ABSTRACT
Background: Patients with SARS-CoV-2 infection are at an increased risk of cardiovascular and thrombotic complications portending an extremely poor prognosis. COVID-19 infection is known to be an independent risk factor for acute ischemic stroke (AIS) and myocardial infarction (MI). Aim(s): We propose to develop risk assessment model (RAM) that can risk stratify hospitalized COVID-19 patients for arterial thromboembolism (ATE). Method(s): This multicenter, retrospective study included adult patients admitted with PCR proven SARS-CoV-2 infection between 3/1/2020 and 9/5/2021. The composite outcome was in-hospital ATE events, including AIS, MI, and other ATE identified by ICD-10 codes. 49 variables, including baseline demographics, past medical history, presenting vitals and laboratory values, were categorized with multiple imputation to impute missing values. Variables selected by LASSO regression were used to build the final RAM. Result(s): Among 3531 patients from training cohort (admitted before 12/31/2020), 548 (15.5%) patients developed acute ATE, compared to 285 of 2508 (11.4%) in the validation cohort (admitted after 12/31/2020). The final score included 16 items: Male gender (1);Non-African American race (1);Age 40-59 (2), Age 60+ (4);Systolic blood pressure > = 160mmHg (1);History of cerebrovascular accident (1), Coronary artery disease (1), Smoking (1);Leukocytes > 11 K/uL (1), B-type natriuretic peptide > 100 pg/ mL (1), Lactate dehydrogenase > 192 U/L (1), Creatinine > 1.4 mg/ dL (1), Aspartate aminotransferase > 41 U/L (1), Troponin-I > 0.03 ng/mL (1), Troponin-I > 0.09 ng/mL (3), Interleukin-6 > 5 pg/mL(1), Potassium < 3.5 mEq/L(1), Magnesium < 1.8 mg/mL (1). RAM had a good discrimination for ATE (training AUC 0.777, 95% CI 0.756-0.797;validation AUC 0.749, 95% CI 0.721-0.778). The validation cohort was stratified as low-risk (score 0-8), intermediate-risk (score 9-13) and high-risk groups (score 14+), with the incidence of ATE 2.1%, 11.3%, and 31.1%, respectively. Conclusion(s): Our prediction model based on 16 parameters commonly available at hospital admission showed moderate performance in identifying hospitalized COVID-19 patients at low and high risk for ATE.
ABSTRACT
Introduction: Some studies suggest an increased incidence of atrial fibrillation (AF) in patients receiving corticosteroids, whereas others suggest a preventive effect of steroids. Data on the impact of steroids on the incidence of new-onset AF in hospitalized COVID-19 patients is lacking. Methods: This retrospective, multicenter cohort study included patients ≥ 18 years admitted to one tertiary care and five community hospitals for treatment of COVID-19 infection between 3/1/2020 and 3/31/2021. Subjects were stratified based on steroid exposure during hospitalization: group 1 (full-dose) received cumulative dosage including dexamethasone ≥ 6 mg/day, methylprednisolone ≥ 80 mg/day or hydrocortisone ≥ 50 mg/day for ≥ 3 days, group 2 (low-dose) did not receive the aforementioned dosage, and group 3 had no steroid usage. Patients with a history of AF and length of stay < 3 days were excluded. Results: Among 4578 (1556 in group 1, 1046 in group 2, 2156 in group 3) patients (mean age 65.4 ± 61 years, 50.4 % females), 542 patients developed new-onset AF. 523 (24.3%) patients in group 1, 97 (9.3%) in group 2, and 125 (8%) in group 3 died during hospitalization. In multivariable logistic regression models adjusted for hypoxia and significant baseline demographics (age, sex, body mass index, hypertension, pulmonary disease, chronic kidney disease, liver disease, and cerebrovascular accident), we found that group 1 had a higher incidence of AF compared to group 3 (adjusted relative risk [aRR] 1.59;95% CI 1.27-1.99;p < 0.001) and group 2 (aRR 1.39;95% CI 1.09-1.77;p = 0.007). The group 2 vs group 3 (aRR 1.14;95% CI 0.87-1.50;p = 0.347) comparison did not reach statistical significance (Figure). Conclusions: Corticosteroids, the mainstay of treatment of hypoxic COVID-19 patients, are associated with an increased risk of developing AF. This suggests that steroids have a potential direct arrhythmogenic effect in COVID-19 patients.
ABSTRACT
Introduction: Data on echocardiographic findings in COVID-19 patients is limited. Atrial arrhythmias (AA) are common in COVID-19 but their impact on echocardiographic phenotypes is not well studied. We aimed to assess transthoracic echocardiographic (TTE) findings in adult hospitalized patients with COVID-19 undergoing TTE, and compare patients with new-onset or history of AA to patients with normal sinus rhythm (NSR). Methods: We studied TTE findings in adult patients who were admitted to one tertiary care and five community hospitals in Michigan with PCR-proven SARS-CoV-2 infection from 3/1/2021 to 12/1/2020, and stratified them into three groups: Group 1 (NSR), group 2 (new-onset AA including atrial fibrillation and atrial flutter), and group 3 (history of AA). Results: Among 6927 (5522 in group 1, 626 in group 2, 779 in group 3) hospitalized patients (mean age 65.4 ± 17.1 years, 50.7 % females) 115 patients underwent TTE (Table). Group 2 and 3 patients were significantly older, more commonly males, Whites, smokers, and more frequently had diabetes mellitus, hypertension, heart failure, history of coronary artery disease, and cerebrovascular accident compared to group 1 (p≤0.05 for all). The most common TTE abnormalities were valvular abnormalities (40.9%), RV dilation (29.6% of patients), elevated PASP (16.5%), reduced LV ejection fraction (13.9%), pericardial effusion (9.6%), and LV dilation (6.1%) with no significant difference in the prevalence of these echocardiographic abnormalities between the 3 groups. Conclusions: TTE abnormalities are common in hospitalized COVID-19 patients with valvular abnormalities, RV dilation, and PASP elevation being the most common. Current or prior history of atrial arrhythmias did not increase the prevalence of echocardiographic abnormalities. Clinicians should have a low threshold to obtain echocardiogram in hospitalized COVID-19 patients if clinically indicated even in the absence of AA.
ABSTRACT
Introduction: Arterial and venous thromboembolism are common complications in COVID-19. Micro-macro thrombosis-related organ dysfunction can confer an increased risk for mortality. The optimal dosage of anticoagulation (AC) in COVID-19 patients remains unclear. Interim data from adaptive randomized control trials (ATTACC, REMAP-CAP, and ACTIV-4a) showed divergent results of therapeutic AC (TAC) versus usual care AC for the primary outcome of organ support free days in hospitalized COVID-19 patients. Components of CHA 2DS 2-VASc, a model originally built for predicting ischemic stroke in atrial fibrillation, are consistent with independent risk factors for COVID-19 severity and mortality. Herein, we analyzed the performance of the CHA 2DS 2-VASc model in hospitalized COVID-19 patients for predicting arterial and venous thromboembolic events, which could potentially aid in risk stratification of hospitalized patients and guide AC dosing. Methods: This is a large, retrospective, multicenter cohort study that included all adult patients from one tertiary care and five community hospitals with PCR-proven SARS-CoV-2 infection between 3/1/2020 and 12/1/2020. The primary composite outcome was acute arterial thromboembolism (ATE) and venous thromboembolism (VTE). We identified patients with ATE [cerebrovascular accident (CVA), myocardial infarction (MI) including both ST-segment elevation MI and non-ST-segment elevation MI], and VTE [deep vein thrombosis (DVT) and pulmonary embolism (PE)] using ICD -10 codes. Mean and standard deviation were reported for continuous variables;proportions were reported for categorical variables. To compare the groups, the Chi-square test was used for categorical variables, and the t-test was used for continuous variables. CHA 2DS 2-VASc scores were calculated on admission and were used as a measure of the predictive accuracy of the scoring system. Sensitivity and specificity with different cut-offs of CHA 2DS 2-VASc scores were calculated. All statistical tests were 2-sided with an α (significance) level of 0.05. All data were analyzed using R version 4.0.5. Results: Among 3526 patients, a total of 619 patients had thromboembolic events: 383 had ATE and 236 had VTE. Of 383 patients who had ATE, 350 patients were found to have acute MI, 48 had CVA, and 15 had both MI and CVA. In patients with VTE, 134 had DVT, 168 had PE, and 66 had both DVT and PE (Figure 1). We analyzed the primary composite outcome of ATE and VTE (group 1) vs no ATE and VTE (group 2). Baseline characteristics are included in Table 1. The in-patient all-cause mortality rate was 28.4% in group 1 vs 12.6% in group 2 (p<0.001). The mean hospital length of stay was 12.3 days in group 1 vs 8.8 days in group 2 (p<0.001). Group 1 had a mean CHA 2DS 2-VASc score of 3.3 ±1.6. vs 2.7±1.7 in group 2 (p<0.001) (Figure 2). At CHA 2DS 2-VASc scores of 3 and 4, the model had a specificity of 46% and 67% and sensitivity of 68% and 42% respectively for predicting ATE/VTE. The CHA 2DS 2-VASc score of 5 had a specificity of 86% and sensitivity of 25%. The score of 7 had 98% specificity but 3% sensitivity (Table 2). Conclusion: Our results suggest that the CHA 2DS 2-VASc model for arterial and venous thromboembolism has a moderate performance. The CHA 2DS 2-VASc score of 5 has a high specificity, though low sensitivity, for predicting thromboembolism. The CHA 2DS 2-VASc score can be used as an adjunct risk stratification tool to initiate TAC. [Formula presented] Disclosures: No relevant conflicts of interest to declare.
ABSTRACT
Background : Severe acute respiratory syndrome coronavirus -2 caused by the novel coronavirus 2019 (Covid-19) has resulted in a global pandemic. Covid-19 disease is associated with a hypercoagulable state, leading to microvascular and/or macrovascular thrombosis. The role of anticoagulation in Covid-19 is debatable. Aims : To compare outcomes of chronic anticoagulation and/or antiplatelets versus no chronic anticoagulation or antiplatelets in Covid-19 patients. Methods : This is a retrospective cohort study of hospitalized patients with polymerase chain reaction confirmed Covid-19 and over the age of 18 years who presented to the Trinity Health hospitals from March 8, 2020, to May 15, 2020. The exposed group was defined as patients who received chronic anticoagulation (warfarin, direct oral anticoagulant) or antiplatelet therapy or both(for more than one-month duration) for reasons other than Covid-19 disease while control group patients were defined as those who did not receive these therapies prior to admission. The primary outcome of the study is a composite outcome to compare mortality, length of hospital stay, readmission rate, rate of intubation, and length of Intensive-Care-Unit admission. Baseline characteristics and Covid-19 related treatment were compared in both groups (Table 1). The chi-square test and the student's t -test were used to compare the outcome in both groups. Statistical analysis was performed using SPSS version 25. Results : There were 3180 patients who were Covid-19 positive during the study period;452 patients met the inclusion criteria. There were 183 patients in the exposed group and 269 patients in the control group. In the exposed group there was a significantly higher three-months mortality rate (30.6% vs. 16%;P < 0.0005) compared to the control group. There were no significant associations between readmission rate, rate of intubation, length of hospital stay, and length of ICU stay by the group. Conclusions : Our results showed higher mortality in patients on chronic anticoagulation or antiplatelet therapy.