Initial High Sensitivity Troponin I Values Predict 28 Day Survival in Coronavirus-19 Patients

Objectives: To determine the 28 day survival prognostic value of the initial Emergency Department (ED) high sensitivity cardiac troponin I (hs-cTnI) measurement in coronavirus-19 disease 2019 (COVID-19) patients. Background(s): Recent reports indicate that the presence of cardiac injury [troponin level > the 99th percentile upper reference limit (99th % URL) using mostly contemporary assays] is predictive of death within 30 days during hospitalization of COVID-19 patients. Troponin values ordered in the ED or after hospitalization were used for these analyses. Method(s): Using an ED centric electronic database of COVID-19 patients (nasopharyngeal swab testing within 1 week prior to or during the ED visit) having at least 1 hs-cTnI (Beckman Coulter, Brea, CA;level of quantitation (LoQ) 4ng/L, non sex specific 99th percentile URL 18 ng/L) value reported during a visit to an urban, academic ED in the United States. All patients were followed for 28 days to determine all-cause mortality. Kaplan Meir survival curves were constructed to compare outcomes amongst predetermined initial hs-cTnI value intervals. Result(s): From March 16-November 2, 2020 1476 consecutive ED COVID-19 patients were identified with 1044 (70.7%) having at least 1 hs-cTnI value resulted in the ED. Patients' mean age and body mass index were 60.8 +/- 16.1 years and 32.4 +/- 11.3 kg/m2 respectively. 531 (50.9%) were male, 804 (77.0%) self-identified as African American and 615 (58.9%) had 2 or more comorbidities with hypertension (42.5%), diabetes (37.4%) and hyperlipidemia (27.23%) commonest. Hs-cTnI interval values were: 147 (14.1%) < 4 (LoQ), 359 (34.4%) 4-10 and 151 (14.5%) 11-18 ng/L. Hs-cTnI values were > 99th % URL in 387 (37.1%) patients with 230 (22.0%) 19-54, 63 (6.0%) 54-99 and 94 (9.0%) = 100 (laboratory reported critical value) ng/L. 145 (13.9%) patients were discharged directly home and 2 (0.2%) died in the ED. 147 (14.1%) were admitted to an ICU with 104 (70.7%) dying. Each of the interval initial ED hs-cTnI values was associated with a different (p < 0.001) 28 day survival curve (Figure). Conclusion(s): Most COVID-19 patients had a hs-cTnI value obtained with 85.9% of these > 4 ng/L. No one with an initial hs-cTnI < 4 ng/L died within 28 days while increasing presenting hs-cTnI values > 4 ng/L were associated with decreased 28 day survival. Our findings indicate that in COVID-19 patients detectable initial ED hs-cTnI values, whether reaching thresholds for cardiac injury or not, are highly prognostic of 28 day survival.Copyright © 2023

High sensitivity troponin I and newly/recently diagnosed coronavirus-19 disease patients presenting to the emergency department: Values above and below the 99th percentile predict 28 day mortality

Background: Studies indicate that the presence of cardiac injury [troponin level > the 99th percentile upper reference limit (99th % URL) using mostly contemporary assays] is predictive of death within 30 days during hospitalization of coronavirus disease 2019 (COVID-19) patients. Troponin measurements in these reports were ordered and/or resulted in the Emergency Department (ED) or during various times after hospital admission and not all patients were followed for 30 days. Purpose(s): Our objective was to determine the 28 day survival prognostic value of Emergency Department (ED) resulted high sensitivity cardiac troponin I (hs-cTnI) measurements in all COVID-19 patients including those discharged after their ED visit or hospitalization. Method(s): An ED centric electronic database of COVID-19 patients (nasopharyngeal swab testing within 1 week prior to or during the ED visit) having at least 1 hs-cTnI (Beckman Coulter, Brea, CA;level of quantitation (LoQ) 4ng/L, non sex specific 99th % URL 18 ng/L) value reported during a visit to an urban, academic ED in the United States was constructed. All patients were followed for 28 days and Kaplan Meir survival curves constructed amongst predetermined initial hs-cTnI value intervals. Result(s): From March 16-November 2, 2020 1476 consecutive ED COVID- 19 patients were identified with 1044 (70.7%) having at least 1 hs-cTnI value resulted in the ED. Patients' mean age and body mass index were 60.8+/-16.1 years and 32.4+/-11.3 kg/m2 respectively. 531 (50.9%) were male, 804 (77.0%) self-identified as African American and 615 (58.9%) had 2 or more comorbidities with hypertension (42.5%), diabetes (37.4%) and hyperlipidemia (27.23%) commonest. Frequent primary presenting complaints were shortness of breath (37.7%), fever/chills (14.5%) and cough (11.9%). Hs-cTnI interval values were: 147 (14.1%) <4 (LoQ), 359 (34.4%) 4-10 and 151 (14.5%) 11-18 ng/L. Hs-cTnI values were >99th % URL in 387 (37.1%) patients with 230 (22.0%) 19-54, 63 (6.0%) 54-99 and 94 (9.0%) >=100 (laboratory reported critical value) ng/L. 145 (13.9%) patients were discharged directly home and 2 (0.2%) died in the ED. 147 (14.1%) were admitted to an ICU with 104 (70.7%) dying. Each of the interval initial ED hs-cTnI values was associated with a different (p<0.001) 28 day survival curve. Conclusion(s): Most COVID-19 patients had a hs-cTnI value obtained with 85.9% of these >4 ng/L. No one with an initial hs-cTnI <4 ng/L died within 28 days while increasing presenting hs-cTnI values >4 ng/L were associated with decreased 28 day survival. Our findings indicate that in COVID-19 patients detectable initial ED hs-cTnI values, whether reaching thresholds for cardiac injury or not, are highly prognostic of 28 day survival. Studies are needed to better define how hs-cTnI values could alter early management of COVID-19 disease to improve outcomes for these patients. (Figure Presented).

INCREASE in FALSE POSITIVE 4TH GENERATION HIV TESTS in PATIENTS with COVID-19 DISEASE

Background: A variety of infections and inflammatory conditions have been associated with false positive (FP) serological tests, including those for HIV. In the context of an HIV counseling, testing, and referral program, an apparent increase in FP 4th generation HIV tests was observed among persons infected with SARS-CoV-2. We sought to determine if there was an association of active coronavirus disease-2019 (COVID-19) with a FP HIV test. Methods: This was a retrospective, cross-sectional study from March 2020 to August 2021 at Henry Ford Hospital. Through electronic medical record extraction, all results for SARS-CoV-2 by PCR within + two weeks of a diagnostic HIV 4th generation assay (Elecsys HIV Duo, Roche Diagnostics, Indianapolis, IN) were selected. Confirmatory HIV-1 and HIV-2 antibodies, as well as quantitative HIV RNA, was performed for all positive 4th generation tests. All positive HIV 4th generation assays were independently reviewed and divided into groups of FP, true positives (TP), and true negatives (TN). Variables included age, race, ethnicity, and sex. Statistical analysis was performed in a pairwise fashion using a Chi-squared test. Multivariate logistic regression was used to predict positive COVID-19 tests. Results: A total of 23,278 medical records meeting the above criteria were reviewed. The rates of COVID positive tests were then arranged in groups of HIV TP, FP, and TN. In total, 23,041 patients had a TN HIV test result, 167 patients had a TP, and 70 patients had a FP (Table 1). Those with HIV FP tests had the highest percentage of COVID positive test results at 22.9% (p=0.001), which was significantly higher than HIV TN (10.2%;p=0.197) and HIV TP (7.2%;p=0.001). After adjustment for all covariates, only FP HIV was significantly associated with COVID-19 (OR=7.04;p=0.001). Conclusion: This study reveals that patients with active COVID-19 disease are significantly more likely to have a false positive 4th generation HIV test. The mechanism for this is unknown but may reflect broad polyclonal antibody generation in acute infections or cross-reactivity to antibodies with the SARS-CoV-2 spike protein. Although only a single 4th generation test was evaluated in this study, acute COVID-19 infection should be considered as a potential etiology for a false positive 4th generation HIV test.

All Initial High Sensitivity Cardiac Troponin I Values Are Prognostic for 28 Day Survival in Coronavirus-19 Disease Patients

Study Objectives: Recent reports indicate that the presence of cardiac injury [troponin level > the 99th percentile upper reference limit (99th % URL) using mostly contemporary assays] is predictive of death within 30 days during hospitalization of coronavirus disease 2019 (COVID-19) patients. Troponin values ordered in the emergency department (ED) or after hospitalization were used for these analyses. Our objective was to determine the 28 day survival prognostic value of ED resulted high sensitivity cardiac troponin I (hs-cTnI) measurements in COVID-19 patients. Methods: We established an ED centric electronic database of COVID-19 patients (nasopharyngeal swab testing within 1 week prior to or during the ED visit) having at least 1 hs-cTnI (Beckman Coulter, Brea, CA;level of quantitation (LoQ) 4ng/L, non sex specific 99th percentile URL 18 ng/L) value reported during a visit to an urban, academic ED in the United States. All patients, whether admitted and expired in the hospital or hospital discharged or sent home directly from the ED were followed for 28 days to determine all-cause mortality. Kaplan Meir survival curves were constructed to compare outcomes amongst predetermined initial hs- cTnI value intervals. Results: From March 16-November 2, 2020 1476 consecutive ED COVID-19 patients were identified with 1044 (70.7%) having at least 1 hs-cTnI value resulted in the ED. Patients’ mean age and body mass index were 60.8 ± 16.1 years and 32.4 ± 11.3 kg/m2 respectively. 531 (50.9%) were male, 804 (77.0%) self-identified as African American and 615 (58.9%) had 2 or more comorbidities with hypertension (42.5%), diabetes (37.4%) and hyperlipidemia (27.23%) commonest. Frequent primary presenting complaints were shortness of breath (37.7%), fever/chills (14.5%) and cough (11.9%). Hs-cTnI interval values were: 147 (14.1%) < 4 (LoQ), 359 (34.4%) 4-10 and 151 (14.5%) 11-18 ng/L. Hs-cTnI values were > 99th % URL in 387 (37.1%) patients with 230 (22.0%) 19-54, 63 (6.0%) 54-99 and 94 (9.0%) ≥ 100 (laboratory reported critical value) ng/L. 145 (13.9%) patients were discharged directly home and 2 (0.2%) died in the ED. 147 (14.1%) were admitted to an ICU with 104 (70.7%) dying. Each of the interval initial ED hs-cTnI values was associated with a different (p < 0.001) 28 day survival curve (Figure). Conclusions: Most COVID-19 patients had a hs-cTnI value obtained with 85.9% of these > 4 ng/L. No one with an initial hs-cTnI < 4 ng/L died within 28 days while increasing presenting hs-cTnI values > 4 ng/L were associated with decreased 28 day survival. Our findings indicate that in COVID-19 patients detectable initial ED hs-cTnI values, whether reaching thresholds for cardiac injury or not, are highly prognostic of 28 day survival. Studies are needed to better define how hs-cTnI values could alter early management of COVID-19 disease to improve outcomes for these patients. [Formula presented]

Feasibility of Virtual Optimization of Guideline Directed Medical Therapy in Hospitalized Patients with HFrEF During the Covid-19 Pandemic: The IMPLEMENT-HF Pilot Study

Introduction: Implementation of GDMT for HFrEF remains low. We assessed the feasibility of a virtual GDMT Team for optimization of GDMT during hospitalization for non-CV conditions. Hypothesis: A GDMT Team will improve GDMT optimization compared with usual care. Methods: Consecutive hospitalized patients with HFrEF≤40% were prospectively identified. Patients with critical illness, cardiology consult, de-novo HF, COVID-19 & SBP ≤90mmHg were excluded. February 3 to March 1, 2020 served as a pre-intervention period during which patients were screened, but did not receive GDMT Team interventions. From March 2 to June 21, 2020, a pharmacist-physician team provided up to 1 suggestion daily for GDMT optimization (evidence-based ß-blockers, ACEi/ARB/ARNI, & MRA) to treating teams based on an evidence-based algorithm. The primary outcome of a composite GDMT optimization score, the net of positive therapeutic changes (+1 for new initiations/uptitrations) & negative therapeutic changes (-1 for discontinuations/downtitrations) during hospitalization, was compared between the pre- vs. post-intervention periods. Multivariable linear regression models were built adjusting associations for clinical factors. Safety outcomes requiring intervention or GDMT downtitration were identified. Results: Of 187 encounters, 84 (45%) met eligibility criteria: 28 pre-intervention, 56 post-intervention. Mean age was 68±11 yrs, 70% men, and 61% White. Of 88 GDMT Team suggestions, 49 (56%) were followed by discharge. During the intervention, cumulative COVID-19 hospitalizations rose from 0 to 11085 in MA. Mean GDMT optimization score was -0.14 (95% CI: -0.58 to +0.30) pre-intervention & +0.64 (95% CI: +0.35 to +0.93) post-intervention (P=0.004). In a model inclusive of demographics, comorbidities, vital signs, potassium levels, eGFR, & LVEF, the intervention was the only factor associated with higher GDMT optimization score (β coeff 0.89;P=0.008). Safety events included 1 instance each of AKI, hyperkalemia, bradycardia, & hypotension. Conclusion: Admission for non-CV conditions is a feasible setting for GDMT optimization. A virtual GDMT Team was associated with improved GDMT;this implementation strategy warrants testing in a prospective RCT.