28. Influenza and Myocardial Infarction with Drs. Steven Schulman and Rhanderson Cardoso
Worldwide cardiovascular disease affects the lives of hundreds of millions dedicated cardio nerds everywhere are working hard to fight this global epidemic. These are their stories. Welcome back Carter nerds. We are continuing our series on cardiovascular implications of Cova nineteen given that there is still so much that is unknown about the cardiovascular consequences of Kobe. Nineteen today we are going to focus on another respiratory virus influenza and one of its unfortunate cardiac complications myocardial. Infarction we are super thrilled to be joined today by our fellowship director and director of the C. C. You at Hopkins Dr Steven Schulman as well as one of our star Co fellows Dr Anderson Cardozo and friends before we dive into this treasure of discussion. Please be sure to subscribe to the Cardio Nurse to channel ringing high yield bite-size education directly to your screens this week. We are just thrilled to feature a phenomenal ten minute video about all things. Cutie interval related by Dr Dino as Kudsy cardiology fellow at the Johns Hopkins Hospital to Cutie is one of our favorite intervals but is especially important. Now as you consider the impact of drugs like hydroxy chloroquine in the era of covered. Nineteen four we get started friends. Just remember this. Podcast is not meant to be used for medical advice. Views expressed here do not necessarily reflect the opinions or policies of our employers. The goal is simply to enjoy learning more cardiology in Kupwara directly from expert. Cardi nerds. Dr Steven Shellman graduated from Johns Hopkins University School of Medicine. He fulfilled his training in internal medicine and chief residency as well as completing his cardiology fellowship at Hopkins Capture. Shulman is the director of the coronary care unit as well as the cardiology fellowship program director at Johns Hopkins. His mean research interests include acute myocardial. Infarction he has won numerous teaching awards from Hopkins residents and fellows over the years while attending in the see. Cu Doctor Shulman teaches and guides the next generation of residents and fellows about acute cardiac care. Dr Ryan Anderson Cardoza Graduated Medical School at the University of go. Yes in his home country. Brazil he then completed internal medicine residency and chief year at the University of Miami Jackson. Memorial hospital has diverse interests in cardiovascular diseases including electrophysiology imaging and prevention. He is especially passionate about teaching and hopes to have a career and he will have a career in. Academic Medicine is currently earning a master's degree in cardiovascular epidemiology at Hopkins Bloomberg School of Public Health and Planning on pursuing additional imaging training at Brigham and women's Hospital in the upcoming academic year. Definitely if everybody could feel free jumping but I have to just comment a few things first of all doctor Shulman. You are just such a leader in this era you have really just lifted up the entire program and all the fellows and faculty feel like you have our back and we feel confident as we face. This endemic in really big crisis. That's coming our way and Randy. Johnson I just as a friend and as a CO fellow. We have just had the best of times together. We teach each other. That's actually more you teaching me. We I definitely could not have passed. Echo boards that use. I just wanted to say this is a real treat to have you both here. Should I just say like thank you for the introduction yet? What everyone thinks. Please please thank us? Thanks a lot for decayed words of introduction. Dan and it's really such an honor to be of Carter nerds. Thanks very much for having me on the show as I pleasure to have. You here still excited that you're here cardio nerds and that's a real treat doctor. Shulman okay. Why don't you take it away okay? So let's start off by introducing patient. Mr Gavin Flu Enza a lovely Italian pizza parlor owner in his mid fifties. He has a history of hypertension and he was in his usual state of health until a week ago when he developed a runny nose. Cough increased sputum production with Associated Malays in myalgia initially wanted to finish it out at home but ultimately he decided to come to the emergency department because he developed chest and shoulder pain developed earlier on the day of presentation his initial vital signs were remarkable for a blood pressure of one hundred sixty three over ninety eight. His heart rate was seventy one respiration at fifteen and he's saying about eighty eight percent on room air and then would bumped up to ninety six percent after being put onto leaders of nasal Kenya his initial. Ekg showed normal sinus rhythm with anterior t wave inversions but a repeat ekg five minutes later demonstrated st elevations in the anterior elites as he's being whisked away to the cath lab the charge nurse in that emergency room hands out masks and gowns to the team because rapid flu senate. The emergency room triage returned positive for influenza A. Wow Heather this definitely sounds like a full blown. Mida me in the setting of the flu. In general there has been a proposed link between acute respiratory virus infections such as influenza and myocardial infarction and this has been reported since the early nineteen. Thirty's a two thousand eighteen study in the New England Journal by Quang. All the link to which will include on our website found that the incidence of admissions for acute am. I was six times as high during the seven days after laboratory confirmation of influenza infection as during the control interval Ron Johnson. What do you think is the mechanism whereby acute respiratory infections might make individuals more susceptible to myocardial infarction? That's a really great question. Korean the mechanism by which influenza and other viral illnesses including right now. Cova nineteen can lead to acute coronary syndrome are several fold. First of all acute him. I can be a type one mechanism because the systemic inflammatory and immune response off of the illness is pro through botox. So there's include increased platelet activity abnormal window telea function and decreased license creating a Milieu second the. Systemic inflammation can also increased activity of inflammatory cells produce Olympic enzymes contributing potentially to an unstable black. These mechanisms can lead to a type. One Am I. But there's also many different ways in which an influenza or other viral upper respiratory infection can cause a type chew in my by either increasing demand or decrease in supply a fox in profusion tomorrow Carter Tissues so those mechanisms include tack Ikaria Hypoc Sena increased systemic metabolic demand hypertension and so many other mechanisms house. Wonderful Render. Send you really create a picture of all the different reasons for for. Why am I can present in these patients? I want to turn now to Dr Shulman in caring for patients in the see. Cu what has been your experience of the association between flu and Am I. Are there certain. Factors that place. Individuals infected with flew at higher risk. For 'em I certainly the Elderly seem to be at higher risk patients with multiple risk factors and of course preexisting coronary disease and this is a group of patients most at risk for type two. Michael in fortune indeed the majority of patients we see are type. Two non stemming events the patient described today with an se segment elevation at my is somewhat atypical in our most recent and DEMOC with covert nineteen. There's a another potential mechanism of Michael Injury. The source corona virus to virus of binds to humid injured tense in converting enzyme two receptor which is highly expressed in the respiratory tract in as well as the heart in itself out seven percent of current covet a nineteen patients admitted to the hospital at positive components and about one in four patients who are critically. Oh what cove. In nineteen will have positive proponent ovations. I wanted to sort of Digress. A Little Bit. Since you brought up cove in nineteen and the proponent elevation. I know you recently completed a stint in the C. C. You when you see the proponent elevation how were you distinguishing between acute coronary syndrome and another possible reason like Myocarditis in these patients? Oh that's a great question. Renew one of the challenges and Asians infected and non infected is distinguishing Mike Coral injury from my coralline fortune. And so we're certainly looking for beyond the enzyme elevation evidence of Schema via symptoms he. Cg Wall motion add the Molly at would let us define this. As a micro and fortune nonetheless. The prognosis whether it's injury or micro fortune both adds significantly to the disease process in an adverse way M. I usually present differently in these patients or is it. Is there a difference in the severity. The presentation depends on the context in my experience and in the Lurch. Mr Does present differently so in contrast the primary reason a patient comes to the corner carrying with acute my com fortune. These patients arrived at the hospital with their viral syndrome. And then through evaluation either worsening shortness of breath E C g changes are full motion. Add the molly gives us a hint. That the Horta's involved with this Processes well and so we have to have a very high index of suspicion particularly in patients the elderly those with pre existing corners easing multiple risk. Factors at this. Is that risk population in that? The heart may ultimately be involved in the process. And you said at n stem is usually the more common presentation compared to stem. -I absolutely soon In the literature and in Randy Johnson study. He didn't ninety percent of patients will have anonymously segment. Elevation of that is sorry guys. This is I may have been quiet so far. But I've just been so mesmerized by this discussion and I have to say house specialises for me. Dark Schulman running with you and learning from you remains a among my favorite memories from residency. And it's a it's so awesome. Learn from you again right. Now when we're talking about the Michael Injury in the within the context of a viral infection jetting is relevant for influence and cove. Ed How are you teasing out in? Acs Presentation from Microsoft is. Can you walk us through your steps in terms of are there differences in the clinical history or proponent trend or ekg? And I asked. Because ideally we would try to minimize trips to imaging testing or the Cath lab to try to prevent exposure to healthcare workers. Just so in the Kovic. Nineteen Pandemic News Ben to patterns of Michael Injury Pattern is a progressive rise in proponent associated with other inflammatory Markers d diner Feridan. I'll six in that likely reflects Cited kind storm of that of shoe patients. Unfortunately develop more than isolated. My Carl Injury. A second group of patients do get by report viral. Full microdyne and deaths as a rise. In proponent with severely dysfunction and heart failure in our units in on the floor it is often challenging to distinguish Shoot micro infarction from the micro titus. We often rely on our clinical instincts. History exam you mean. Cg to help guide us the patient. The Micronesia's might have myocarditis with evidence of Perkins died his son he's Cj a persistent to elevation tr- opponent markers instead of a rise and fall of to opponent elevations that is evident The cute micro fortune often lacking the discreet wall motion. Add the Meli That Mike Has Aware Microdyne may have diffused depression of LV function although rarely isolated wall motion. Add them Albee's can occur. We think that's very helpful. It sounds like it's difficult to make that distinction overall at the bedside but the tr- opponent trend and pattern as well as a focal wall. Motion Maladies can help clue us in. Jaen the CG also we buy often with their cube micro fortune. There's a focal. G changes where there may be diffuse to weight changes or evidence. Appropriateness in the micronized Thank you Dr Showman. So we had already alluded to this idea and we know as we talked about earlier that a lot of these patients with the influenza or a viral illness that come in with just being in. Anaheim I tend to be more of the instant type and we know that with an end semi we have patients that come in with a plaque rupture event versus demand. I know that this is a very challenging thing for me to Suss out when I'm dealing with patients but you're one of the smartest cleanest as we know. So if you could walk us through how you make the distinctions clinically if there is a real distinction to make even especially without invasive testing imaging before you make a treatment plan for this patient team this is one of the more challenging clinical situations. We deal with time and time again. And the relevance is we treat type one a sales events with the standard eight. Jcc guideline therapies type. Two events we just tryin decreased demand and so the distinguishing type. One in demands advancer very important and often very very challenging at thank the influenza in viral illness patient. Many of these patients are GONNA have type two demands events where treating light granderson said tweeting. The POXY MIA treating the fever tweeting. A inflammatory state at driving. The demand is what's best for the heart tweeting dehydration on the like. And we have to also be ready to pick out that plaque rupture of that which Gem Lay as Someone who will have symptoms of Mike corless Schema where the demand eventless likely symptoms of Michael Schema and With in the rare event that there's Seo allegation will that is In my experience always a plaque rupture plaque fisher Definitely a challenging and we know that patients come in with this mixed picture especially in these cases and so it could be very challenging to suss out even sometimes after they go to the Cath lab and they do have underlying coronary disease as they very likely. Do you know even then. It's hard to know if it's a plaque rupture unless you see like a large lesion calf agreed in. I don't think tripling in helps them much. Asians with very large proponent elevations with a type two event and smaller elevations with a type one events. So that is not very helpful in the challenge with studying type two events is. It's such a mixed bag. Patients that the exact treatment except treating what's driving it has not been readily elucidated in Well-studied given the diverse population that develops as we do know is bad noces has type one event and these patients have to be evaluated and watch. We recently talked to an Italian cardiologists in Milan and he was saying that in addition to Kobe. hid presentations like myocarditis. He was seeing a lot of late. Presentations of 'em is in patients without coated. Who were kind of staying at home? Because they didn't want to leave and get infected into their presenting pretty late in their course. Have you seen this yet in the new Baltimore were still early in this pandemic? Uh certainly emotional. Stress is well associated with the onset of q Mike Cohen Fortune and we have to not only people infected but love lunches and people not infected with the stressors of what's going on may be at Risk for two Mike. I WANNA move onto our next topic but before I do I I was telling the group earlier. I interviewed a cardiologists in Spain today. And they're like just really trying to stay afloat they're dealing with. It's like a crazy crisis over there. But he actually mentioned. They've seen a huge draw in a my presentations as well. Probably for the same reason he didn't he didn't elaborate but I think it'll be really interesting to see over the course of this pandemic how things sort of shift around I also worry Patients are afraid to come ospel. Yeah no exactly Dr Shamma. What are your thoughts on Coronary CPA for some of these patients season as you're trying to sort out it's really a type. One or type chew event or even myocarditis into acute setting and especially as our our technique gets better able to image patients with a higher heart rate and also thinking about protecting the Cath lab personnel. What do you think about? Cpa in some of these settings sorry city could be a very useful tool we are in the covert nineteen patients in those under investigation. We are trying to limit moving them in and out of their rooms. Any evaluation would have to wait. 'til things have stabilized. You really interesting randomly. You brought up that point because docker Gianluca on donating or Italy. Experience episode did mention that they were trying to use her French Lee more. Cpa to help. Triage Cath Lab us. By as a way of trying to minimize exposure but even going to the Cath Lab of course presents problems sternly does we're also being judicious Catholic abuse and we are getting circum sat in all our tests and isolate. What's best for the patient and best for caregivers soon to get the best outcomes for everyone? Okay so back to our patient. Gavin Flu Enza. Clearly stem is suspected and with proper droplet precautions. The patient is brought to the Cath Lab. Where a proximal. Led inclusion is identified and successfully balloon treated with drug alluding stent once am. I is suspected or identified doctor. Shulman is there a difference in management in these patients so unaware of increased risk of stent thrombosis though concerned that they're a pro thromboembolic? State and platelets are activated with a viral syndromes as render sin stated in so when one thinks about dual anti platelet therapy Consider weighing clotting and bleeding risk but a more potent one of the more potent platelet antagonists. In addition the aspirin would probably be a reasonable treatment. Definitely makes sense. And then you know we. We've already touched on this a bit but particularly in the Cova era. What are your impressions in terms of Protective Management? How we can sort of best handle that. While taking patients to the Cath Lab. We've had a few patients. Taken the Cath lab with ESI signal vision in mind and or patients under investigation known Begovic positive emphasis is on safety of the patient and safety of the staff and less emphasis on door to balloon. Time of ninety minutes so all protective equipment has to be in place we have designated a specific Cath lab suite for care of these patients and share be given to safely getting this patient to the kappa in safely performing the procedure. Incredible and I think that judicious use of the Cath. Lab is going to be really important. Moving forward returning to our patient. Korean awesome job opening up that led really happy to see Mr Flu Enza back on its feet doing laps around the unit. Getting good physical therapy without any difficulty by day. Three of his event he is tolerating his awesome regimen of Aspirin Keg or high-intensity Staten and mature Polo and an echocardiogram sheild ethical hypoc nieces but the Egyptian fraction overall preserved turning now to how long term outcomes are different in these patients from those observant types of m. i. that are not confounded by viral infections. Ron Johnson really enjoyed reading your paper in the American Journal. Cardiology examined the short term prognosis and management of patients with my cardio fortune but competent influenza. You mind walking us through the steady what you found and what that may mean for the clinicians taking care of patients absolutely on it before I get into the details of the city also want to acknowledge too hard work if all my co-authors involved especially my friend Dr Manuel Rivera. He's a cardiology fellow at the Washington University in St Louis and also Dr Mad Sarin. You WanNa far interventional cardiologists who are really instrumental in disfavor. The study was actually motivated by patient. That I cared for very similar. Mr Flu Enza. We reviewed the literature at the time and found many reports on dissociation of influenza and other viral respiratory illnesses with acuity my very little data on the outcome of these spacious. So we set out to examine this question in the national inpatient sample. This is the largest database of inpatient care in the United States in the period that we interrogated the database. We've found four point. Two million acute him is an off does about thirteen. Thousand patients had a concomitant diagnosis of influenza on the same admission so we did chew things into study. I wanted to report the descriptive outcomes of these patients with influenza and accused him. I and second compared the outcomes in these patients true controls with acute am I and no influenza. So what did we find I to fall the patients with acute on my end influenza there were older and they had a higher burden of some commodities like heart failure diabetes but a lower rate of atherosclerotic risk factors like tobacco smoke in hypoglycemia compared to patients with acute. Am I in no influenza? What about how the the spacious STU? What were there in hospital outcomes? What about the descriptive outcomes of these patients so it turns out that? About ninety percent of this population had honesty elevations myocardial infarctions in only ten percent had stems about a quarter of them had coronary geography. An eleven percent underwent some type of coronary vascular ization most commonly now. This is a really important point. The in hospital mortality of these patients was very high was about fourteen percent and one third of these patients with acute M. I. N. Influenza had multi organ failure moving on to the second objective which was to compare. The outcomes of these patients should those without influenza. You can't imagine that there's a lot of confounds this comparison because these populations are different in many levels. Not just with regards to influence the diagnosis to minimize confounding with did a propensity score matched analysis and we were very strict are matching criteria Indiana. We compared almost twelve thousand patients with acute in my who had influence A to an equal number. We've found influenza so even with propensity matching. We've found that. The patients with influenza had a higher in hospital Mortality Acute Kidney Injury Multi Organ Failure Live for stay compared to those acute in my and without influenza. So what this data really highlights is really that did first outcome and prognosis of patients with acute in my influenza. And yes there's an an important limitation is that we're not able to differentiate type one or type two. Mi's based on this data alone but like Doctor Schumann eluded chewed these patients. Really even with type. Chew Him I have a poor prognosis and it's important to recognize that and I also want to say that all those studies that reported association of acute in my and influenza they really didn't differentiate those type of myocardial infarctions. Because it's often hard to do that without doing routine Korean geography and all the patients. So this data really highlights adverse outcomes in these patients and how they're currently manage. Wow Anderson thank you so much and thank you for all your work on this subject and that was really a stellar explanation. So what Next Steps in research so we can maybe make a dent in the poor outcomes that we're seeing with patients who are presenting with both flu. And am I so I think an important aspect of the treatment of these patients will be finding better ways to phenotype these patients. Ideally we would do that. Noninvasive Lee because we can't the routine coordinating geography or intra coronary imaging in all patients. As our noninvasive imaging tools get better. I think it's really an area that deserves more attention and research on how we can better manage these patients with a virus. Pretoria illnesses or other situations that can lead to a type shoe am I but also. There is a significant portion of these patients. Who HAVE BLACK RUPTURE IN HAVE TYPE? One event and another potential area for research would be to develop the ideal therapies for these patients. I think that despite widespread knowledge that type two events are common in associated with an adverse prognosis. There's such a heterogeneous population that we really haven't figured out exactly how to treat them effectively. And I think it all starts first with fina typing population better so we can ultimately come up with better treatment strategies while rendered. I'm so glad that smart people like you are looking into things like this and I can imagine only become more relevant in a covert era. I'm wondering Doctor Shulman. What parallels do you see or anticipate with the Kobe? Nineteen affected patients. And do you have any thoughts in terms of what will be encountering moving forward so given a random person so wonderful article in explanation? It strikes me that When only twenty three percents of flu when my patients are going that a Cath? Lab was such a POOR PROGNOSIS. Just raises the alarm. That in this high risk group of patients with flu and I'm sure with cove in nineteen at as Corday August. We have to be on the lookout for more aggressive therapies and figure out who should be in the GAFF lot and it strikes me a much higher percentage in ten percent to look at their anatomy. Figure OUT WHO said a plaque rupture type one of that too. Vast grows of those patients and in those. We don't leave Astros at least better. Risks Ratify as so. We could figure out who needs more aggressive therapies. I think we'll be saying a whole host of Mike Complications. Mike nation's third complications in Cove in nineteen population and ongoing. Research will help us figure out who needs a Catholic who needs a mechanical support and noninvasive evaluation and we have to get better or a restaurant find these patients to decrease future rest. That's absolutely wonderful. Show tonight I agree you know as terrifying an uncertain as this pandemic is. I think the one thing that remains true is that there is definitely going to be a lot to learn from this. You know from a cardiovascular standpoint from a medicine standpoint and so they'll be a lot of potential for research moving forward Doctor Shulman Dr Cardozo. We WanNa thank you from the bottom of our hearts for taking the time to teach us more about this important topic. Not only. Are we still in flu season. But as we've discussed at many points in this interview were going to undoubtedly be facing several unanticipated cardiovascular complications such as Acute Coronary Syndrome Maya Card itis a heart failure like doctor Shulman met me mentioned in patients infected with cove in nineteen and it will be so important for us. Cardio nerds to be on the lookout for these potential complications. Moving forward there are a lot of units that are trying to learn how to plan for the surge and just logistics doctor Shulman as the director of the Johns Hopkins. Ccu I think many are wondering. What are the steps? You're taking to prepare for the surge of Kobe. Patients thanks mid. It's certainly a stressful time for patients nursing staff antlers staff how staff fellows in attempting alike. Everyone has gotten trained in outer put on your personal protective equipment when we have a patient under investigation in or corner curious and we said five. During my two weeks there who had heart failure and transplantation and sern for infection we had Someone from infection control a watch us as we donned a protective equipment to make sure that we did it correctly. We have two rooms with negative pressure. That are where omitting or patience to who are under investigation who also helping out or medical intensive care unit colleagues taking routine omit you patients into our units since Mick you as a turn it into a bio containment unit. I think it takes full team. Effort by nurse says infection control how staff fellows and attending alike to help each other and to get through this crisis credible. Thanks thanks for sharing that and we really appreciate your time in this really just crazy time. When you're not gonNA have enough time to talk dozen yet. You make your way and talk to us which is just We're overwhelmed with gratitude. Pleasure thank you card. That's the end of our show so it's time to make like an S. two and split. You can follow us on twitter at cardiac nerds and please share. What made your heart flutter this week. Send us a clip two Cardi innards g mail dot com if you enjoyed the show the narrative and spread the word and now aflutter moment cardio narrates my name is Sherry Wilson. Emma nurse on coronary ICU. At the Cleveland Clinic. And something that really makes my heart. Flutter is when my patients are grateful for the care that I've given nurses work really really hard to do right by their patients. And when the acknowledge us and our grateful. For What we've done and these say thank you it really makes my heart flutter.