The role of cardiovascular calcifications in COVID-19

Background: Coronary, thoracic aorta and aortic valve calcium can be measured from a non-gated chest computer tomography (CT) and are validated predictors of cardiovascular events and all-cause mortality. However, their prognostic role in acute systemic inflammatory diseases, such as COVID-19, has not been investigated. Purpose: The principal aim was to evaluate the association of coronary artery calcium (CAC) and total thoracic calcium on in-hospital mortality in COVID-19 patients. Then, to evaluate the prognostic impact of clinical and subclinical coronary artery disease (CAD), as assessed by CAC. Methods: 1093 consecutive patients from 16 Italian hospitals with a positive swab for COVID-19 and an admission chest CT for pneumonia severity assessment were included in the SCORE COVID-19 registry (calcium score for COVID-19 Risk Evaluation). At CT, coronary, aortic valve and thoracic aorta calcium were qualitatively and quantitatively evaluated separately and combined together (total thoracic calcium) by a central Corelab blinded to patients' outcomes. A specific sub analysis on CAC was performed stratifying the patients in three groups: (a) “clinical CAD” (prior revascularization history), (b) “subclinical CAD” (CAC >0), (c) “No CAD” (CAC=0). In-hospital mortality was the primary endpoint, while a composite of myocardial infarction and cerebrovascular accident (MI/CVA) was the secondary one. Results: Non-survivors compared to survivors had higher coronary artery [(487.7±565.3 vs 207.7±406.8, p<0.001)], aortic valve [(322.4±390.9 vs 98.2±250.7 mm2, p<0.001)] and thoracic aorta [(3786.7±4225.5 vs 1487.6±2973.1 mm2, p<0.001)] calcium values. Coronary artery calcium (HR 1.308;95% CI, 1.046 - 1.637, p=0.019) and total thoracic calcium (HR 1.975;95% CI, 1.200 - 3.251, p=0.007) resulted to be independent predictors of in-hospital mortality. In the sub - analysis increasing rates of in-hospital mortality (11.3% vs. 27.3% vs. 39.8%, p<0.001) and MI/CVA events (2.3% vs. 3.8% vs. 11.9%, p<0.001) were observed from the No CAD to the clinical CAD groups. Among patients with subclinical CAD, increasing CAC burden was associated with higher rates of in-hospital mortality (20.5% vs. 27.9% vs. 38.7% for patients with CAC score thresholds ≤100, 101-400 and >400, respectively, p<0.001) Conclusion: Coronary, aortic valve and thoracic aortic calcium assessment on admission non-gated CT permits to stratify the COVID-19 patients in-hospital mortality risk. Cardiovascular calcifications may represent a bystander of an impaired vascular reserve, both microvascular and endothelial, but also a sign of vascular senescence. Therefore, it can be considered an index of biological frailty, likely more accurate than age and other risk factors. (Figure Presented).

Is pleural effusion in COVID-19 interstitial pneumonia related to in-hospital mortality?

The recent severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) pandemic has highlighted the importance of pulmonary computed tomography (CT) for diagnosis and prognostic stratification of this new viral pneumonia. 1370 lung CT scans (performed at the time of admission) of consecutive patients hospitalized for SARS-CoV-2 in Northern Italy during the first epidemic wave were analyzed by a radiological CoreLab. The presence of pleural effusion on pulmonary CT scan was present in 188 patients (13.3% of the population) and identified a population with more comorbidities. Patients with pleural effusion had more cardio-respiratory complications with higher mortality. Pleural effusion was an independent predictor of death on multivariate analysis with an HR of 1.4 (95% confidence interval 1-1.9). Pulmonary CT pleural effusion was an independent predictor of mortality.