The Heavy Burden of Sars-Cov-2 Related Pneumonia Requiring High-Oxygen Flow

Aim: there is evidence of significant clinical sequelae of COVID-19 that may impair both life length and its quality. Aim of this study was to assess the long-term consequences of moderate to severe SARS-CoV-2-related pneumonia in patients requiring high-flow oxygen treatment. Method(s): This prospective follow-up study included 45 patients with confirmed COVID-19 admitted to a medical ward at the Montichiari Hospital, Brescia, Italy from November 2020 to April 2021 Patients had COVID-19 related pneumonia with respiratory failure and needed at least treatment with an inspired fraction of oxygen of 40% (of them, 59% were treated with Venturi mask and 41% needed noninvasive ventilation). Patients underwent a clinical assessment with standard laboratory testing, chest CT scan, lung function tests with DLCO, and evaluation of vital parameters after a mean of 382 days after hospital discharge. A quality-of-life questionnaire was administered to each willing patient. Result(s): See table for details. While standard laboratory testing showed a substantial normalization, we found persistence of radiological alterations (i.e. groundglass opacities, irregular linear/reticular opacities) in 61% of patients;mean Tiffenau index (FEV1/FVC) was reduced, although not clearly pathologic (79%) and 38% of patients showed a mild to moderate reduction in CO lung diffusion (DLCO). Interestingly, 54% of subjects showed concomitant presence of radiologic alterations AND persistence of dyspnea OR reduction in CO lung diffusion, while 21% had all three concomitant conditions, compatible with the diagnosis of lung fibrosis. Overall, a total of 75% patients had some degree of functional or structural alteration of respiratory apparatus. We also evaluated quality of life thorough a structured questionnaire: after more than one year 62% of the patients still lamented fatigue, 62% effort dyspnea, 12% anorexia, 29% dysgeusia or anosmia, 31% insomnia and 43% anxiety. Conclusion(s): these data seem to demonstrate that SARS-CoV-2-related pneumonia requiring high flow oxygen has a heavy long-term burden, both in terms of persistence of functional and structural pulmonary damage (which may be progressive and evolve to a more severe degree) and of burden on overall quality daily life. (Figure Presented).

Absence of Major Cardiovascular Event in a Group of Patients Followed for More Than One Year after Severe Covid-19 Pneumoniae

Introduction: The Coronavirus disease 2019 (COVID-19), doesn't affect only respiratory system, but it also involves other organs including cardiovascular system, possibly causing acute or chronic cardiovascular events. Preexisting cardiovascular diseases enhance COVID-19 morbidity, as well. Aim(s): In this retrospective analysis we investigated the onset of cardiovascular events during a time-span of more than one year since hospitalization (384 days). Method(s): The analysis included 43 patients, who were hospitalized in Internal Medicine Department of Montichiari Hospital (ASST Spedali Civili of Brescia) for moderate to severe SARS-CoV2 related pneumonia treated with high-flow oxygen support (ranging from 40% fraction of inspired oxygen to non-invasive ventilation) Mean age was 63 years, 28% (12/43) were female and 72% (31/43) were male. Thirty-five percent of the patients suffered from heart diseases, 56% of them were hypertensives and 23% had type 2 diabetes;12% had chronic kidney disease (CKD) and 5% an active neoplasm. 49% of the sample was obese. Nineteen percent took ACE inhibitors and 19% was on ARBs. Statins were taken by 37% of the patients;an antiaggregant by 21%, and an anticoagulant by 2% (see table) Results: The follow-up visit included the evaluation of post-covid infection quality-of-life, standard laboratory tests, chest computed tomography, spirometry with evaluation of DLCO. The onset of cardiovascular events during the average period of 384 days was evaluated. None of the 43 patients had major cardiovascular events: coronary heart disease, cerebrovascular disease, peripheral arterial disease, deep vein thrombosis and pulmonary embolism. Conclusion(s): Even if this study failed to demonstrate new-onset CV events, longer follow-up studies performed to evaluate cardiovascular risk following SARS-CoV1 infection showed persistent hyperlipidemia, cardiovascular system abnormalities, and glucose metabolism disorders in a very high number of patients. Further analyses are needed to further investigate longer term cardiovascular consequences of SARS-CoV2 infection. (Figure Presented).

Ace-Inhibitors and Angiotensin Receptor Blockers Do Not Impacton Outcome nor in Long Term Consequences of Covid-19

Introduction: COVID-19 pandemic still represents a major clinical problem worldwide. Many studies are actively being carried out to better understand prognostic factors of outcome as well as optimal treatment. Aim(s): ACE-2 receptor is highly expressed on the surface of cardiac and pulmonary cells, and it is used by coronaviruses to enter host cells;this makes the role of ACE-inhibitors and Angiotensin Receptor Blockers (ARBs) drugs controversial. Moreover, it is still unclear whether these drugs may have any impact on sequelae. Method(s): In this retrospective study, we analysed a group of 244 hypertensive unvaccinated patients (134 on ACE-inhibitors, 110 on ARBs) admitted formoderate to severe COVID-19 pneumonia. As shown in the table, the two groups where homogeneous. Of these patients, 46 (20 treated with ACE-I and 26 treated with ARBs) came to a follow-up visit after a mean of 260 days;they underwent a quality-of-life assessment, laboratory and radiologic tests and spirometry (with DLCO). Result(s): A total of 20 of 110 (18%) patients under treatment with ARBs and 23 of 134 (17%) died during hospitalization (p=0.8, NS). At discharge, biochemical, radiological and respiratory data were not significantly different. We did not find any significant difference in terms of radiologic alterations, lung fibrosis, spirometry data, DLCO, persisting effort dyspnea. Biochemical data were substantially super-imposable in the two groups. Conclusion(s): we could not detect any difference in outcome nor in complications type or number in the two groups undergoing treatment with ACE-inhibitor or ARBs. This result seems to support and to strengthen the idea that ACE-inhibitors and ARBs do not play a significant role in onset, evolution and outcome of moderate to severe COVID-19 pneumoniae. Although the number of follow-up patients is small, we did not find any difference in follow-up sequelae in both groups. (Figure Presented).

Moderate to Severe Sars-Cov2 and Cardiovascular Events at One Year: A Descriptive Retrospective Analysis

Introduction: The Coronavirus disease 2019 (COVID-19), doesn't affect only respiratory system, but it also involves other organs including cardiovascular system, possibly causing acute or chronic cardiovascular events. Preexisting cardiovascular diseases enhance COVID-19 morbidity, as well. Aim(s): In this retrospective analysis we investigated the onset of cardiovascular events during a time-span of more than one year since hospitalization (384 days). Method(s): The analysis included 43 patients, who were hospitalized in Internal Medicine Department of Montichiari Hospital (ASST Spedali Civili of Brescia) for moderate to severe SARS-CoV2 related pneumonia treated with high-flow oxygen support (ranging from 40% fraction of inspired oxygen to non-invasive ventilation) Results: Mean age was 63 years, 28% (12/43) were female and 72% (31/43) were male. Thirty-five percent of the patients suffered from heart diseases, 56% of them were hypertensives and 23% had type 2 diabetes;12% had chronic kidney disease (CKD) and 5% an active neoplasm. 49% of the sample was obese. Nineteen percent took ACE inhibitors and 19% was on ARBs. Statins were taken by 37% of the patients;an antiaggregant by 21%, and an anticoagulant by 2% (see table) Table 1: Main demographic data, comorbidities and ongoing therapies The follow-up visit included the evaluation of post-covid infection quality-of-life, standard laboratory tests, chest computed tomography, spirometry with evaluation of DLCO. The onset of cardiovascular events during the average period of 384 days was evaluated. None of the 43 patients had major cardiovascular events: coronary heart disease, cerebrovascular disease, peripheral arterial disease, deep vein thrombosis and pulmonary embolism. Conclusion(s): Even if this study failed to demonstrate new-onset CV events, longer follow-up studies performed to evaluate cardiovascular risk following SARS-CoV1 infection showed persistent hyperlipidemia, cardiovascular system abnormalities, and glucose metabolism disorders in a very high number of patients. Future analyses are needed to further investigate longer term cardiovascular consequences of SARS-CoV2 infection.

Ongoing Ace-Inhibitor or Atii-Antagonist Treatment Doesn't Impact on Outcome nor on Sequelae of Patients with Moderate to Severe Covid-19 Pneumonia

Introduction: COVID-19 pandemic still represents a major clinical problem worldwide. Many studies are actively being carried out to better understand prognostic factors of outcome as well as optimal treatment. Aim(s): ACE-2 receptor is highly expressed on the surface of cardiac and pulmonary cells, and it is used by coronaviruses to enter host cells;this makes the role of ACE-inhibitors and Angiotensin Receptor Blockers (ARBs) drugs controversial. Moreover, it is still unclear whether these drugs may have any impact on sequelae. Method(s): In this retrospective study, we analysed a group of 244 hypertensive unvaccinated patients (134 on ACE-inhibitors, 110 on ARBs) admitted for moderate to severe COVID-19 pneumonia. As shown in Table 1, the two groups were homogeneous. Of these patients, 46 (20 treated with ACE-I and 26 treated with ARBs) came to a follow-up visit after a mean of 260 days;they underwent a quality-of-life assessment, laboratory and radiologic tests and spirometry (with DLCO). Result(s): A total of 20 of 110 (18%) patients under treatment with ARBs and 23 of 134 (17%) died during hospitalization (p = 0.8, NS). At discharge, biochemical, radiological and respiratory data were not significantly different. We did not find any significant difference in terms of radiological alterations, lung fibrosis, spirometry data, DLCO, persisting effort dyspnea. Biochemical data were substantially super-imposable in the two groups. Conclusion(s): In conclusion, we could not detect any difference in outcome nor in complications type or number in the two groups of hypertensive patients undergoing treatment with ACE-inhibitor or ARBs. This result seems to support and to strengthen the idea that ACE-inhibitors and ARBs do not play a significant role in onset, evolution and outcome of moderate to severe COVID-19 pneumoniae. Although the number of follow-up patients is small, we did not find any difference in follow-up sequelae in both groups.

Secondary Infections in Patients Requiring Extracorporeal Membrane Oxygenation (ECMO) for Severe Acute Respiratory Distress Syndrome (ARDS) due to COVID-19 Pneumonia (PNA)

Background. Rescue ECMO has been used worldwide in patients (pts) with ARDS caused by COVID-19. Bacterial super-infections affect 3.5-14.3% of hospitalized pts with COVID-19. Pts requiring ECMO may be at an increased risk of infection due to their severity of illness, gut translocation and ECMO impact on host immunity. Methods. This was a retrospective review of pts requiring ECMO for COVID-19 from April 2020-2021 at a single center. Strict definitions of infections (including ventilator-associated PNA, VAP) were in accordance with CDC criteria. Results. 43 ECMO pts with 1065 ECMO days were evaluated. Median age was 53 yrs (range: 21-62) and median BMI was 36.2 (range: 19.4-75.8). 70% were men and 65% were white. 37 patients (86%) experienced a total of 40 infectious episodes with a median onset from ECMO cannulation to first infection of 10.5d (range: 4-50). Median SOFA and SAPSII scores at time of infection were 12 (6-20) and 63 (30-90), respectively. PNA was the most common infection (78%, with 19% of cases complicated by bacteremia and 3% by empyema) (Fig. 1). The most common organisms isolated were Enterobacterales (37%), S. aureus (25%) and P. aeruginosa (16%) (Fig. 2). Only 2% of all organisms were multi-drug resistant. 3 pts had fungal infections (1 candidemia, 2 aspergillus PNA). Duration of ECMO was significantly longer for infected pts (26d, range: 5-92d) vs (11d, range: 3-24d), p=.01. 95% of infected pts had received steroids vs. 67% of uninfected pts, p=0.09. Treatment success at 1 week was 50%, and 24% and 40% of pts had recurrent infections and persistent/recurrent organisms in clinical cultures, respectively. S. aureus (54%) and Enterobacterales (26%) were associated with persistent or recurrent clinical cultures, requiring prolonged antimicrobial therapy. Mortality rate at 30 days was 65% and was significantly higher for pts with infection than those without (67% vs 33%, p=.02). Conclusion. Super-infection (most commonly PNA) occurred in almost all COVID-19 pts requiring ECMO for >4 days, and was a significant risk factor for death. Recurrent infections among survivors were common, especially when caused by Enterbacterales or S. aureus. Super-infection and mortality rates of ARDS pts on ECMO for COVID-19 were worse than for ARDS pts on ECMO for influenza at our center.