ABSTRACT
Background: Patients suffering from COVID-19 with pre-existing chronic heart failure (CHF) are considered to have a significant risk regarding morbidity and mortality. Similarly, older patients on the intensive care unit (ICU) constitute another vulnerable subgroup. This study investigated the association between pre-existing CHF and clinical practice in critically ill older ICU patients with COVID-19. Method(s): Patients with severe COVID-19 and who were >=70 years old were recruited from this prospective multicenter international study. Patients' treatment, follow-up, and pre-existing heart failure data were collected during ICU stay. Univariate and multivariate logistic regression analyses examined the association between pre-existing heart failure and the primary endpoint of 30-day mortality. Result(s): The study included 3,917 patients, with 407 patients (17%) evidencing pre-existing CHF. These patients were older (77+/-5 versus 76+/-5, p<0.001) and more frail (Clinical Frailty Scale 4+/-2 versus 3+/-2, p<0.0001). The other comorbidities were also significantly more common in CHF patients. Before hospital admission, CHF patients suffered fewer days from symptoms (5 days (3-8) versus 7 days (4-10), p<0.001), but there was no difference in the days in the hospital before ICU admission (2 days (1-5) versus 2 (1-5) days, p=0.21). At ICU admission, disease severity assessed by SOFA scores was significantly higher in CHF patients (7+/-3 versus 5+/-3). During ICU-stay, intubation, mechanical ventilation, and tracheostomy occurred significantly more often in patients without CHF (63% versus 69%, p=0.017;and 13% versus 18%, p=0.002, respectively). In contrast, there was no difference regarding non-invasive ventilation (28% versus 27%, p=0.20), and the need for vasoactive drugs (66% versus 64, p=0.30). Regarding the limitation of life-sustaining therapy, therapy was significantly more often withheld (32% versus 25%, p=0.001) but not withdrawn (18% versus 17%, p=0.21) in CHF patients. Length of ICU stay was significantly shorter in CHF patients (166 (72-336) hours versus 260 hours (120-528), p<0.001). CHF patients had significantly higher ICU-(52% versus 46%, p=0.007), 30-day mortality (60% vs. 48%, p<0.001;OR 1.87, 95% CI 1.5- 2.3) and 3-month mortality (69% vs. 56%, p<0.001). In the univariate regression analysis, having pre-existing CHF was significantly associated with 30-day mortality (OR 1.89, 95% CI 1.5-2.3;p<0.001), but after adjusting for confounders (SOFA, age, gender, frailty), heart failure was not independently associated any more (aOR 1.2, 95% CI 0.5-1.5;p=0.137). Conclusion(s): In critically ill old COVID-19 patients, pre-existing chronic heart failure is associated with significantly increased short-and long-term mortality, but heart failure is not independently associated with increased 30-day mortality when adjusted for confounders.
ABSTRACT
Approximately 14% of COVID-19 patients have a more severe and approximately 5% a critical course of disease. The elderly, males, smokers, and severely obese people are particularly at risk. If the patient is ventilated invasively or non-invasively, mortality rises to 53% and 50% respectively. As a rule, it takes ten days from the onset of symptoms to admission to the intensive care unit. The average length of stay in the intensive care unit is nine days. Prioritization is based on the clinical chances of success of intensive care treatment and the patient's wishes. Central criteria for admission to the intensive care unit are hypoxemia (SpO(2) < 90% by admitting 2-4 liters of oxygen/min., if no pre-existing therapy is used), dyspnea, an increased respiratory rate (> 25-30/min) and systolic blood pressure <= 100mmHg. The protection of the personnel has priority in all measures. All aerosol generating procedures should be performed with great care. If adequate oxygenation is not achieved under high flow (SpO(2) >= 90% or a paO(2) > 55mmHg), escalation should be considered (NIV, invasive ventilation). The patients should be ventilated lung-protectively. Intubation should be performed as rapid sequence induction. An ECMO can be considered. Thromboembolic complications are very frequent. Antibiotics should not be given routinely. The best data currently available is for dexamethasone. Remdesivir can accelerate the convalescence. Long-term consequences after COVID-19 are very common. Cardiac, pulmonary, and neurological problems are in the foreground.