ABSTRACT
SESSION TITLE: Imaging Across the Care Spectrum SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Mortality from coronavirus disease 2019 (COVID-19) has been associated with multiple risk factors. Despite this, prediction of illness trajectory remains difficult. We conducted a retrospective, exploratory case control study to determine risk factors for death among COVID-19 hospitalized patients in our local patient population. METHOD(S): Data was ed from 03/01 to 05/31/2020. Study population included hospitalized COVID-19 patients. We reviewed their demographics, past medical history, symptoms, oxygen requirements, BMI, imaging, laboratory markers, admission location, length of stay, requirement of CRRT/HD, final outcome. We compared those who died to those who survived to discharge. Mortality rates within individual risk factors were analyzed using an independent t-Test of percentages. The percentages were compared across the most common risk factors and tested for statistical significance with Chi square analysis at p< 0.05. RESULT(S): There were 281 patients admitted with COVID-19, 48 of them died. There was a significant increased risk of death with age (p<0.0001, OR=1.07;CI=1.05-1.1);history of obstructive sleep apnea (p=0.03), CKD/ESRD (p=0.01), CAD (p=0.02);presenting symptoms of dyspnea (p=0.04), respiratory rate (p=0.0002, OR=1.07;CI=1.03-1.12);absolute lymphopenia (p=0.03);LDH (p<0.0001, OR = 1.00;CI=1.001-1.004);AST (p=0.03);CRP (p=0.003, OR = 1.00;CI=1.00-1.01);on initial presentation, requiring non-rebreather (p<0.0001, OR 3.60;CI 95%, 1.73-7.50), BiPAP (p=0.004, OR 4.592;CI 95%, 1.47-14.34), invasive ventilation (p< 0.0001, OR 7.36;CI 95%, 2.73-19.85);imaging findings of bilateral infiltrates/consolidation (p=0.04);CRRT/HD (p< 0.0001, OR 6.78;CI 95%, 2.69-17.12);admission to ICU (p-< 0.0001, OR 3.52CI 95%, 1.82-6.81);transfer to ICU (p<0.0001, OR 3.62CI 95%, 1.81-7.22). There was no significant association between death and sex, hypertension, diabetes, CHF, COPD, asthma, obesity, length of stay, fever, cough, fatigue, GI symptoms, D-Dimer, Ferritin, Fibrinogen, PaO2/FiO2 ratio, and requiring nasal cannula on presentation. CONCLUSION(S): We identified a range of patient characteristics, comorbidities, symptoms, and laboratory markers that are suggestive of an increased risk of mortality from COVID-19. There were some factors that differed but did not reach statistical significance. A larger sample size is needed to resolve this. Interestingly, we identified obesity to have a protective trend with a relative 30% lower death rate, and a larger sample size could make this significant, suggesting a possible obesity paradox. However, many experts argue against this, citing that obesity is a detrimental risk factor and these patients need aggressive monitoring and treatment. CLINICAL IMPLICATIONS: Although COVID-19 mortality is associated with multiple risk factors, a physician's clinical judgment is still imperative in triaging which patients are at increased risk of death. DISCLOSURES: No relevant relationships by Mohamed Ghiath Bayasi No relevant relationships by Alan Bridgmon No relevant relationships by Kristen Hartnett No relevant relationships by Bineh-Karan Kalra No relevant relationships by Joanna Wieckowska No relevant relationships by Elise Wojcik Copyright © 2022 American College of Chest Physicians
ABSTRACT
Observational studies have suggested that respiratory failure in COVID-19 is not solely driven by the development of ARDS but also concomitant micro-and macrovascular thrombosis. Many patients with COVID-19 develop a hypercoagulable state that has been associated with an increased risk of death. Current treatment guidelines do not support the use for or against empiric anticoagulation. We present a case of a 57-year-old Caucasian male with COVID-19 who was started on full-dose anticoagulation empirically based on an elevated D-Dimer level and was later found to have bilateral pulmonary emboli with right heart strain and pulmonary infarction. Patient had a medical history significant for diabetes mellitus type II, hypertension, hyperlipidemia, and presented to the hospital on 4/18/20 with fever, fatigue, myalgias, weakness, productive cough, shortness of breath, non-bloody diarrhea, abdominal pain, after testing positive for COVID-19 outpatient on 4/1/20. His O2 saturation was 72% on pulse oximetry. He had no prior pulmonary history. In the ED, chest x-ray demonstrated no abnormality (image 1) and D-dimer was 5325 ng/mL. In light of significantly elevated D-dimer, the patient was started empirically on systemic anticoagulation with unfractionated heparin drip. Due to low pre-test probability and trying to limit further exposure to COVID-19, doppler ultrasound of bilateral lower extremities was chosen to rule out VTE. It was negative. Patient clinically improved over the next day and was subsequently transferred out of the ICU. Prior to discharge the patient underwent CTA to rule out PE on 4/21/20. Results demonstrated acute bilateral pulmonary emboli, including large saddle embolism left main pulmonary artery distally, with right heart strain and pulmonary infarction. Since the patient was hemodynamically stable, no systemic or catheter-based thrombolysis was indicated. Patient was started on a DOAC and discharged on 4/23/20 with oxygen only at night. Although the exact etiology of VTE associated with COVID-19 remains unclear, the available data has shown it to cause a prothrombotic state. Studies have shown the risk of VTE in COVID-19 patients admitted to the ICU to be around 2.5-5 times higher than the general ICU population. Our case serves to highlight the need for heightened vigilance for VTE as well as question the utility of common risk stratification tools such as the Well's score in COVID-19. Further studies are needed to identify when and how to anticoagulate patients with COVID-19 in addition to validating risk stratification tools that may aid clinicians in these situations.