Atherosclerosis is a disease of the large and middle arteries and is characterized mainly by endothelial dysfunction, inflammation of the vascular wall and the accumulation of lipids, cholesterol, calcium and cell debris in the intima of the vascular wall. This accumulation leads to plaque formation, vascular remodeling, acute and chronic obstruction of the vessel lumen, blood flow abnormalities, and reduced oxygen supply to target organs. As a result, blood vessels become harder and their lumen shrinks, which increases the risk of obstruction and thrombosis. Depending on the affected area, the corresponding symptoms appear - angina or myocardial infarction when affecting the coronary circulation; transient ischemic attack (TIA) or stroke affecting cerebral circulation; claudication or gangrene when affecting the limbs; aneurysm or dissection affecting the aorta. Various risk factors are known to affect the onset of the disease. They are divided into adjustable (dyslipoproteinemia, hypertension, diabetes mellitus, smoking, obesity, inactivity, emotional stress, etc.) and unadjustable (gender, age, family predisposition). The risk of developing atherosclerosis increases significantly in the presence of several risk factors. For example, the presence of 2 risk factors increases the risk of developing atherosclerosis 4 times. The atherosclerotic process is multifocal - it develops everywhere in the body - affecting the cardiac, cerebral and peripheral arteries almost simultaneously or sequentially. Its isolated manifestations in only one area are an exception.
One out of four patients affected by COVID-19 will experience persistent (>3-4 weeks) signs and symptoms (Post COVID-19 conditions or Post-Acute Sequelae of SARS-CoV-2 – PASC) and this fact will have a major significance for the healthcare and economic systems in the upcoming years. The cardiovascular system is one of the key targets for the Post COVID-19 syndrome, given the pathogenesis of the virus and prevalence of ACE-2 receptors. According to our initial personal experience via the campaign “Life after COVID” of the Bulgarian Cardiac Institute, a substantial proportion of patients having suffered from COVID-19 develop long-term cardiovascular consequences. They could range from rhythm disorder and blood pressure variation, through impairment of myocardial mechanics and heart failure, and to acute vascular manifestations of Post COVID-19 conditions, such as acute coronary syndrome, acute pulmonary embolism, and acute limb ischemia. These cardiovascular complications require special and dedicated medical attention, and we could share our personal experience on the matter.
Objective: Studies have indicated that hydroxychloroquine (HCQ) exerts antiviral effects against SARS-CoV-2 in vitro. However, trials regarding its effects in patients are very controversial. This study aims to evaluate the efficacy of (HCQ) in the treatment of hospitalized patients with COVID-19. Methods: We prospectively enrolled 260 patients hospitalized for COVID-19 in Heart and Brain Center of Excellence- Pleven, Bulgaria, for the period from November 6 to December 28, 2020. This study is not randomized, which we compensated for with Propensity Score Matching. Patients in the HCQ group were given HCQ 200 mg 3 times a day (600mg daily) for the duration of their hospitalization plus conventional treatment, while those in the control group were given conventional treatment only. The primary endpoints were transferred to the intensive care unit, needed for mechanical ventilation, and in-hospital death. Results: Of the 260 COVID-19 patients, 178 (68,5%) were male and the mean age was of 63,78 ± 12.45 years, with the most prevalent comorbidity hypertension (68,5%). We had two subgroups: treated with HCQ and conventional treatment (128 patients) and treated with conventional treatment only (132 patients). In the primary analysis, patients in HCQ group presented with less comorbidities and were younger than the group without HCQ. Patients treated with HCQ demonstrated a significant benefit in the primary endpoints compared to those without HCQ, namely, transferred to ICU – 20 (20,8%) vs 41 (36,9%), p=0,011, need for mechanical ventilation 13 (13,4%) vs 33 (28,2%), p=0,009 and in- hospital death 14 (10,9%) vs 35 (26,5%), p=0,001, respectively. We repeated this analysis with PSM, where 70 matched pairs were identified. Regarding the primary endpoints, we found again a statistically significant difference between the groups. Comparing transferring to ICU, better outcomes were presented in the HCQ group: 8 (17,4%) vs 27 (44,3%), with p= 0,003. Besides, a smaller proportion of the patients needed mechanical ventilation: 6 (12,8%), compared to the control group, 23 (35,4%), p= 0,007. Notably, patients from the HCQ group died during hospitalization: 8 (11,4%) in comparison with 19 (27,1%) from the control group, p= 0,018. Conclusion: Patients treated with HCQ demonstrated a significant benefit in the primary endpoints in our study, namely, transfer to the intensive care unit, need for mechanical ventilation, and in-hospital death. HCQ improves prognosis in hospitalized patients with COVID- 19.
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