Clinical Outcomes of Outpatients With Suspected Covid-19 Treated With Chloroquine Compounds in Brazil: A Nationwide Telemedicine Study

Introduction: Following the inception of the COVID-19 pandemic, chloroquine compounds were proposed as potential therapeutic strategies, at the cost of a potential increase in cardiovascular risk. We aimed to evaluate clinical outcomes of patients with COVID-19, comparing those using chloroquine compounds to individuals without specific treatment. Method(s): Outpatients with suspected COVID-19 in Brazil who had at least 1 ECG transmitted to a Telehealth Network, were prospectively enrolled in 2 arms (G1: treatment with chloroquine compounds and G2: without specific treatment) and G3: registry of other specific treatments. Outcomes were assessed through follow-up phone calls on days 3 and 14, and also administratively collected from national mortality and hospitalization databases. The primary outcome was composed of: hospitalization and all-cause death. The association between treatment groups and the primary outcome was evaluated by logistic regression. Significant variables (p<0.10) were included in 4 multivariate models: 1: unadjusted;2: adjusted for age and sex;3: adjusted for model 2 plus cardiovascular risk factors and 4: adjusted for model 3 plus COVID-19 symptoms (when available from phone contact). Result(s): In 303 days, 712 (10.2%) patients were allocated in G1 (chloroquine), 3623 (52.1%) in G2 (control) and 2622 (37.7%) in G3 (other treatments). Median age was 49 (IQR 38 - 62) years, 57% women. Of these, 1969 had successful phone contacts (G1: 260;G2: 871;G3: 838). The primary outcome was more frequent in groups 1 and 3 compared to the control group, when assessed exclusively by phone (G1: 38,5% vs. G2: 18,0% vs. G3: 34,2%, p<0,001) or combined with administrative data (G1: 19,5% vs. G2: 11,0% vs. G3: 18,2%, p<0,001). In the adjusted models, chloroquine independently associated with a greater chance of the primary outcome: phone contact (model 4): OR=3.24 (95% CI 2.31 - 4.54), p<0.001;phone + administrative data (model 3): OR=1.99 (95% CI 1.61 - 2.44), p<0.001. Chloroquine also independently associated with higher mortality, as assessed by phone + administrative data (model 3): OR=1.67 (95% CI 1.20 - 2.28). Conclusion(s): Chloroquine compounds associated with a higher risk of poor outcomes in outpatients with COVID-19 compared to standard care.

REDUCTION IN HOSPITAL ADMISSIONS ASSOCIATED WITH CORONARY EVENTS DURING THE COVID-19 PANDEMIC IN THE BRAZILIAN PRIVATE HEALTH

Background The COVID-19 pandemic significantly impacted the Brazilian healthcare system, resulting in deferral of elective cardiac procedures and avoidance of medical care due to social distancing. We aimed to evaluate the impact of COVID-19 on hospital admissions and death rates associated with coronary events in a Brazilian large-scale private health system. Methods From March 18 - Sep 30, 2020 we evaluated the administrative database of UNIMED-BH, a cooperative Brazilian private insurance, with over 1.25 million clients from a large urban center. We collected data from admissions in all owned and accredited hospitals related to urgent and elective coronary events (acute coronary syndromes, coronary interventions, clinical management of coronary artery disease and invasive diagnostic procedures). Admissions in 2020 were compared to the 2-year historical series (2018, 2019), and rates/100,000 were calculated considering the mean covered population. Outcomes were assessed until October 15th, 15 days after the last enrollment. Results In the 196-day period, the number of coronary admissions in 2018, 2019 and 2020 were, respectively, 2,789, 3,519 and 2,348, and patients had a median age of 67 [58-76] years, being 59% men. The mean length of hospital stay was 6.7±9.3 days, and 27% had >1 admission in 3 years. The adjusted rates of admissions were 221, 278 and 184/100,000 clients, resulting in a significant 26% (95% CI 22 - 30) reduction in 2020 compared to the historical series (p<0.001). The reduction was more pronounced from March to May (36%) - when social isolation started - compared to the peak of the pandemic (June to September, 19%). In-hospital mortality was also significantly higher in 2020 (5.4%, 95% CI 4.5 - 6.4) compared to 2018/2019 (3.6%, 95% CI 3.2 - 4.1), p<0.001, despite the similar age (67 [57-76) vs. 67 [58-76], p=0.15) and length of hospital stay (6.9±8.9 vs. 6.7±9.5 days, p=0.43). Conclusion There was a significant decrease in admissions due to coronary events during the COVID-19 pandemic in Brazil, in parallel with increased in-hospital mortality. Deferral of elective procedures and avoidance of medical care possibly resulted in delayed presentation and unfavorable outcomes.

Reduction in Hospital Admissions Associated with Coronary Events during the COVID-19 Pandemic in the Brazilian Private Health System: Data from the UNIMED-BH System

INTRODUCTION: We aimed to evaluate the impact of the new coronavirus disease 2019 on coronary hospitalizations in the Brazilian private health system. METHODS: Data on coronary admissions in 2020 and a 2-year historical series were collected from the UNIMED-BH insurance system. RESULTS: Admission rates in 2020 reduced by 26% (95%CI, 22-30) in comparison with 2018/2019, markedly from March to May (37%) compared to the peak of the pandemic (June-September, 19%). Mortality was higher in 2020 (5.4%, 95%CI 4.5-6.4) than in 2018/2019 (3.6%, 95%CI 3.2-4.1). CONCLUSIONS: There was a significant decrease in coronary admissions, with higher mortality during the COVID-19 pandemic.

Bedside echocardiography to predict mortality of COVID-19 patients beyond clinical data: Data from the PROVAR-COVID study

INTRODUCTION: Cardiac involvement seems to impact prognosis of COVID-19, being more frequent in critically ill patients. We aimed to assess the prognostic value of right ventricular (RV) and left ventricular (LV) dysfunction, evaluated by bedside echocardiography (echo), in patients hospitalized with COVID-19. METHODS: Patients admitted in 2 reference hospitals in Brazil from Jul to Sept/2020 with confirmed COVID-19 and moderate/severe presentations underwent clinical and laboratory evaluation, and focused bedside echo (GE Vivid-IQ), at the earliest convenience, with remote interpretation. The association between demographics, clinical comorbidities and echo variables with all-cause hospital mortality was assessed, and factors significant at p<0.10 were put into multivariable models. RESULTS: Total 163 patients were enrolled, 59% were men, mean age 64+/-16 years, and 107 (66%) were admitted to intensive care. Comorbidities were present in 144 (88%) patients: hypertension 115 (71%), diabetes 61 (37%) and heart failure 22 (14%). In-hospital mortality was 34% (N=56). In univariate analysis, echo variables significantly associated with death were: LV ejection fraction (LVEF, OR=0.94), RV fractional area change (OR=0.96), tricuspid annular plane systolic excursion (TAPSE, OR=0.83) and RV dysfunction (OR=5.3). In multivariate analysis, after adjustment for clinical and demographic variables, independent predictors of mortality were age>=63 years (OR=5.53, 95%CI 1.52-20.17), LVEF<64% (OR=7.37, 95%CI 2.10-25.94) and TAPSE<18.5 mm (OR=9.43, 95% CI 2.57-35.03), and the final model had good discrimination, with C-statistic=0.83 (95%CI 0.75-0.91). CONCLUSION: Markers of RV and LV dysfunction assessed by bedside echo are independent predictors of mortality in hospitalized COVID-19 patients, after adjustment for clinical variables.