Outcomes of Heart Failure in COVID-19 Patients: An Appalachian Experience.

Background: The Southeastern rural areas of the USA have a higher prevalence of heart failure (HF). Coronavirus disease 2019 (COVID-19) infection is associated with poor outcomes in patients with HF. Our study aimed to compare the outcomes of hospitalized HF patients with and without COVID-19 infection specifically in rural parts of the USA. Methods: We conducted a retrospective cohort study of HF patients with and without COVID-19 hospitalized in Southeastern rural parts of the USA by using the Appalachian Regional Healthcare System. Analyses were stratified by waves from April 1, 2020 to May 31, 2021, and from June 1, 2021 to October 19, 2021. Results: Of the 14,379 patients hospitalized with HF, 6% had concomitant COVID-19 infection. We found that HF patients with COVID-19 had higher mortality rate compared to those without COVID-19 (21.8% versus 3.8%, respectively, P < 0.01). Additionally, hospital resource utilization was significantly higher in HF patients with COVID-19 compared to HF patients without COVID-19 with intensive care unit (ICU) utilization of 21.6% versus 13.8%, P < 0.01, mechanical ventilation use of 17.3% versus 6.2%, P < 0.01, and vasopressor/inotrope use of 16.8% versus 7.9%, P < 0.01. A lower percentage of those with COVID-19 were discharged home compared to those without a COVID-19 diagnosis (63.4% versus 72.0%, respectively). There was a six-fold greater odds of dying in the first wave and seven-fold greater odds of dying in the second wave. Conclusions: Our study confirms previous findings of poor outcome in HF patients with COVID-19. There is a need for review of healthcare resources in rural hospitals which already face numerous healthcare challenges.

Renin-Angiotensin System Blocker in COVID-19. A Single Center Study.

ABSTRACT: Early during the Coronavirus disease 2019 (Covid-19) pandemic, concerns were raised regarding potential adverse outcomes in patients taking angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs). These concerns were based on animal studies showing increased ACE-2 expression in mice treated with ACEI/ARB. This is a single-center, retrospective, cohort study of 289 patients diagnosed with 2019 Novel Coronavirus (SARS-CoV-2) hospitalized between March of 2020 and June of 2020. The study was intended to investigate the impact of ACEIs and/or ARBs on in-hospital mortality, intensive care unit (ICU) admission, postadmission hemodialysis requirement, and the need for mechanical ventilation in patients with COVID-19. This cohort of 289 patients included 139 of 289 women (48%) with a mean age of 61 ± 19 years. Patients using ACEIs/ARBs were older (69.68 vs. 57.9 years; P < 0.0001), more likely to have a history of hypertension (97% vs. 36%; P < 0.0001), diabetes mellitus (48% vs. 20.9%; P < 0.0001), chronic heart failure (11.39% vs. 4.29%; P < 0.0512), coronary artery disease (20.25% vs. 7.14%; P < 0.0025), stroke/Transient Ischemic Attack (7.59% vs. 2.38%; P < 0.0761), chronic kidney disease (11.39% vs. 3.33%; P < 0.0167), atrial fibrillation/flutter (18.99% vs. 7.14%; P < 0.0080), and dementia (22.7% vs. 11.4%; P < 0.0233) compared with the nonuser group. There was significantly higher in-hospital mortality in patients using ACEIs/ARBs than nonusers, respectively (32.9% vs. 15.2%; P < 0.0015). However, a multivariate logistics regression analysis performed to adjust for common confounders demonstrated no significant difference in all-cause in-patient mortality (P 0.7141). Admission to ICU, postadmission hemodialysis requirement, and mechanical ventilation showed no significant differences between the 2 groups (P = NS). This study suggests that the use of ACEIs and ARBs in patients with COVID-19 was not found to significantly increase all-cause in-hospital mortality, ICU admissions, and hemodialysis and mechanical ventilation requirements.

Predictors of Mortality for Patients with COVID-19 in the Rural Appalachian Region.

BACKGROUND: The prevalence and outcome of coronavirus disease 2019 (COVID-19) in rural areas is unknown. METHODS: This is a multi-center retrospective cohort study of hospitalized patients diagnosed with COVID-19 from April 5, 2020 to December 31, 2020. The data were extracted from 13 facilities in the Appalachian Regional Healthcare system that share the same electronic health record using ICD-10-CM codes. RESULTS: The number of patients diagnosed with COVID-19 per facility ranged from 5 to 535 with a median of 106 patients. Total mortality was 11.4% and ranged from 0% to 22.6% by facility (median: 9.0%). Non-survivors had a greater prevalence of congestive heart failure (CHF), hypertension, type 2 diabetes mellitus, stroke, transient ischemic attack (TIA), and pulmonary embolism. Patients who died were also more likely to have had chronic obstructive pulmonary disease (COPD), acute respiratory failure (ARF), liver cirrhosis, chronic kidney disease (CKD), dementia, cancer, anemia, and opiate dependence. CONCLUSION: The aging population, multiple co-morbidities, and health-related behaviors make rural patients vulnerable to COVID-19. A better understanding of the disease in rural areas is crucial, given its heightened vulnerability to adverse outcomes.

HIGH INCIDENCE OF SPONTANEOUS PNEUMOTHORAX IN CRITICALLY ILL PATIENTS WITH SARS-COV-2

SESSION TITLE: Disorders of the Pleura Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Spontaneous pneumothorax is a relatively common complication in critically ill patients with severe acute respiratory distress syndrome (ARDS). Limited data exists regarding pneumothorax in severe acute respiratory coronavirus 2 (SARS-CoV-2) patients. This study depicts cases of spontaneous pneumothorax in critically ill SARS-CoV-2 patients and explores the potential underlying mechanisms. METHOD(S): This is a retrospective cohort study of SARS-CoV-2 patients with severe ARDS admitted to a tertiary care center between March 9, 2020 to April 5, 2020. SARS-CoV-2 was diagnosed via polymerase chain reaction. Only patients on mechanical ventilation were analyzed. RESULT(S): A total of 22 patients with confirmed SARS-CoV-2 infection on mechanical ventilation were identified and analyzed. Out of these, 7 patients developed a spontaneous pneumothorax. The patients were predominantly male (86%) with an age range between 67 and 82 years old. Cough (100%) and shortness of breath (71%) were the most common presenting symptoms. Chronic obstructive pulmonary disease was not present in any of the patients. Pneumothoraxes were diagnosed 6 to 33 days after hospital admission. All 7 patients had subclavian central lines that were placed by 4 different providers with more than 15 years of critical care experience. All 7 patients had right sided pneumothoraxes of varying sizes but only 42% had right-sided lines. Remarkably, the mean peak inspiratory pressure (Ppeak) for these patients was 25 cm H2O and the mean positive end expiratory pressure (PEEP) was 11 cm H2O. Prone positioning was utilized in 57% of patients and 42% of patients received convalescent plasma. The mortality rate was 71% and the 2 patients who survived were discharged to long term acute care hospitals. CONCLUSION(S): Traditionally, ventilator associated pneumothorax is associated with a Ppeak greater than 40 cm H2O, which contrasts with the mean Ppeak of 25 cm H2O observed in this study. While iatrogenic pneumothoraces are common following subclavian central line placement, the majority of the pneumothoraces in this study occurred on the opposite side of the procedure. ARDS secondary to SARS-CoV-2 infection appears to have a completely different pathophysiology than that of traditional ARDS, which is typically managed with low PEEP and Ppeak. Utilizing the ARDSnet protocol in patients with ARDS secondary to SARS-CoV-2 may be deleterious. Further investigation is needed to evaluate this hypothesis. CLINICAL IMPLICATIONS: ARDS secondary to SARS-CoV-2 appears to be distinct from ARDS caused by other disease processes and may have a different risk of pneumothorax development. As elderly, critically ill SARS-CoV-2 patients with ARDS have been found to have increased risk of death, identifying modifiable risks associated with the development of a spontaneous pneumothorax could help mitigate morbidity and mortality in this population. DISCLOSURES: No relevant relationships by Andres Chacon Martinez, source=Web Response No relevant relationships by robert chait, source=Web Response No relevant relationships by Kai Chen, source=Web Response No relevant relationships by Nakeya Dewaswala, source=Web Response No relevant relationships by Katherine Hodgin, source=Web Response no disclosure on file for Jesus Pino;No relevant relationships by Fergie Ramos Tuarez, source=Web Response No relevant relationships by Renuka Reddy, source=Web ResponseCopyright © 2020 American College of Chest Physicians

Does Thrombocytopenia Truly Correlate with COVID-19 Severity?

Introduction:On March 11, 2020, the World Health Organization (WHO) declared SARS-CoV-19 a pandemic with about 114 countries affected. Many studies and metanalyses have investigated the risk factors associated with poor outcomes from COVID-19 infection. Different clinical as well as laboratory parameters have been shown to correlate with disease severity, including age, male gender, smoking history, presence of one or more co-morbidities, heart disease, hypertension, diabetes, obesity, and chronic lung disease.Among these risk factors, several studies suggest that a decreased platelet count is associated with more severe disease course. A lower platelets count was also observed to be associated with a poor prognosis. On the contrary, not all reports seem to show the same association.Objective:Our study is aimed at investigating the prognostic impact of the platelet count in patients admitted with COVID-19 infection and understanding its association with disease severity and mortality.Methodology:All patients admitted to JFK Medical center in Atlantis, Florida and diagnosed with COVID-19 from March 2020 to May 2020 were identified and included in this retrospective cohort. Certain demographic and clinical data were collected for each patient, including age, gender, comorbidities, complete blood count and blood chemistry values on admission. The following data was calculated: quick Sequential Organ Failure Assessment (qSOFA), the ratio of oxygen saturation to the fraction of inspired oxygen ratio (SpO2/FiO2) were calculated, presence or absence of adult respiratory distress syndrome (ARDS), and the outcome in terms of mortality. Data regarding the radiographic findings on chest X-ray (CXR) were determined to be normal, mild, moderate, or severe by a radiologist.Patients were identified as having severe disease if they met the following criteria: Admission to the intensive care unit (ICU) during hospitalization or met criteria for ARDS.Results:A total of 175 patients were identified. The mean age was 62.97 years(SD 17.9years), 97 patients (55.4%) were males, 36 (20.6%) had an ICU admission during their hospitalization, 18 (10.3%) met the criteria for ARDS, 131 (74.9%) had qSOFA of 0 with only 3 (1.7%) having qSOFA of 2. The majority of CXR findings were mild 66 out of valid 155 cases (37.7%) while 19.4% read as severe infiltrate. The mean platelets count on admission was 227.71 x 109/L (SD 104 x 109/L). 43 patients (24.6%) died in the hospital.Patients with severe disease versus non-severe disease did not differ significantly in the platelet count at admission. Platelet counts were also not associated with in-hospital mortality. No significant correlation was found between the platelets count and the qSOFA scale, the SpO2/FiO2 and the CXR findings (table 2).Conclusion:In our retrospective Cohort study, no significant association was found between the platelet count on admission and disease severity or mortality.Studies examining the risk factors for severe COVID-19 infection and mortality showed that thrombocytopenia is a significant risk factor.(13) Other studies showed that patients with significantly elevated platelets (>300 x 109/L) during treatment had longer average hospitalization days.(12).Finding practical and actionable indicators of disease severity can help clinicians guide patients with potentially worse outcomes to aggressive therapies that may lead to better outcomes when instituted earlier. More work should be done to clarify the role platelet counts can play in the prognostication of patients with COVID-19 infection.Our Study will be followed by further investigation of the correlation between day 3 platelet count and COVID-19 severity. We are also examining the validation of a scoring system involving the platelet count among other parameters to use as a predictor for disease course and outcome.

Model of End-Stage Liver Disease (MELD) Score as a Predictor of In-Hospital Mortality in Patients with COVID-19: A Novel Approach to a Classic Scoring System.

Background Limited data is available for reliable and accurate predictors of in-hospital mortality in patients diagnosed with COVID-19. Methods This scientific study is a retrospective cohort study of patients without a known history of liver diseases who were hospitalized with COVID-19 viral infection. Patients were stratified into low score groups (Model of End-Stage Liver Disease [MELD] score <10) and high score groups (MELD ≥10). Clinical outcomes were evaluated, including in-hospital mortality, hospital length of stay, and intensive care unit length of stay (ICU LOS).  Results Our cohort of 186 COVID-19 positive patients included 88 (47%) women with a mean age of 60 years in the low score group and mean age of 73 years in the high score group. Patients in the high score group were older in age (p<0.0001) and more likely to have history of diabetes mellitus (p=0.0020), stage 3 chronic kidney disease (CKD) (p=0.0013), hypertension (p<0.0001), stroke/transient ischemic attack (TIA) (p=0.0163), asthma (p=0.0356), dementia (p<0.0001), and chronic heart failure (p=0.0055). The in-hospital mortality or discharge to hospice rate was significantly higher in the high-score group as opposed to the low-score group (p=0.0014). Conversely, there was no significant difference among both groups in the hospital length of stay (LOS) and ICU LOS (p=0.6929 and p=0.7689, respectively). Conclusion Patients hospitalized with COVID-19 infection and found to have a MELD score greater than or equal to 10 were found to have a higher mortality as compared to their counterparts. Conversely a low MELD score is a very strong indicator of a more favorable prognosis, indicating hospital survival. We propose using the MELD score as an adjunct for risk stratifying patients diagnosed with COVID-19 without prior history of liver dysfunction.

Cardiac Troponin-I and COVID-19: A Prognostic Tool for In-Hospital Mortality.

BACKGROUND: The number of fatalities due to coronavirus disease 2019 (COVID-19) is escalating with more than 800,000 deaths globally. The scientific community remains in urgent need of prognostic tools to determine the probability of survival in patients with COVID-19 and to determine the need for hospitalization. METHODS: This is a retrospective cohort study of patients with a diagnosis of COVID-19 admitted to a tertiary center between March 2020 and July 2020. Patients age 18 years and older were stratified into two groups based on their troponin-I level in the first 24 h of admission (groups: elevated vs. normal). The aim of the study is to explore the utility of cardiac troponin-I level for early prognostication of patients with COVID-19. RESULTS: This cohort of 257 patients included 122/257 (47%) women with a mean age of 63 ± 17 years. Patients with an elevated troponin-I level were more likely to be older (77 ± 13 vs. 58 ± 16 years, P < 0.0001), have a history of hypertension (P < 0.0001), diabetes mellitus (P = 0.0019), atrial fibrillation or flutter (P = 0.0009), coronary artery disease (P < 0.0001), and chronic heart failure (P = 0.0011). Patients with an elevated troponin-I level in the first 24 h of admission were more likely to have higher in-hospital mortality (52% vs. 10%, P < 0.0001). Troponin-I level in the first 24 h of admission had a negative predictive value of 89.7% and a positive predictive value of 51.9% for all-cause in-hospital mortality. CONCLUSIONS: Troponin-I elevation is commonly seen in patients with COVID-19 and is significantly associated with fatal outcomes. However, a normal troponin-I level in the first 24 h of admission had a high negative predictive value for all-cause in-hospital mortality, thereby predicting favorable survival at the time of discharge.