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Background and Aim Innate immune disarray is a key component in the development and progression of acute on chronic liver failure (ACLF) and predisposition to infections. We evaluated the neutrophil dysfunction and its impact on outcomes in patients with ACLF. Methods Forty patients with acute decompensation of cirrhosis (10 each of grades 0, 1, 2, and 3 ACLF) and 10 healthy controls were prospectively evaluated for neutrophil immunophenotype (NP), neutrophil phagocytic capacity (NPC), and oxidative burst (OB) in both resting and stimulated conditions. The patients were followed up for 90 days or until death or transplant, whichever was earlier. Results NP was normal (in %) and NPC (in mean fluorescence intensity [MFI]) was better in controls compared to patients with ACLF (83.74 ± 12.38 vs 63.84 ± 22.98; P = 0.007 and 98.33 ± 130.60 vs 18.73 ± 17.88, P = 0.001, respectively). Resting OB was higher in patients with ACLF compared to controls (97 ± 4.9% vs 91 ± 9%; P = 0.034), but it failed to increase further after stimulation, suggesting an immune exhaustion. NP was normal (in %) and NPC (in MFI) was better in 90‐day survivors compared to nonsurvivors (78 ± 11.9 vs 62.2 ± 24.11, P = 0.02 and 33.3 ± 22.7 vs 16.36 ± 13.3; P = 0.004, respectively). Phenotypically normal neutrophils >71.7% had 78.6% sensitivity and 65.4% specificity with an area under receiver operating curve (AUROC) of 0.70 (95% confidence interval [CI]: 0.55–0.90); P = 0.017, and NPC >17.32. MFI had 71.4% sensitivity and 69.6% specificity with an AUROC of 0.73 (95% CI: 0.54–0.86), P = 0.035, in predicting 90‐day survival. Conclusion Neutrophils have impaired bactericidal function in patients with ACLF compared to healthy adults. Neutrophil phenotype and phagocytic capacity may be used to predict 90‐day survival in patients with ACLF.

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Aim Patients with Covid-19 are theoretically at a higher risk of ACS, as respiratory infections can often lead to coronary endothelial damage and plaque rupture. Initial reports during start of pandemic suggested decrease in STEMI patients, however this has been explained by iatrophobia rather than actual decrease. Data on pathophysiology and outcome of patients presenting with ACS is scarce. We did a prospective observational study to study epidemiology and outcomes of Covid-19 patients with ACS. Methods A total of 654 patients were admitted with Covid-19 at PGIMER, Chandigarh from August 2020 to February 2021, 35 (5.3%) consecutive patients of ACS were enrolled into the study. Acute myocardial infarction was defined as per fourth universal definition of myocardial infarction. Diagnosis of Covid-19 was established using RT-PCR from nasopharyngeal swab. Angiographic assessment was done by two interventional cardiologists. Results Mean age of patients was 59.5±11.8 years, males comprised majority (80%) of study group. Most common risk factor was hypertension seen in around 70% followed by DM in 57% patients. Most common symptom at presentation was rest angina seen >90% while history of fever was present in only 31.4%. STEMI was most common ACS seen in 45.7% followed by USA in 23% patients. CS was present in 15% patients at presentation while another 5% developed shock in hospital. Oxygen requirement was required in over half the patients while 25% patients succumbed to illness in hospital.Thrombolysis was done in half the patients of STEMI. In view of Covid-19 disease 71.4% required dexamethasone and remdesivir. Coronary angiography was done in around 20% patients, which revealed obstructive CAD in 83% patients with 60% patients having 100% occlusion of IRA. Percutaneous intervention was done in 66% patients. Hypoalbuminemia was commonly seen patients with mean albumin of 3.3 gm/dL. Low T3 syndrome was most common thyroid function abnormality seen in 37.1%.On univariate analysis age, BNP levels and albumin were able to predict 30-day mortality. Conclusion ACS can be first presentation of patients with Covid-19 as shown by our study only 30% patients had prior history of fever. Our data reaffirms that patients with Covid-19 and ACS have worse prognosis. Interestingly mortality in our study was comparable to western study, despite low rate of angiography and intervention thus underscoring individualization of therapy. We believe Type-2 myocardial infarction is common in pathophysiology of patients who benefit most from medical therapy. Funding Acknowledgement Type of funding sources: None.

Funding Acknowledgements Type of funding sources: None. Background Primary percutaneous intervention remains the principal treatment modality for anterior wall myocardial infarction (AWMI). However, a large fraction of patients especially in the developing countries present outside the window period (OWP) with no chest pain and akinetic left anterior descending (LAD) territory on echocardiography. Revascularization in these patients is primarily guided by viability status. Purpose This study was conducted to determine the accuracy of strain echocardiographic parameters compared to single-photon emission computed tomography (SPECT) in predicting myocardial viability in patients of AWMI presenting OWP. Methods All patients presenting with AWMI-OWP without ongoing chest pain and akinetic LAD territory on echocardiography from December 2020 to June 2021 were recruited. All patients underwent determination of both Global longitudinal strain (GLS) and territorial longitudinal strain (TLS) within 24-72 hours on AWMI. In addition, all underwent SPECT to determine the percentage of non-viable myocardium. On SPECT, a defect >5% myocardial territory showing severe reperfusion defect was considered as a marker of non-viability.  Results A total of 27 patients were recruited. The mean age of the population was 61.66 + 12.6 years. Acute left ventricular failure (LVF) and cardiogenic shock (CS) was present in 6 (22.2%) and 5 (18.5%) patients respectively. Out of 22 patients who underwent angiography, majority of the patients 19 (86%) had single vessel disease involving the LAD. The mean left ventricular ejection fraction (LVEF) of the study group was 29.6 + 6.5%. The mean GLS and LAD territory TLS of the study group was -11.13 + 3.14% and -7.2 + 2.75% respectively. On SPECT, 8 (29.6%) patients had non-viable underlying myocardium. Parameters that very significantly associated with non-viability on SPECT included past history of CAD (p = 0.004), smoking (p = 0.05) and presentation with LVF (p = 0.0008) and CS (p = 0.001). The mean LVEF was significantly lower in the group with non-viability on SPECT (32.3 + 5.1% vs 23.1 + 4.5%; p < 0.001). Both GLS (-12.8 + 1.4% vs -7.1+ 2.3%; p < 0.001) and TLS (-8.7 + 1.4% vs -3.8 + 1.8%; p < 0.001) were significantly lower in group showing non-viability on SPECT. On receiver operating curves, a GLS of > -10.45% and TLS of > -6.65%, both had a sensitivity of 87.5% and specificity of 89.5% in predicting non-viability on SPECT. Both showed good accuracy in predicting non-viability on overall quality model. (Figures 1 and 2) Conclusion Modalities like cardiac magnetic resonance, SPECT or positron emission tomography are resource dependent and take time to be performed. Hence, performing these investigations is challenging in unstable patients. Strain echocardiography provides GLS of the myocardium which has good sensitivity and specificity in predicting viability and can be performed safely and quickly in this high-risk group. Abstract Figure.  Abstract Figure. Overall quality model

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