The relationship between coronary artery disease and clinical outcomes in COVID-19: a single-center retrospective analysis.

INTRODUCTION: Recent studies have reported evidence that coronavirus disease 2019 (COVID-19) has disproportionately affected patients with underlying comorbidities. Our study aims to evaluate the impact of both cardiac and noncardiac comorbidities on a high-risk population with COVID-19 infection and coronary artery disease (CAD) compared to those without CAD. METHODS: This is a retrospective study of patients who tested COVID-19 positive via reverse transcriptase-PCR (RT-PCR) assay. We compared the characteristics and outcomes of patients with and without CAD. Population demographics, comorbidities and clinical outcomes were collected and analyzed. Multivariate logistic regression analysis was used to identify factors associated with inpatient mortality. RESULTS: A final sample population of 355 patients was identified, 77 of which had a known diagnosis of coronary artery disease. Our study population had a higher proportion of females, and those with CAD were significantly older. The rates of cardiovascular risk factors including hypertension, diabetes mellitus and chronic kidney disease, as well as heart failure and chronic obstructive pulmonary disease were significantly higher in the CAD population. Lactate dehydrogenase was the only inflammatory marker significantly lower in the CAD group, while troponin and brain natriuretic peptide were significantly higher in this population. Patients with CAD also had significantly higher inpatient mortality (31% vs 20%, P = 0.046) and need for renal replacement therapy (33% vs 11%, P < 0.0001) compared to the non-CAD group. However, only age [odds ratio 1.041 (1.017-1.066), P = 0.001] was significantly associated with mortality in the overall population after adjusting for demographics and comorbidities, while the presence of CAD was not independently associated with mortality. CONCLUSION: Patients with CAD and COVID-19 have higher rates of comorbidities, inpatient mortality and need for renal replacement therapy compared to their non-CAD counterparts. However, CAD in itself was not associated with mortality after adjusting for other covariates, suggesting that other factors may play a larger role in the increased mortality and poor outcomes in these patients.

Factors associated with hospital readmissions among patients with COVID-19: A single-center experience.

Identify factors associated with readmission after an index hospital admission for coronavirus disease 2019 (COVID-19) infection in a single center serving an underserved and predominantly minority population. This retrospective descriptive study included 275 patients who tested COVID-19 positive via reverse transcriptase-polymerase chain reaction assay at our institution and who survived the index hospitalization. The main outcomes were 1- and 6-month readmission rates after an index hospitalization for COVID-19. The mortality rate among the readmitted patients was also determined. Factors independently associated with readmission were investigated using multivariable logistic regression. A final sample of 275 patients was included. The mean age was 64.69 ± 14.64 (SD), 133 (48%) were female and 194 (70%) were African American. Their chronic medical conditions included hypertension 203 (74%) and diabetes mellitus 121 (44%). After the hospitalization, 1-month readmission rate was 7.6%, while 6-month readmission rate was 24%. Nine percent of patients who were readmitted subsequently died. Coronary artery disease (CAD) was significantly associated with 6-month readmission odds ratio (OR), 2.15 (95% confidence interval [CI]: 1.04-4.44; p = 0.039) after adjustment for age, gender, ethnicity, and comorbidities. Readmissions were due to cardiac, respiratory, and musculoskeletal symptoms. Hispanic ethnicity was associated with increased readmission OR, 3.16 (95% CI: 1.01-9.88; p = 0.048). No significant difference was found between inflammatory markers or clinical outcomes during the index hospitalization among patients who were readmitted compared to those who were not. A significant number of patients hospitalized for COVID-19 may be readmitted. The presence of CAD is independently associated with high rates of 6-month readmission.

Characteristics and clinical outcomes of COVID-19 patients in an underserved-inner city population: A single tertiary center cohort.

There is limited information describing the characteristics and clinical outcomes of patients infected with coronavirus disease 2019 (COVID-19) especially those in underserved urban area with minority population in the United States. This is a retrospective single-center study for patients who were admitted with COVID-19 infection. Data collection was from 1 March through 24 April 2020. Demographic, clinical, laboratory, and treatment data were presented using descriptive statistics and frequencies. The χ2 test and multivariate logistic regression were used to determine association of risk factors and clinical outcomes. A total of 242 inpatients were included with a mean age of 66 ± 14.75 (±standard deviation). A total of 50% were female and 70% were African American. Comorbidities included hypertension (74%), diabetes mellitus (49%), and 19% had either COPD or asthma. Older age was associated with higher risk of inpatient death odds ratio (OR): 1.056 (95% confidence interval [CI]: 1.023-1.090; P = .001). Inpatient mortality occurred in 70% who needed mechanical ventilation (OR: 29.51; 95% CI: 13.28-65.60; P < .0001), 58% who required continuous renal replacement therapy/hemodialysis (CRRT/HD) (OR: 6.63; 95% CI: 2.74-16.05; P < .0001), and 69% who needed vasopressors (OR: 30.64; 95% CI: 13.56-69.20; P < .0001). Amongst biomarkers of disease severity, only baseline CRP levels (145 ± 116 mg/L) were associated with mortality OR: 1.008 (95% CI: 1.003-1.012; P = .002). Majority of hospitalized patients had hypertension and diabetes. Older age was an independent risk factor for inpatient mortality. Requirement of mechanical ventilation, vasopressor use, and CRRT/HD was associated significantly with inpatient mortality. Higher baseline CRP was significantly associated with inpatient death.

Bacterial infections and patterns of antibiotic use in patients with COVID-19.

Bacterial coinfection is associated with poor outcomes in patients with viral pneumonia, but data on its role in the mortality of patients with coronavirus disease 2019 (COVID-19) is limited. This is a single-center retrospective analysis of 242 patients with confirmed COVID-19 admitted to both intensive care and non-intensive care settings. Bacterial coinfection was determined by the presence of characteristic clinical features and positive culture results. Multivariable logistic regression was used to analyze the association of concomitant bacterial infection with inpatient death after adjusting for demographic factors and comorbidities. Antibiotic use pattern was also determined. Bacterial coinfection was detected in 46 (19%) patients. Genitourinary source was the most frequent, representing 57% of all coinfections. The overall mortality rate was 21%. Concomitant bacterial infections were independently associated with increased inpatient mortality (OR, 5.838; 95% CI, 2.647-12.876). Patients with bacterial coinfection were relatively older (71.35 ± 11.20 vs 64.78 ± 15.23; P = .006). A total of 67% of patients received antibiotic therapy, yet 72% did not have an obvious source of bacterial infection. There was a significantly higher rate of inpatient mortality in patients who received antibiotics compared to those who did not (30% vs 5%; P < .0001). Bacterial coinfection in COVID-19 is associated with increased mortality.

Predictors of venous thromboembolism in patients with COVID-19 in an underserved urban population: A single tertiary center experience.

INTRODUCTION: Venous thromboembolism (VTE) is reported in up to 27% of patients with COVID-19 due to SARS-CoV-2 infection. Dysregulated systemic inflammation and various patient traits are presumed to underlie this anomaly. Optimal VTE prophylaxis in COVID-19 patients has not been established due to a lack of validated models for predicting VTE in this population. Our study aims to address this deficiency by identifying demographic and clinical characteristics of COVID-19 patients associated with increased VTE risk. METHODS: This study is a retrospective analysis of all adult patients (final sample, n = 355) hospitalized with confirmed COVID-19 at Einstein Medical Center Philadelphia between March 1 and April 24, 2020. Demographic and clinical patient data were collected and factors associated with VTE were identified and analyzed using t-tests, multivariable logistic regression, and receiver operating characteristic (ROC) curves. RESULTS: Thirty patients (8.5%) developed VTE. Patients with VTE had significantly higher D-dimer levels on admission (P = 0.045) and peak D-dimer levels (P < 0.0001), in addition to higher rates of vasopressor requirements (P = 0.038), intubation (P = 0.003), and death (P = 0.023). Age (OR 1.042), obstructive sleep apnea (OR 5.107), and need for intubation (OR 3.796) were associated with significantly increased odds of VTE. Peak D-dimer level was a good predictor of VTE (AUC 0.806, P < 0.0001) and a D-dimer cutoff of >6640 ng/mL had high (>70%) sensitivity and specificity for VTE. CONCLUSION: Peak D-dimer level may be the most reliable clinical marker in COVID-19 patients for predicting VTE and future prospective studies should attempt to further validate this.

Association of Pre-Admission Statin Use With Reduced In-Hospital Mortality in COVID-19.

BACKGROUND: Coronavirus disease-19 (COVID-19) infection is associated with an uncontrolled systemic inflammatory response. Statins, given their anti-inflammatory properties, may reduce the associated morbidity and mortality. This study aimed to determine the association between statin use prior to hospitalization and in-hospital mortality in COVID-19 patients. METHODS: In this retrospective study, clinical data were collected from the electronic medical records of patients admitted to the hospital with confirmed COVID-19 infection from March 1, 2020 to April 24, 2020. A multivariate regression analysis was performed to study the association of pre-admission statin use with in-hospital mortality. RESULTS: Of 255 patients, 116 (45.5%) patients were on statins prior to admission and 139 (54.5%) were not. The statin group had a higher proportion of end stage renal disease (ESRD) (13.8% vs. 2.9%, p = 0.001), diabetes mellitus (63.8% vs. 35.2%, p<0.001), hypertension (87.9% vs. 61.1%, p < 0.001) and coronary artery disease (CAD) (33.6% vs. 5%, p < 0.001). On multivariate analysis, we found a statistically significant decrease in the odds of in-hospital mortality in patients on statins before admission (OR 0.14, 95% CI 0.03- 0.61, p = 0.008). In the subgroup analysis, statins were associated with a decrease in mortality in those with CAD (OR 0.02, 95% CI 0.0003-0.92 p = 0.045) and those without CAD (OR 0.05, 95% CI 0.005-0.43, p = 0.007). CONCLUSIONS: Our study suggests that statins are associated with reduced in-hospital mortality among patients with COVID-19, regardless of CAD status. More comprehensive epidemiological and molecular studies are needed to establish the role of statins in COVID-19.

Prevailing patterns of liver enzymes in patients with COVID-19 infection and association with clinical outcomes.

BACKGROUND: COVID-19 is now a critical threat to global public health. Although the majority of patients present with respiratory illness, several studies have described multiorgan involvement. This study evaluated the prevailing patterns of liver enzymes in COVID-19 patients on admission and their association with clinical outcomes. METHODS: This was a single-center retrospective analysis of all inpatients with COVID-19. Demographic and clinical factors, and liver enzyme tests, including aspartate aminotransferase (AST) and alanine aminotransferase (ALT), were noted on admission. The association of liver enzyme elevation with outcomes such as inpatient death, need for intubation, and vasopressor use was determined using the chi-square test and multivariate regression analysis. RESULTS: Among 200 patients, AST and ALT elevation was seen in 55% and 20%, respectively. Alkaline phosphatase elevation was seen in 28%. AST elevation was associated with inpatient death (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05; P=0.035), need for vasopressors (OR 1.034, 95%CI 1.015-1.055; P=0.001), and intubation (OR 1.03, 95%CI 1.01-1.05; P=0.002). An AST/ALT ratio of 2 or more was seen in 34% of patients and was associated with need for intubation (OR 2.678, 95%CI 1.202-5.963; P=0.016), and need for vasopressors (OR 3.352, 95%CI 1.495-7.514; P=0.003). CONCLUSION: Serum aminotransferase levels are useful markers of hepatocellular injury. Patients with elevated AST or AST/ALT ratio are at higher risk of severe disease, as evidenced by intubation, vasopressor use, and inpatient death. These patients should be monitored closely given their propensity for severe disease.

Severe COVID-19 in Third Trimester Pregnancy: Multidisciplinary Approach.

The rapidly expanding cases of the coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have exposed vulnerable populations, including pregnant women to an unprecedented public health crisis. Recent data show that pregnancy in COVID-19 patients is associated with increased hospitalization, admission of the intensive care unit, and intubation. However, very few resources exist to guide the multidisciplinary team in managing critically ill pregnant women with COVID-19. We report our experience with managing a morbidly obese pregnant woman at 36 weeks' gestation with history of asthma and malignancy who presented with persistent respiratory symptoms at an outside hospital after being tested positive for SARS-CoV-2 polymerase chain reaction (PCR). Early in the course of the hospitalization, patient received remdesivir, convalescent plasma, bronchodilator, systemic steroids, and IV heparin for COVID-19 and concomitant asthma exacerbation and pulmonary embolism. Due to increasing oxygen requirements, she was eventually intubated and transferred to our institution for higher level of care. Respiratory acidosis, severe hypoxemia, and vent asynchrony were managed with vent setting adjustment and paralytics. After 12 hours from spontaneous rupture of her membranes and with stabilization of maternal status, patient underwent a term cesarean delivery for nonreassuring fetal heart tracing. The neonate was discharged on the 2nd day of life, while the patient was extubated on the 6th postpartum day and was discharged to acute inpatient rehabilitation facility on the 19th hospital day. This report highlights the disease progression of COVID-19 in a pregnant woman, the clinical challenges in the critical care aspect of patient management, and the proposed multidisciplinary strategies utilizing an algorithmic approach to optimize maternal and neonatal outcomes.

Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers and outcomes in patients with COVID-19: a systematic review and meta-analysis.

BACKGROUND: The use of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) in patients with coronavirus disease 2019 (COVID-19) given their interaction with the angiotensin-converting enzyme-2 (ACE-2) receptor remains controversial. . OBJECTIVE: To investigate the impact of ACEI/ARB on COVID-19 disease severity and mortality through a systematic review and meta-analysis. METHODS: We searched PubMed and CINAHL databases as well as pre-print servers for studies investigating usage of ACEIs/ARBs in patients with COVID-19 compared to a control group of COVID-19 patients without ACEI/ARB use. COVID-19 related severity of disease, and death were identified as end points. Pooled odds ratios (OR) and their 95% confidence intervals (CI) were calculated using random-effects model. RESULTS: 21 studies were included in the meta-analysis. For mortality with ACEI/ARB use, the pooled odds ratio was 1.29 [0.89-1.87] p = 0.18 with heterogeneity of 91%, while the pooled OR for COVID-19 severity was 0.94 [0.59-1.50] p = 0.81 with heterogeneity of 89% (Figure 2). In combining both mortality and severe disease outcomes, the pooled odds ratio was 1.09 [0.80-1.48] p = 0.58 but with heterogeneity of 92%. EXPERT OPINION: Even on pooled analysis of both un-adjusted data, adjusted data(studies with matched controls) and taking into account factors such as risk of bias of studies via meta regression and sensitivity analyses, the results hold true that ACEI/ARB use is not associated with COVID-19 disease severity or mortality. To look for any potential beneficial effects, randomized controlled trials are needed. CONCLUSION: use of ACEI/ARB was not associated with increased mortality or severe COVID-19.

Anticoagulation and bleeding risk in patients with COVID-19.

BACKGROUND: There is no current standardized approach to anticoagulation in patients with Coronavirus Disease 2019 (COVID-19) while potential bleeding risks remain. Our study characterizes the patterns of anticoagulation use in COVID-19 patients and the risk of related bleeding. METHODS: This is a single center retrospective analysis of 355 adult patients with confirmed diagnosis of COVID-19 from March 1 to May 31, 2020. Chi-square was used to analyze the relationship between degree of anticoagulant dose and bleeding events by site. Multivariable logistic regression was used to look at factors associated with inpatient death. RESULTS: 61% of patients were being treated with prophylactic doses of anticoagulation, while 7% and 29% were being treated with sub-therapeutic and therapeutic anticoagulation (TA) doses respectively. In 44% of patients, we found that the decision to escalate the dose of anticoagulation was based on laboratory values characterizing the severity of COVID-19 such as rising D-dimer levels. There were significantly higher rates of bleeding from non-CNS/non-GI sites (p = 0.039) and from any bleeding site overall (p = 0.019) with TA. TA was associated with significantly higher rates of inpatient death (41.6% vs 15.3% p < 0.0001) compared to those without. All patients who developed CNS hemorrhage died p = 0.011. After multivariable logistic regression, only age OR 1.04 95% CI (1.01 to 1.07) p = 0.008 and therapeutic anticoagulation was associated with inpatient mortality OR 6.16 95% CI (2.96 to 12.83) p ≤ 0.0001. CONCLUSION: The use of TA was significantly associated with increased risk of bleeding. Bleeding in turn exhibited trends towards higher inpatient death among patients with COVID-19. These findings should be interpreted with caution and larger more controlled studies are needed to verify the net effects of anticoagulation in patients with COVID-19.

Characteristics of peripheral blood differential counts in hospitalized patients with COVID-19.

BACKGROUND: A lot remains unknown about the features and laboratory findings that may predict worse outcomes in patients with coronavirus disease 2019 (COVID-19). The aim of this study was to evaluate the difference in complete blood count parameters and differential counts in patients hospitalized with COVID-19 who survived compared to those who died. DESIGN: We performed a single-center retrospective study including 242 patients with confirmed COVID-19. We described the characteristics of the complete blood count parameters in these patients. Mann-Whitney U test was used to compare hematologic parameters of patients who died and those who survived; multivariate logistic regression was used to look for associations with mortality. RESULTS: Patients with COVID-19 who died had significantly lower median absolute monocyte count (AMC) (0.4 vs 0.5, P = .039) and median platelet count (169 vs 213, P = .009) compared to those who survived. Patients who died had a significantly higher neutrophil-to-lymphocyte ratio (6.4 vs 4.5, P = .001). The NLR was positively associated with death (OR = 1.038; 95% CI, 1.003-1.074, P = .031), while AMC was inversely associated with death (OR = 0.200; 95% CI, 0.052-0.761, P = .018). CONCLUSION: Among patients with COVID-19, a lower AMC and higher NLR are associated with higher mortality.

The relationship between diabetes and clinical outcomes in COVID-19: a single-center retrospective analysis.

AIMS: Coronavirus disease 19 (COVID-19) has become a pandemic. Diabetic patients tend to have poorer outcomes and more severe disease (Kumar et al. in Diabetes Metab Syndr 14(4):535-545, 2020. https://doi.org/10.1016/j.dsx.2020.04.044 ). However, the vast majority of studies are representative of Asian and Caucasian population and fewer represent an African-American population. METHODS: In this single-center, retrospective observational study, we included all adult patients (> 18 years old) admitted to Einstein Medical Center, Philadelphia, with a diagnosis of COVID-19. Patients were classified according to having a known diagnosis of diabetes mellitus. Demographic and clinical data, comorbidities, outcomes and laboratory findings were obtained. RESULTS: Our sample included a total of 355 patients. 70% were African-American, and 47% had diabetes. Patients with diabetes had higher peak inflammatory markers like CRP 184 (111-258) versus 142 (65-229) p = 0.012 and peak LDH 560 (384-758) versus 499 (324-655) p = 0.017. The need for RRT/HD was significantly higher in patients with diabetes (21% vs 11% p = 0.013) as well as the need for vasopressors (28% vs 18% p = 0.023). Only age was found to be an independent predictor of mortality. We found no significant differences in inpatient mortality p = 0.856, need for RRT/HD p = 0.429, need for intubation p = 1.000 and need for vasopressors p = 0.471 in African-Americans with diabetes when compared to non-African-Americans. CONCLUSIONS: Our study demonstrates that patients with COVID-19 and diabetes tend to have more severe disease and poorer clinical outcomes. African-American patients with diabetes did not differ in outcomes or disease severity when compared to non-African-American patients.

Clinical Characteristics and Outcomes of Community- and Hospital-Acquired Acute Kidney Injury with COVID-19 in a US Inner City Hospital System.

INTRODUCTION: Emerging data have described poor clinical outcomes from infection with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV 2) among African American patients and those from underserved socioeconomic groups. We sought to describe the clinical characteristics and outcomes of acute kidney injury (AKI) in this special population. METHODS: This is a retrospective study conducted in an underserved area with a predominance of African American patients with coronavirus disease 2019 (COVID-19). Descriptive statistics were used to characterize the sample population. The onset of AKI and relation to clinical outcomes were determined. Multivariate logistic regression was used to determine factors associated with AKI. RESULTS: Nearly half (49.3%) of the patients with COVID-19 had AKI. Patients with AKI had a significantly lower baseline estimated glomerular filtration rate (eGFR) and higher FiO2 requirement and D-dimer levels on admission. More subnephrotic proteinuria and microhematuria was seen in these patients, and the majority had a pre-renal urine electrolyte profile. Patients with hospital-acquired AKI (HA-AKI) as opposed to those with community-acquired AKI (CA-AKI) had higher rates of in-hospital death (52 vs. 23%, p = 0.005), need for vasopressors (42 vs. 25%, p = 0.024), and need for intubation (55 vs. 25%, p = 0.006). A history of heart failure was significantly associated with AKI after adjusting for baseline eGFR (OR 3.382, 95% CI 1.121-13.231, p = 0.032). CONCLUSION: We report a high burden of AKI among underserved COVID-19 patients with multiple comorbidities. Those who had HA-AKI had worse clinical outcomes compared to those who with CA-AKI. A history of heart failure is an independent predictor of AKI in patients with COVID-19.

Palliative Care Utilization Among Patients With COVID-19 in an Underserved Population: A Single-Center Retrospective Study.

BACKGROUND: As health-care institutions mobilize resources to address the coronavirus disease 2019 (COVID-19) pandemic, palliative care may potentially be underutilized. It is important to assess the use of palliative care in response to the COVID-19 pandemic. METHODS: This is a retrospective single-center study of patients with COVID-19 diagnosed via reverse transcriptase-polymerase chain reaction assay admitted between March 1, 2020, and April 24, 2020. An analysis of the utilization of palliative care in accordance with patient comorbidities and other characteristics was performed while considering clinical outcomes. Chi-square test was used to determine associations between categorical variables while t-tests were used to compare continuous variables. RESULTS: The overall mortality rate was 21.5% (n = 52), and in 48% (n = 25) of these patients, palliative care was not involved. Fifty-nine percent (n = 24) of those who had palliative consults eventually elected for comfort measures and transitioned to hospice care. Among those classified as having severe COVID-19, only 40% (n = 31) had palliative care involvement. Of these patients with severe COVID-19, 68% (n = 52) died. Patients who got palliative care consults were of older age, had higher rates of intubation, a need for vasopressors, and were dead. CONCLUSION: There was a low utilization rate of palliative care in patients with COVID-19. Conscious utilization of palliative care is needed at the time of COVID-19.