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 Patients hospitalized with COVID-19 have an increased incidence of venous thromboembolism (VTE) and arterial thromboembolism (ATE) events. These thrombotic events increase readmission and mortality rate in COVID-19 survivors who are recently discharged from hospital. To lower the risk of VTE, a short course of post-discharge anticoagulation at either prophylactic or therapeutic dose has been variably prescribed among different facilities to COVID-19 patients. This practice, however, is challenged by less than 3% incidence of VTE in unselected patients. The net clinical benefit of extended thromboprophylaxis beyond hospitalization remains unclear. Methods We conducted a retrospective multicenter observational study of 5613 hospitalized COVID-19 patients. After applying the inclusion and exclusion criteria, 2838 patients were included in statistical analysis. Patients were excluded if they had negative SARS-CoV-2 PCR, remained hospitalized at the time of analysis, or were discharged to hospice service. The first symptomatic ATE and VTE events up to 90 days after patients' discharge from their index admission for COVID-19 were identified using ICD-10 codes, and subsequently validated by chart review. The predictors for post-discharge VTE were identified using multivariate logistic regression. The average protective effect of anticoagulation was assessed using inverse propensity score weighting. Results The mean age (SD) of our cohort was 63.4 (16.7) years old and 47.6% were male. Black, white and other races were 38.9%, 50.7% and 10.3%, respectively. Thirty-six (1.3%) patients developed post-discharge VTE events that require hospital visits (18 deep vein thromboses, 16 pulmonary embolisms and 2 portal vein thromboses). Fifteen (0.5%) patients developed post-discharge ATE events (14 acute coronary syndromes and 1 transient ischemic attack). The incidence of VTE decreased with time (p <.001) with the median event time of 16 days (Figure 1). The incidence of ATE was unchanged with time (p =.369) with the median event time of 37 days (Figure 1). Patients who had a history of VTE (OR=3.24, 95% CI 1.34-7.86), peak D-dimer >3 µg/mL (OR=3.76, 95% CI 1.86-7.57), and predischarge C-reactive protein >10 mg/dL (OR=3.02, 95% CI 1.45-6.29) were at a high risk of developing VTE after hospital discharge (Figure 2). A short course of prophylactic or therapeutic anticoagulation after hospital discharge markedly reduced VTE (OR=0, 95% CI 0-0, p<.001, and OR=0.176, 95% CI 0.04-0.75, p=.02, respectively). Conclusions Although extended thromboprophylaxis in unselected COVID-19 patients is not recommended, post-discharge anticoagulation may be considered in high-risk patients who have a history of VTE, peak D-dimer >3 µg/mL and predischarge C-reactive protein >10 mg/dL if their bleeding risk is low. Our study has provided the first evidence to guide the selection of hospitalized COVID-19 patients who may benefit from post-discharge anticoagulation. [Formula presented] Disclosures: Kaatz: Gilead: Consultancy;Novartis: Consultancy;CSL Behring: Consultancy;Bristol Myer Squibb: Consultancy, Research Funding;Alexion: Consultancy;Pfizer: Consultancy;Janssen: Consultancy, Research Funding;Osmosis Research: Research Funding.
ABSTRACT
Background : Coronavirus disease 2019 (COVID-19) is associated with a high incidence of thrombotic events during hospitalization, however, the need for postdischarge thromboprophylaxis remains unclear. Aims : To quantify the 90-day post hospital discharge rates of venous and arterial thromboembolism in COVID-19. Methods : A retrospective single institution observational study of adult patients hospitalized with COVID-19 confirmed by positive SARS-CoV-2 testing from 3/1/2020 to 8/31/2020. Patients were excluded if they: remained hospitalized at time of analysis, died during hospitalization or were discharged to hospice. For patients with multiple admissions related to COVID-19, the first admission was included. Thromboembolism was identified with ICD-10 codes up to 90 days of discharge: pulmonary embolism (PE: I26), deep vein thrombosis (DVT: I82), portal vein thrombosis (I81), intracranial venous thrombosis (I67),transient ischemia attack (TIA: G45), stroke (I63), acute coronary syndrome (ACS: I20, I21, I22, I24), intracardiac thrombosis (I23, I51.3), and acute limb ischemia (I74). Results : Of 1653 hospitalized patients, 26 (1.6%) developed post discharge venous thrombosis events (12 PE, 13 DVT and 1 portal vein thrombosis). Eleven (0.7%) post discharge arterial thrombosis events were observed(1 TIA and 10 ACS). The risk of VTE decreases with time (Mann-Kendall trend test P -value < 0.001) with median event time 15.5 days (IQR: 6-27). The risk of arterial thrombosis is constant with time (Mann-Kendall trend test P -value = 0.86) with median event time 54 days (IQR: 24-65). Conclusions : The rate thromboembolism is relatively low among COVID-19 patients after they leave the hospital. Results of ongoing randomized trials of the efficacy of post-discharge anticoagulation prophylaxis are eagerly awaited.
ABSTRACT
Background: Coronavirus 2019 (COVID19) has impacted acute stroke (AS) care with several reports globally showing drops in AS volumes during the pandemic. We studied the impact of COVID19 on AS and transient ischemic attack (TIA) care in a health system serving Southeast Michigan as we rolled out a policy aimed at limiting admissions and transfers. Methods: In this retrospective study conducted at 2 hospitals, we included consecutive patients presenting to the emergency department (ED) for whom a Stroke Alert (SA) was activated during the period 3/20 to 5/20/20 (COVID) and a similar period in 2019 (pre-COVID). We compared demographics, time metrics, and discharge outcomes. Results: 264 patients were seen pre-COVID compared to 121 during COVID (p<0.001). Patients seen during COVID had an equal proportion of males (55% vs 51%, p=0.444), were majority African American (57 vs 58%, p=0.74), but had a higher presenting NIHSS (median: 5 vs 2, p=0.01) and longer times since last-known-well to ED arrival (median: 9.4 vs 4.8 hours, p=0.03) compared to pre-COVID. Fewer patients were transferred from other centers (42 vs 27% p=0.008). SA activation on arrival (median: 9.6 vs 15 min, p=0.004) and imaging initiation from arrival (median: 26.4 vs 34.8 min, p=0.042) were faster as well as a trend toward statistical significance for time to tPA administration (median: 37.8 vs 51 min, p=0.051) compared to pre-COVID. There were higher rates of AS and TIA (69% vs 55%) and lower rates of stroke mimics (17 vs 37%, p<0.001). Patients discharged from the stroke unit had significantly higher discharge NIHSS (median: 3 vs 2, p=0.002) and were more likely to have an unfavorable discharge mRS (3-6) (56 vs 33%, p=0.004). There were no significant differences in medical, social histories, time to first pass for patient undergoing thrombectomy and stroke etiologies between the groups. In 2020, 9 patients (8%) were COVID19 positive, 2 had unfavorable mRS 3-5 while 3 died. Conclusion: There was greater than 50% reduction in stroke admissions during the COVID19 pandemic which is consistent with other reports. Although patients were managed more quickly, they tended to have more severe strokes, fewer stroke mimic diagnoses, and worse outcomes compared to patients treated in the pre-COVID period.
ABSTRACT
Background: We propose that social distancing policies during COVID-19 may have negatively impacted the timely administration of intravenous tPA and mechanical thrombectomy (MT) in acute ischemic strokes (AIS). Methods: In this retrospective study conducted at 2 large stroke centers serving Southeast Michigan, we included consecutive patients admitted to our stroke unit from 3/20/20 to 5/20/20 (COVID) and a similar epoch in 2019 (pre-COVID). We compared demographics and time metrics. Results: 247 patients with AIS were included in the tPA analysis, 167 (68%) in 2019 vs 80 (32%) in 2020. Overall mean age was 67.2, 60% male and 49% African Americans (AA). tPA was given in 13/80 in 2019 vs 17/167 patients in 2019 (16% vs 10%, p=0.143). There was no difference in tPA rates between AA and non-AA in 2020. There was a trend toward faster tPA administration in 2020 vs 2019 (median: 37.8 vs 51 min, p=0.051), significant among AA (37.8 vs 58.8 min, p=0.029). Mild/rapidly improving strokes was less frequently a tPA exclusion in 2020 vs 2019 (0% vs 10%). Delayed presentation was significantly less frequent among non-AA in 2020 vs 2019 (54% vs 66%, p=0.045) but there was a trend toward more frequent delayed presentations in AA vs non-AA in 2020 (76 vs 54%, P=0.073). 69 patients were eligible to receive MT, 42 (61%) in 2019 and 27 (39%) in 2020. Mean age was 67.9 and 36% were AA. No differences were detected between 2019 and 2020 in MT rates or time metrics. In 2020, there was a slight trend toward lower MT rates for AA vs non-AA patients (69% vs 30%, p=0.10). Conclusion: During the COVID-19 pandemic in Detroit there was a trend toward faster tPA administration compared to the same period pre-COVID, especially among AA. There was no significant difference in MT rates or time metrics. In our AA-majority city, there was a trend towards more delayed presentations and lower MT rates among AA during COVID. The reasons for these differences are yet to be determined and warrant further research.