Impact of the "atherosclerotic pabulum" on in-hospital mortality for SARS-CoV-2 infection. Is calcium score able to identify at-risk patients?

BACKGROUND: Although the primary cause of death in COVID-19 infection is respiratory failure, there is evidence that cardiac manifestations may contribute to overall mortality and can even be the primary cause of death. More importantly, it is recognized that COVID-19 is associated with a high incidence of thrombotic complications. HYPOTHESIS: Evaluate if the coronary artery calcium (CAC) score was useful to predict in-hospital (in-H) mortality in patients with COVID-19. Secondary end-points were needed for mechanical ventilation and intensive care unit admission. METHODS: Two-hundred eighty-four patients (63, 25 years, 67% male) with proven severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who had a noncontrast chest computed tomography were analyzed for CAC score. Clinical and radiological data were retrieved. RESULTS: Patients with CAC had a higher inflammatory burden at admission (d-dimer, p = .002; C-reactive protein, p = .002; procalcitonin, p = .016) and a higher high-sensitive cardiac troponin I (HScTnI, p = <.001) at admission and at peak. While there was no association with presence of lung consolidation and ground-glass opacities, patients with CAC had higher incidence of bilateral infiltration (p = .043) and higher in-H mortality (p = .048). On the other side, peak HScTnI >200 ng/dl was a better determinant of all outcomes in both univariate (p = <.001) and multivariate analysis (p = <.001). CONCLUSION: The main finding of our research is that CAC was positively related to in-H mortality, but it did not completely identify all the population at risk of events in the setting of COVID-19 patients. This raises the possibility that other factors, including the presence of soft, unstable plaques, may have a role in adverse outcomes in SARS-CoV-2 infection.

Impact of ‘atherosclerotic pabulum’ on in hospital mortality for SARS-CoV-2 infection. Is calcium score alone enough to identify at risk patients?

Although the primary cause of death in COVID-19 infection is respiratory failure, there are evidences that cardiac manifestations may contribute to overall mortality and can even be the primary cause of death. More importantly, it is recognized that COVID-19 is associated with a high incidence of thrombotic complications. Two-hundred-eighty-four patients with proven SARS-CoV-2 infection who had a non-contrast Chest CT at our facility were analysed for coronary calcium score. Clinical and radiological data were retrieved. Patients with coronary calcium had higher inflammatory burden at admission (d-dimer, CRP, Procalcitonin) and higher Troponin at admission and at zenith. While there was no correlation with presence of consolidation and ground glass opacities, patients with coronary calcium had higher incidence of bilateral infiltration and higher in-hospital mortality. Peak troponin was associated with higher mortality, intensive care unit admission and mechanical ventilation in both univariable at multivariate analysis. Calcium score has demonstrated to be a good prognostic indicator for in-hospital mortality in patients with SARS-CoV-2 infection. Patients with higher atherosclerotic burden are at higher risk of fatality and complications. Our findings could have significant clinical implications in selecting at risk patients for allocation of resources especially in those with ‘atherosclerotic pabulum’, where inflammation activated by SARS-CoV-2 may play a role in fatal and non-fatal events.

Reduced muscle mass as predictor of intensive care unit hospitalization in COVID-19 patients.

PURPOSE: To evaluate if reduced muscle mass, assessed with Computed Tomography (CT), is a predictor of intensive care unit (ICU) hospitalization in COVID-19 patients. METHODS: In this Institution Review Board approved study, we retrospectively evaluated COVID-19 patients treated in our tertiary center from March to November 2020 who underwent an unenhanced chest CT scan within three weeks from hospitalization.We recorded the mean Hounsfield Unit (Hu) value of the right paravertebral muscle at the level of the 12th thoracic vertebra, the hospitalization unit (ICU and COVID-19 wards), clinical symptoms, Barthel Index, and laboratory findings.Logistic regression analysis was applied to assess if muscle loss (Hu<30) is a predictor of ICU admission and outcome.Fisher's exact and Student's tests were applied to evaluate if differences between patients with and without muscle loss occurred (p<0.05). RESULTS: One-hundred-fifty patients matched the inclusion criteria (46 females; mean age±SD 61.3±15 years-old), 36 treated in ICU. Patients in ICU showed significantly lower Hu values (29±24 vs 39.4±12, p = 0.001). Muscle loss was a predictor of ICU admission (p = 0.004).Patients with muscle loss were significantly older (73.4±10 vs 56.4±14 years), had lower Barthel Index scores (54.4±33 vs 85.1±26), red blood-cell count (3.9±1 vs 4.6±1×1012L-1), and Hb levels (11.5±2 vs 13.2±2g/l) as well as higher white blood-cell count (9.4±7 vs 7.2±4×109L-1), C-reactive protein (71.5±71 vs 44±48U/L), and lactate dehydrogenase levels (335±163 vs 265.8±116U/L) (p<0.05, each). CONCLUSIONS: Muscle loss seems to be a predictor of ICU hospitalization in COVID-19 patients and radiologists reporting chest CT at admission should note this finding in their reports.

Validation of a composed COVID-19 chest radiography score: the CARE project.

OBJECTIVES: The aim of this study was to validate a composed coronavirus disease 2019 (COVID-19) chest radiography score (CARE) based on the extension of ground-glass opacity (GG) and consolidations (Co), separately assessed, and to investigate its prognostic performance. METHODS: COVID-19-positive patients referring to our tertiary centre during the first month of the outbreak in our area and with a known outcome were retrospectively evaluated. Each lung was subdivided into three areas and a three-grade score assessing the extension of GG and Co was used. The CARE was derived from the sum of the subscores. A mixed-model ANOVA with post hoc Bonferroni correction was used to evaluate whether differences related to the referring unit (emergency room, COVID-19 wards and intensive care unit (ICU)) occurred. Logistic regression analyses were used to investigate the impact of CARE, patients' age and sex on the outcome. To evaluate the prognostic performance of CARE, receiver operating characteristic curves were computed for the entire stay and at admission only. RESULTS: A total of 1203 chest radiographs of 175 patients (120 males; mean age 67.81±15.5 years old) were examined. On average, each patient underwent 6.8±10.3 radiographs. Patients in ICU as well as deceased patients showed higher CARE scores (p<0.05, each). Age, Co and CARE significantly influenced the outcome (p<0.05 each). The CARE demonstrated good accuracy (area under the curve (AUC)=0.736) using longitudinal data as well as at admission only (AUC=0.740). A CARE score of 17.5 during hospitalisation showed 75% sensitivity and 69.9% specificity. CONCLUSIONS: The CARE was demonstrated to be a reliable tool to assess the severity of pulmonary involvement at chest radiography with a good prognostic performance.

Radiological management of COVID-19: structure your diagnostic path to guarantee a safe path.

The current COVID-19 outbreak is requiring a tremendous effort not only regarding the diagnostic and therapeutic approach but also in terms of global management of the delivered care. Hospital administrations had to provide a prompt response to a rapidly evolving emergency characterized by the necessity of giving access to an enormous number of infected patients, guaranteeing appropriate care to patients in need of other types of treatment, and simultaneously preserving the well-being of healthcare providers. To optimize the diagnostic pathway during the current COVID-19 outbreak, the hospital administration of our tertiary center applied a highly structured framework assigning specific tasks to the different units composing the Department of Imaging. In particular, since the beginning of the pandemic, a mobile CT scanner in a truck was rented and became operative for all patients with a confirmed diagnosis of COVID-19 and another CT was assigned for all suspected cases. The success and efficacy of the management applied by our administration is demonstrated by the fact that during the outbreak, the radiological workflow was never interrupted. In fact, despite the national lockdown only a 29.3% decrease of CT scans occurred compared to the previous year. Moreover, none of the healthcare providers of the Department contracted the infection at work. Thus, according to the experience gained in our center, we recommend to all hospital administrations facing the COVID-19 outbreak to promptly adapt their resources, creating precise and safe pathways for their diagnostic units.

It's not over until it's over: the chameleonic behavior of COVID-19 over a six-day period.

The current global outbreak of COVID-19 represents a major challenge in terms of epidemiology, contagiousness, treatment, as well as clinical and radiological behavior of this disease. Radiological imaging plays a key role in the diagnostic process and during the monitoring of the clinical conditions especially of patients with severe symptoms. According to the preliminary data collected in our tertiary center, we have documented a peculiar behavior in patients requiring endotracheal intubation who underwent seriate chest X-rays. In fact, the radiological pattern of COVID-19 patients may worsen despite a prompt amelioration after the onset of mechanical ventilation. Thus, according to our initial evidence, we recommend to perform seriate chest X-rays in the days following the onset of mechanical ventilation even if the immediate monitoring suggests an improvement. Studies on a larger scale are necessary to fully assess the findings at chest radiographs of critical, mechanically ventilated patients and their correlation with the long-term outcome.