients. Though it has been shown that the pre-existing CV disease or development of CVD complications are associated with worse outcomes in COVID-19 patients, it remains unclear (9).

The purpose of the study was to summarize the therapeutic approaches for cardiovascular complications of COVID-19. The study aimed to associate clinical and therapeutic aspects of cardiovascular complications in COVID-19 patients at a tertiary care hospital. Also, the study describes the clinical pattern of COVID-19 positive patients with underlying cardiovascular risk factors and complications and also evaluates the cardiovascular complications and the therapeutic management followed in a tertiary care hospital.

Material and Methods

This study was a single-centre cross-sectional analysis from May 2020 to December 2020 of COVID-19 positive patients >18 years of age. The study was conducted after getting approval from Institutional Ethics Committee (ECR/131/Inst/TN/2013/RR-19). Data were collected from the case sheets in the Medical Records Department of Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India, for 8 months. In the present study, all the case sheets of COVID-19 positive patients from May 2020 to December 2020 with cardiovascular complications were analysed from the Medical Records Department (MRD).

Inclusion criteria: Case sheets with a confirmed diagnosis of COVID-19 via Reverse Transcriptase-Polymerase Chain Reaction assays (RT-PCR) performed on nasopharyngeal swab specimens were included. The study had included adult (>18 years) COVID-19 positive patients with or without cardiovascular risk factors like hypertension, diabetes and hypercholesterolaemia who developed cardiovascular complications like myocardial infarction, cardiomyopathy, arrhythmias and heart failure.

Exclusion criteria: Patients <18 years old with COVID-19 positive patients were excluded from the study.

The study was done by analyzing the case sheets of 100 patients who tested positive via RT-PCR for COVID-19. Three patients were excluded who had incomplete clinical data on outcomes, leaving a final sample of 97 patients. A total of 97 patient’s data was obtained from MRD.

Procedure

The data obtained from the medical records were demographic details like age (years), gender and other details like Systolic Blood Pressure (BP) (mmHg), diastolic BP (mmHg) and random blood glucose (mg/dL) co-morbid conditions, RT-PCR status, time of presentation, clinical features including chest pain, palpitation, bleeding, breathlessness, vitals like blood pressure, oxygen saturation, pulse rate and laboratory parameters like complete blood count, blood sugar (mg/dL), Electrocardiogram (ECG), D-dimer (ng/mL) (small fibrin degradation product in the blood present due to degradation of a blood clot by fibrinolysis), liver function test, renal function test, C-Reactive Protein (CRP) (mg/L), Interleukin 6 (pg/mL), lactate dehydrogenase (U/mL), coagulation profile (Prothrombin Time/ International Normalized Ratio (PT/INR)} and radiographic findings (Chest X-Ray/Computed Tomography).

The therapy given to each patient like remdesivir, steroids, cardiac drugs and/or thrombolytic drugs was obtained from the data and the outcome of the treatment in terms of ICU admission and duration of stay in the hospital was obtained.

Statistical Analysis

Data were analysed using the statistical software package Microsoft Excel and Statistical Package for Social Sciences (SPSS) version 20.0. Demographic and clinical variables were tabulated. Continuous variables were expressed as Mean (M) ± Standard Deviation (SD) if normally distributed and non normally distributed data were expressed as median (range). The 95% Confidence Intervals (CI) were used when appropriate. Categorical variables were summarized by frequencies and percentages and Fischer’s-exact test or Chi-square test or Odds ratio was used to analyse. A p-value <0.05 was considered to be statistically significant.

Results

Among 97 patients, the mean age was 58.48±13.1 years, 30 (30.9%) were female and 67 (69.1%) were male (Table/Fig 1). Chronic medical conditions of these patients included hypertension 75 (77.3%), known case of Coronary Artery Disease (CAD) 58 (59.8%) and diabetes mellitus 51 (52.6%). Total 86 (88.7%) patients presented early to the hospital. Dyspnoea was seen in 80 (82.5%) patients and chest pain in 42 (43.3 %) patients, were the common clinical presentations (Table/Fig 2). Laboratory Investigations for markers like ferritin, CRP, Interleukin-6, D-dimer and Lactate Dehydrogenase (LDH) were higher than their normal limits.

The most common cardiovascular complications include acute coronary syndrome 45 (46.4%), conduction abnormalities 21 (21.6%), cardiac failure 18 (18.6%) and accelerated hypertension 11 (11.3%). Thromboembolic complications (acute coronary syndrome, deep vein thrombosis, pulmonary embolism) were seen in 52 (53.6%) patients. Renal complications like acute kidney injury was seen in 7 (7.2%) of patients. Around 99% of patients were treated with cardiac-related drugs. The other drugs used in the treatment were steroids 68 (70.1%), remdesivir 51 (52.6%) and thrombolytic drugs 41(42.3%) (Table/Fig 2).

There was a statistically significant difference found between CAD patients on remdesivir treatment as compared to those patients with CAD without remdesivir treatment in terms of reduction in the duration of ICU stay to <5 days (p-value <0.001). Remdesivir treatment reduced the duration of ICU stay by <5 days in patients without CAD as compared to those patients without CAD who did not receive remdesivir treatment (p-value <0.01) (Table/Fig 3).

Remdesivir use significantly reduced the duration of ICU stay in COVID-19 patients (OR: 8.18; 95%CI: 2.9-22.9). There was no effect found with remdesivir on cardiovascular complications like Acute coronary syndrome, conduction abnormalities, Cardiac failure and accelerated hypertension (Table/Fig 3).

Cardiac drugs significantly reduced the duration of ICU stay in COVID- 19 patients (OR: 3.3; 95%CI: 2.4-4.48). There was a significant reduction in cardiovascular complications like thromboembolism (OR: 2.18; 95%CI: 1.7-2.7) and conduction abnormalities (OR: 4.8; 95%CI: 3.2-7.08) with the use of cardiac drugs (p-value <0.05) (Table/Fig 3).

In contrast, the use of steroids had no impact on the duration of ICU stay and other Cardiovascular (CV) complications except for conduction abnormalities (OR, 5.2; 95% CI, 1.1-24.1). Duration of ICU stay for lesser than 5 days was seen in 67.6% of patients (Table/Fig 3).

In a subgroup analysis, the majority of patients who were known cases of CAD were staying for <5 days in ICU than patients who did not had a history of CAD (OR: 0.37; 95%CI: 0.15-0.90). Complications at presentations related to thromboembolism were seen both in patients with a history of CAD and without a history of CAD. While conduction defects and cardiac failure were common among patients with a known case of CAD. In contrast, accelerated hypertension was common among those who did not had a history of CAD (Table/Fig 4).

(Table/Fig 5), (Table/Fig 6) shows association showing a reduction in ICU stay in relation with/without CAD patients and remdesivir respectively. The result was significant at a p-value <0.05.

Discussion

Pre-existing CV manifestations or development of CVD complications are associated with worse outcomes in COVID-19 patients. In this single-centre cross-sectional study, the clinical pattern of COVID-19 positive patients with underlying cardiovascular risk factors and complications were associated with the therapeutic management followed in a tertiary care hospital. In the final sample of 97 patients, the mean age was 58.48±13.1 years and 30 (30.9%) were female. This is in contrast to a study by Petersen E et al., where the mean age was more than 60 years with a predominantly female population (11).

Dyspnoea (82.5%) and chest pain (43.3 %) were the common clinical presentation. A study by Peng Y et al., showed that in CV patients with COVID-19, apart from fever and cough, chest pain and dyspnoea were the common symptoms (7).

Among 97 patients, 54% of patients had hypertension with CAD and 39% of patients had hypertension with diabetes mellitus, 41% of patients had CAD with diabetes mellitus, 35% of patients had hypertension with diabetes mellitus with CAD and 40% of patients were not a known case of CAD. This is in accordance with Ejaz H et al., and Lee S et al., where hypertension being the most common comorbidity associated with COVID-19 (5),(12).

About 88.7% of patients presented early within 7 days of COVID-19 infection and 11.3% of patients presented late after 7 days of COVID-19 infection. Of the 97 patients, 46.4% of patients presented with the acute coronary syndrome, 21.6% of patients presented with conduction abnormalities and 18.6% of patients presented with cardiac failure (6). Total 86% of patients accounted for myocardial injury out of 97 patients as inferred by the study by Bardaji A et al., stating that myocardial injury was detected in one in every five patients with confirmed or ruled out COVID-19 cases (10),(13).

Laboratory markers like ferritin, C-reactive protein, IL-6, D-dimer and lactate dehydrogenase were higher than their normal limits. Out of 97 patients, 84 patients had elevated CRP whose mean value was 57, which is inferred by the study by Ali N, stating that elevated CRP might be linked to the overproduction of inflammatory cytokines in severe patients with COVID-19 but remains to be a non specific marker. Out of 84 patients with elevated CRP, 38 patients had acute coronary syndrome, 20 patients had conduction abnormalities and 13 patients had a cardiac failure (14).

In a pooled analysis of nine studies, Henry BM et al., showed that elevated LDH levels were associated with a ~6-fold increase in odds of developing the severe disease in patients with COVID-19 (15) which goes with this study where 19 patients had elevated LDH with a mean value of about 737 indicating the severity like acute coronary syndrome (five patients), conduction abnormalities (13 patients) and cardiac failure (three patients) accounting for myocardial injury.

As stated by Qeadan F et al., higher values of serum ferritin and D-dimer was associated with diffusing thrombosis which might require ICU (16), 57 patients had elevated serum ferritin and 11 patients had elevated D-dimer out of which 11 patients developed pulmonary embolism and deep vein thrombosis.

In the current study, remdesivir use significantly reduced the duration of ICU stay in COVID -19 patients (OR:8.18; 95%CI: 2.9-22.9). This finding is consistent with the study by Garibaldi BT et al., which inferred that remdesivir recipients had a shorter time to clinical improvement than matched controls without remdesivir treatment (median, 5.0 days (interquartile range: 4.0-8.0 days) vs 7.0 days (interquartile range: 4.0-10.0 days); adjusted hazard ratio:1.47 [95%CI: 1.22-1.79] (17).

While remdesivir therapy is correlated with each cardiovascular complications like acute coronary syndrome, conduction abnormalities, cardiac failure and accelerated hypertension, there was no effect found. This was similar to a study by Wang Y et al., which showed that in adult patients admitted to hospital for severe COVID-19, remdesivir was not associated with statistically significant clinical benefits (18).

Cardiac drug use in COVID-19 patients with cardiovascular complications significantly reduced the duration of ICU stay in COVID-19 patients (OR:3.3; 95%CI: 2.4-4.48) and significantly reduced cardiovascular complications like thromboembolism and conduction abnormalities. Therefore, the addition of cardiac drugs to remdesivir therapy renders benefit in improving cardiovascular complications in COVID-19 patients.

There was a statistically significant difference found between CAD patients on Remdesivir treatment as compared to those patients with CAD without remdesivir treatment in terms of reduction in the duration of ICU stay to <5 days (p-value <0.001). Steroids had no impact on the duration of ICU stay and other CV complications except for conduction abnormalities (OR:5.2; 95%CI: 1.1-24.1). This is consistent with a study by Garibaldi et al., where the addition of remdesivir and corticosteroid did not reduce the time to death compared with remdesivir alone (Hazard Ratio: 1.94; 95%CI: 0.67-5.57) (17).

In subgroup analysis, the majority of patients who were known cases of CAD were staying for <5 days in ICU compared to those who did not had a history of CAD. The reason might be in patients with a history of CAD, the regular intake of cardiac drugs might have significantly reduced the duration of ICU stay in COVID-19 patients.

The pre-existing cardiovascular disease seems to be linked with worse outcomes and increased risk of death in patients with COVID-19. Whereas, COVID-19 itself can also induce myocardial injury, arrhythmia, acute coronary syndrome and venous thromboembolism (8). Potential contributors to acute cardiac injury in the setting of COVID-19 include (13):

• Acute changes in myocardial demand and supply due to tachycardia, hypotension, and hypoxemia resulting in type 2 myocardial infarction
• Acute coronary syndrome due to acute atherothrombosis.
• Microvascular dysfunction due to diffuse microthrombi or vascular injury
• Stress-related cardiomyopathy (Takotsubo syndrome)
• Non ischemic myocardial injury due to a hyperinflammatory cytokine storm
• Direct viral cardiomyocyte toxicity and myocarditis.

This study signifies that the early diagnosis, prevention and treatment of predisposing conditions might reduce cardiovascular complications in COVID-19 patients.

So, it was very important for good and appropriate management of cardiovascular diseases as the COVID-19 pandemic was associated with a significant worsening of the mental health and mortality of patients with CVD (7),(19).

Limitation(s)

This is a single-centre cross-sectional study with predominantly South Indian patients which may limit its generalizability. The sample population with CAD was relatively small. This study included only patients with documented evidence of CAD, which may underestimate CAD prevalence in this study. This study did not include patients who were still admitted at the time of analysis due to a lack of outcome data such as mortality and other potentially significant clinical outcomes such as length of stay were not taken into account. Compliance with guideline-recommended therapies for CAD was not considered and may influence clinical outcomes.

Conclusion

COVID-19 is associated with cardiovascular complications like acute myocardial infarction, heart failure, dysrhythmia, cardiogenic shock and hypertensive urgency. Patients presenting with cardiovascular complications post-COVID-19 infection were associated predominantly with pre-existing hypertension. The use of remdesivir significantly reduced the duration of ICU stays in COVID-19 patients. Also, patients with a history of CAD and intake of cardiac drug use significantly reduced the duration of ICU stay in COVID-19 patients. However, CAD in itself was not independently associated with an increase in ICU stay. Other covariates may play an important role in the poor outcomes and increased ICU stay in these COVID-19 patients.

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DOI and Others

DOI: 10.7860/JCDR/2022/55071.16505

Date of Submission: Jan 26, 2022
Date of Peer Review: Mar 17, 2022
Date of Acceptance: May 19, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 29, 2022
• Manual Googling: Feb 25, 2022
• iThenticate Software: May 18, 2022 (19%)

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