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Damage to heart found in more than half of COVID-19 patients discharged from hospital

Around 50% of patients who have been hospitalized with severe COVID-19 and who show raised levels of a protein called troponin have damage to their hearts. The injury was detected by magnetic resonance imaging (MRI) scans at least a month after discharge, according to new findings.

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Around 50% of patients who have been hospitalized with severe COVID-19 and who show raised levels of a protein called troponin have damage to their hearts. The injury was detected by magnetic resonance imaging (MRI) scans at least a month after discharge, according to new findings published (Thursday) in the European Heart Journal [1].

Damage includes inflammation of the heart muscle (myocarditis), scarring or death of heart tissue (infarction), restricted blood supply to the heart (ischaemia) and combinations of all three.

The study of 148 patients from six acute hospitals in London is the largest study to date to investigate convalescing COVID-19 patients who had raised troponin levels indicating a possible problem with the heart.

Troponin is released into the blood when the heart muscle is injured. Raised levels can occur when an artery becomes blocked or there is inflammation of the heart. Many patients who are hospitalized with COVID-19 have raised troponin levels during the critical illness phase, when the body mounts an exaggerated immune response to the infection. Troponin levels were elevated in all the patients in this study who were then followed up with MRI scans of the heart after discharge in order to understand the causes and extent of the damage.

Professor Marianna Fontana, professor of cardiology at University College London (UK), who led the research together with Dr. Graham Cole, a consultant cardiologist at Imperial College London, said: “Raised troponin levels are associated with worse outcomes in COVID-19 patients. Patients with severe COVID-19 disease often have pre-existing heart-related health problems including diabetes, raised blood pressure and obesity. During severe COVID-19 infection, however, the heart may also be directly affected. Unpicking how the heart can become damaged is difficult, but MRI scans of the heart can identify different patterns of injury, which may enable us to make more accurate diagnoses and to target treatments more effectively.”

The researchers investigated COVID-19 patients discharged up until June 2020 from six hospitals across three NHS London trusts: Royal Free London NHS Foundation Trust, Imperial College Healthcare NHS Trust and University College London Hospital NHS Foundation Trust. Patients who had abnormal troponin levels were offered an MRI scan of the heart after discharge and were compared with those from a control group of patients who had not had COVID-19, as well as from 40 healthy volunteers.

“The recovering COVID-19 patients had been very ill; all required hospitalization and all had troponin elevation, with around one in three having been on a ventilator in the intensive care unit,” said Prof. Fontana.

“We found evidence of high rates of heart muscle injury that could be seen on the scans a month or two after discharge. Whilst some of this may have been pre-existing, MRI scanning shows that some were new, and likely caused by COVID-19. Importantly, the pattern of damage to the heart was variable, suggesting that the heart is at risk of different types of injury. While we detected only a small amount of ongoing injury, we saw injury to the heart that was present even when the heart’s pumping function was not impaired and might not have been picked up by other techniques. In the most severe cases, there are concerns that this injury may increase the risks of heart failure in the future, but more work is needed to investigate this further.”

The function of the heart’s left ventricle, the chamber that is responsible for pumping oxygenated blood to all parts of the body, was normal in 89% of the 148 patients but scarring or injury to the heart muscle was present in 80 patients (54%). The pattern of tissue scarring or injury originated from inflammation in 39 patients (26%), ischaemic heart disease, which includes infarction or ischaemia, in 32 patients (22%), or both in nine patients (6%). Twelve patients (8%) appeared to have ongoing heart inflammation.

Prof. Fontana said: “Injury relating to inflammation and scarring of the heart is common in COVID-19 patients with troponin elevation discharged from hospital, but is of limited extent and has little consequence for the heart’s function.

“These findings give us two opportunities: firstly, to find ways of preventing the injury in the first place, and from some of the patterns we have seen, blood clotting may be playing a role, for which we have potential treatments. Secondly, detecting the consequences of injury during convalescence may identify subjects who would benefit from specific supporting drug treatments to protect heart function over time.”

The findings of the study are limited by the nature of patient selection and included only those who survived a coronavirus infection that required hospital admission.

“The convalescent patients in this study had severe COVID-19 disease and our results say nothing about what happens to people who are not hospitalized with COVID, or those who are hospitalized but without elevated troponin. The findings indicate potential ways to identify patients at higher or lower risk and suggest potential strategies that may improve outcomes. More work is needed, and MRI scans of the heart have shown how useful it is in investigating patients with troponin elevation,” concluded Prof. Fontana.

The study is also the subject of a discussion between Prof. Fontana and Prof. Eike Nagel, at the Society for Cardiovascular Magnetic Resonance annual meeting on Friday 19 February, where it will be presented for the first time [2]. Prof. Nagel, director of the Centre for Cardiovascular Imaging at Deutsches Zentrum Für Herz-Kreislauf-Forschung (DZHK), Frankfurt, Germany, is the senior author on an earlier paper [3] that found ongoing heart problems in up to 78% of COVID-19 patients who were less sick and most of whom did not require admission to hospital.

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Notes:

[1] “Patterns of myocardial injury in recovered troponin-positive COVID-19 patients assessed by cardiovascular magnetic resonance”, by Tushar Kotecha et al. European Heart Journal. doi:10.1093/eurheartj/ehab075

[2] Society for Cardiovascular Magnetic Resonance virtual scientific sessions 2021, 09.00-09.45 hrs Central Standard Time in USA (6 hours behind GMT): https://bit.ly/3oMn84t

[3] JAMA Cardiol. 2020;5(11):1265-1273. doi: 10.1001/jamacardio.2020.3557.

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Closeness with dads may play special role in how kids weather adolescence

Additionally, father-youth intimacy was associated with higher self-esteem from early through mid-adolescence for both boys and girls. Mother-youth intimacy was associated with higher self-esteem across most of adolescence for girls, and during early and late adolescence for boys.

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Adolescence can be an emotionally turbulent time, but new research at Penn State found that close, supportive relationships with parents — especially dads — at key points during adolescence can help stave off certain adjustment problems.

The researchers examined how emotionally close and supportive relationships with parents — referred to in the research as “parental intimacy” — in families with mothers and fathers affected their children’s self-esteem, weight concerns, and depressive symptoms at different points across adolescence.

They found that closeness with fathers had broad, positive effects across adolescence for both daughters and sons. But while close relationships with mothers also had benefits, they were more limited by their children’s age, and weren’t protective against all the adjustment issues measured in the study for both girls and boys.

Anna Hochgraf, doctoral candidate in human development and family studies, said the findings suggest that while close relationships with moms are certainly important, fathers may play an important, distinct role in fostering healthy adjustment in adolescents.

“Adolescents tend to feel emotionally closer to their mothers than to their fathers and mothers tend to have supportive conversations with their children more frequently than fathers do,” Hochgraf said. “This may make emotional closeness with fathers more salient and, in turn, protective against these common adjustment problems experienced during adolescence.”

According to the researchers, adolescence is a period of development that includes many biological, cognitive, emotional and social changes that can lead to certain adjustment issues, with weight concerns, low self-esteem, and symptoms of depression being some of the most common, especially for girls.

But, previous research has also shown that close relationships with parents have the potential to help protect against the development of some of these problems. Hochgraf said she and the other researchers wanted to explore the topic further, breaking the results down by participants’ age, gender, and relationship with each parent.

“We wanted to investigate when during the course of adolescence intimacy with mothers and fathers becomes a protective factor for body image concerns, depressive symptoms, and low self-esteem, and whether intimacy is more strongly associated with positive adjustment at some ages than at others,” Hochgraf said. “We also wanted to see if patterns differed for girls and boys.”

The researchers recruited 388 adolescents from 202 two-parent families with both fathers and mothers for the study. Data was gathered at three checkpoints when the participants were between the ages of 12 and 20, and included information on participants’ weight concerns, symptoms of depression, and self-esteem, as well as measurements of intimacy between parents and their kids.

Intimacy was measured by the participants answering questions such as how much they go to their mother or father for advice or support and how much they share inner feelings or secrets with them, to which the adolescents responded with a score ranging from one to five.

Hochgraf said it was important to gather data at several points in time because problems with adjustment, as well as relationships with parents, can change and develop swiftly throughout adolescence.

“Rather than assume that the associations between parent-adolescent intimacy and adolescent adjustment problems are static across adolescence, we studied changes in these links as a function of age,” Hochgraf said. “This approach enabled us to determine at which ages parent-youth intimacy may be most protective against body image concerns, depressive symptoms and self-esteem.”

After analyzing the data, the researchers found several different effects of parental intimacy on their sons and daughters at different times throughout adolescence. These effects were also different between mothers and fathers.

“For example, while father-adolescent intimacy was associated with fewer depressive symptoms across adolescence, mother-adolescent intimacy was associated with fewer depressive symptoms during mid-adolescence, around age 15,” Hochgraf said.

They also found that father-youth intimacy was associated with fewer weight concerns for both girls and boys throughout most of adolescence, with the greatest effects in mid-adolescence for girls and late adolescence for boys. In contrast, mother-youth intimacy was only associated with fewer weight concerns for boys, and only in early adolescence.

Additionally, father-youth intimacy was associated with higher self-esteem from early through mid-adolescence for both boys and girls. Mother-youth intimacy was associated with higher self-esteem across most of adolescence for girls, and during early and late adolescence for boys.

Hochgraf said the study — recently published in the Journal of Family Psychology — underscores the importance of parents being close, open and supportive with their children.

“Parents can promote their adolescents’ healthy development by fostering emotionally warm, accepting, and supportive relationships with them,” Hochgraf said. “There are a number of evidence-based, family-centered prevention programs that can help parents improve or maintain positive relationship quality and communication with their children throughout adolescence and that have been shown to prevent multiple adolescent adjustment problems.”

Gregory Fosco, associate professor of human development and family studies; Stephanie Lanza, professor of biobehavioral health and human development and family studies; and Susan McHale, distinguished professor of human development and family studies, also participated in this work.

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Heart patients need more help to lose weight

Positive associations were found between lifestyle improvements and weight loss in obese or overweight patients. Compared to those who gained 5% or more of their body weight, those who lost at least 5% of their body weight had more frequently reduced fat and sugar intake, increased consumption of fruit, vegetables, and fish, done regular physical activity, attended a cardiac rehabilitation and prevention program and followed dietary advice from a health professional.

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Weight loss is given insufficient priority in the management of heart patients despite the benefits, according to a study published today in European Heart Journal – Quality of Care and Clinical Outcomes, a journal of the European Society of Cardiology (ESC).

The study of more than 10,000 patients found that less than 20% had a healthy body mass index (BMI) at the time of hospitalisation for a heart event. Some 16 months later, 86% of patients who were obese during hospitalisation were still obese while 14% of overweight patients had become obese. Young women were particularly affected, with nearly half of those under 55 years being obese. Yet more than a third of obese patients said they had not received advice on physical activity or nutrition and nearly one in five said they had not been informed that they were overweight.

“It seems that obesity is not considered by physicians as a serious medical problem, which requires attention, recommendations and obvious advice on personal weight targets,” stated the authors.

Weight loss is strongly recommended in overweight and obese patients with coronary heart disease to improve blood pressure and lipids levels and reduce the risk of type 2 diabetes, thereby lowering the likelihood of another heart event. This study investigated the management of patients who were overweight or obese at the time of hospitalization for a first or recurrent heart event (e.g. heart attack or elective procedure to unblock clogged arteries). The researchers examined lifestyle advice received, actions taken, and the relationship between weight changes and health status.

The researchers pooled data from the EUROASPIRE IV (2012 to 2013) and EUROASPIRE V (2016 to 2017) studies, which were conducted in 29 countries. The analysis included 10,507 patients with coronary heart disease. Patients were visited 6 to 24 months after hospitalisation for their heart event (the average gap was 16 months). The visit consisted of an interview, questionnaires and a clinical examination including weight, height and blood tests.

One in four participants (24.8%) were women and the average age at the time of hospitalisation was 62.5 years. At the time of hospitalisation, 34.9% of patients were obese and another 46.0% were overweight.3 By the time of the study visit (on average 16 months later), an even greater proportion of patients were obese (36.9%). Rates of obesity rates were higher in younger patients with a prevalence of 40.1% in those aged under 55 years (men 38.3%, women 48.4%).

Regarding the link between weight changes and health status, overweight or obese patients who lost 5% or more of their body weight had significantly lower levels of hypertension, dyslipidaemia, and previously unrecognised diabetes compared to those who gained 5% or more of their body weight – despite being equally treated with blood pressure and lipid lowering medications. They also reported higher levels of physical and emotional quality of life.

As for the advice patients received, half of all patients were advised to follow a cardiac prevention and rehabilitation programme, with no difference in advice according to their weight status. For obese patients, less than two-thirds were advised to follow dietary recommendations (63.7%) or to do regular physical activity (64.2%).

Positive associations were found between lifestyle improvements and weight loss in obese or overweight patients. Compared to those who gained 5% or more of their body weight, those who lost at least 5% of their body weight had more frequently reduced fat and sugar intake, increased consumption of fruit, vegetables, and fish, done regular physical activity, attended a cardiac rehabilitation and prevention program and followed dietary advice from a health professional.

The authors noted that weight gain was significantly associated with smoking cessation. In patients who were overweight or obese at hospitalisation, those who quit smoking gained 1.8 kg on average in contrast to the 0.4 kg average weight gain observed in persistent smokers.

Study author Professor Catriona Jennings of the National University of Ireland – Galway said cardiac rehabilitation programs, which typically emphasize exercise, should give equal priority to dietary management. She said: “Weight loss is best achieved by adopting healthy eating patterns and increasing levels of physical activity and exercise. Whilst actively trying to lose weight at the same time as trying to quit smoking is not advised, adopting a cardio-protective diet and becoming more physically active has the potential to mitigate the effects of smoking cessation on weight gain in patients trying to quit. Their aim is to maintain their weight and to avoid gaining even more weight following their quit.”

“Uptake and access to cardiac rehabilitation programs is poor with less than half of patients across Europe reporting that they completed a program,” added Professor Jennings. “Such programs would provide a good opportunity to support patients in addressing overweight and obesity, especially for female patients who were found to have the biggest problem with overweight and obesity in the study. Uptake and access could be improved with the use of digital technology, especially for women, who possibly are less likely to attend a program because they have many other competing priorities, such as caring for others. There are good reasons for people to address their weight after a cardiac event. – but it’s not easy and they do need help.”

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Coffee doesn’t raise your risk for heart rhythm problems

Each additional daily cup of coffee consumed among several hundred thousand individuals was associated with a 3 percent lower risk of any arrhythmia occurring, including atrial fibrillation, premature ventricular contractions, or other common heart conditions.

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In the largest study of its kind, an investigation by UC San Francisco has found no evidence that moderate coffee consumption can cause cardiac arrhythmia.

In fact, each additional daily cup of coffee consumed among several hundred thousand individuals was associated with a 3 percent lower risk of any arrhythmia occurring, including atrial fibrillation, premature ventricular contractions, or other common heart conditions, the researchers report. The study included a four-year follow up.

The paper is published in JAMA Internal Medicine.

“Coffee is the primary source of caffeine for most people, and it has a reputation for causing or exacerbating arrhythmias,” said senior and corresponding author Gregory Marcus, MD, professor of medicine in the Division of Cardiology at UCSF.

“But we found no evidence that caffeine consumption leads to a greater risk of arrhythmias,” said Marcus, who specializes in the treatment of arrhythmias. “Our population-based study provides reassurance that common prohibitions against caffeine to reduce arrhythmia risk are likely unwarranted.”

While some professional societies suggest avoiding caffeinated products to lower the risk for arrhythmia, this connection has not been consistently demonstrated – indeed, coffee consumption may have anti-inflammatory benefits and is associated with reduced risks of some illnesses including cancer, diabetes, and Parkinson disease.

In the new study, UCSF scientists explored whether habitual coffee intake was associated with a risk of arrhythmia, and whether genetic variants that affect caffeine metabolism could modify that association. Their investigation was conducted via the community-based UK Biobank, a prospective study of participants in England’s National Health Services.

Some 386,258 coffee drinkers took part in the coffee research, with an average mean age of 56 years; slightly more than half were female. It was an unprecedented sample size for this type of inquiry.

In addition to a conventional analysis examining self-reported coffee consumption as a predictor of future arrhythmias, the investigators employed a technique called “Mendelian Randomization,” leveraging genetic data to infer causal relationships. As those with the genetic variants associated with faster caffeine metabolism drank more coffee, this analysis provided a method to test the caffeine-arrhythmia relationship in a way that did not rely on participant self-report and should have been immune to much of the confounding inherent to most observational studies.

With a mean four-year follow up, data were adjusted for demographic characteristics, health and lifestyle habits.

Ultimately, approximately 4 percent of the sample developed an arrhythmia. No evidence of a heightened risk of arrhythmias was observed among those genetically predisposed to metabolize caffeine differently. The researchers said that higher amounts of coffee were actually associated with a 3 percent reduced risk of developing an arrhythmia.

The authors noted limitations including the self-reporting nature of the study, and that detailed information on the type of coffee – such as espresso or not – was unavailable.

“Only a randomized clinical trial can definitively demonstrate clear effects of coffee or caffeine consumption,” said Marcus. “But our study found no evidence that consuming caffeinated beverages increased the risk of arrhythmia. Coffee’s antioxidant and anti-inflammatory properties may play a role, and some properties of caffeine could be protective against some arrhythmias.”

Co-authors are Eun-jeong Kim, MD; Thomas J. Hoffmann, PhD; Gregory Nah, MA; Eric Vittinghoff, PhD; and Francesca Delling, MD, all of UCSF.

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