ABSTRACT
BACKGROUND: Coronavirus disease 2019 (COVID-19) has spread worldwide determining dramatic impacts on healthcare systems. Early identification of high-risk parameters is required in order to provide the best therapeutic approach. 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. OBJECTIVES: The aim was to evaluate the association of coronary artery calcium and total thoracic calcium on in-hospital mortality in COVID-19 patients. 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. At CT, coronary, aortic valve and thoracic aorta calcium were qualitatively and quantitatively evaluated separately and combined together (total thoracic calcium) by a central Core-lab blinded to patients' outcomes. RESULTS: Non-survivors compared to survivors had higher coronary artery [Agatston (467.76 â± â570.92 vs 206.80 â± â424.13 âmm2, p â< â0.001); Volume (487.79 â± â565.34 vs 207.77 â± â406.81, p â< â0.001)], aortic valve [Volume (322.45 â± â390.90 vs 98.27 â± â250.74 mm2, p â< â0.001; Agatston 337.38 â± â414.97 vs 111.70 â± â282.15, p â< â0.001)] and thoracic aorta [Volume (3786.71 â± â4225.57 vs 1487.63 â± â2973.19 mm2, p â< â0.001); Agatston (4688.82 â± â5363.72 vs 1834.90 â± â3761.25, p â< â0.001)] calcium values. Coronary artery calcium (HR 1.308; 95% CI, 1.046-1.637, p â= â0.019) and total thoracic calcium (HR 1.975; 95% CI, 1.200-3.251, p â= â0.007) resulted to be independent predictors of in-hospital mortality. 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.
Subject(s)
COVID-19/mortality , COVID-19/physiopathology , Computed Tomography Angiography , Vascular Calcification/mortality , Vascular Calcification/physiopathology , Aged , Aged, 80 and over , Aorta, Thoracic/diagnostic imaging , Aortic Diseases/diagnostic imaging , Aortic Diseases/mortality , Aortic Diseases/physiopathology , Aortic Valve/diagnostic imaging , COVID-19/diagnostic imaging , Coronary Vessels/diagnostic imaging , Female , Humans , Italy/epidemiology , Male , Middle Aged , Pneumonia, Viral/diagnostic imaging , Pneumonia, Viral/mortality , Pneumonia, Viral/physiopathology , Pneumonia, Viral/virology , Predictive Value of Tests , Retrospective Studies , SARS-CoV-2 , Severity of Illness Index , Vascular Calcification/diagnostic imagingABSTRACT
BACKGROUND: Severe acute respiratory syndrome coronavirus 2 infection can lead to a constellation of viral and immune symptoms called coronavirus disease 2019. Emerging literature increasingly supports the premise that severe acute respiratory syndrome coronavirus 2 promotes a prothrombotic milieu. However, to date there have been no reports of acute aortic occlusion, itself a rare phenomenon. We report a case of fatal acute aortic occlusion in a patient with coronavirus disease 2019. CASE REPORT: A 59-year-old Caucasian male with past medical history of peripheral vascular disease presented to the emergency department for evaluation of shortness of breath, fevers, and dry cough. His symptoms started 5-7 days prior to the emergency department visit, and he received antibiotics in the outpatient setting without any effect. He was found to be febrile, tachypneic, and hypoxemic. He was placed on supplemental oxygen via a non-rebreather mask. Chest X-ray showed multifocal opacifications. Intravenous antibiotics for possible pneumonia were initiated. Hydroxychloroquine was initiated to cover possible coronavirus disease 2019 pneumonia. During the hospitalization, the patient became progressively hypoxemic, for which he was placed on bilevel positive airway pressure. D-dimer, ferritin, lactate dehydrogenase, and C-reactive protein were all elevated. Severe acute respiratory syndrome coronavirus 2 reverse transcription polymerase chain reaction was positive. On day 3, the patient was upgraded to the intensive care unit. Soon after he was intubated, he developed a mottled appearance of skin, which extended from his bilateral feet up to the level of the subumbilical plane. Bedside ultrasound revealed an absence of flow from the mid-aorta to both common iliac arteries. The patient was evaluated emergently by vascular surgery. After a discussion with the family, it was decided to proceed with comfort-directed care, and the patient died later that day. DISCUSSION: Viral infections have been identified as a source of prothrombotic states due to direct injury of vascular tissue and inflammatory cascades. Severe acute respiratory syndrome coronavirus 2 appears to follow a similar pattern, with numerous institutions identifying elevated levels of thrombotic complications. We believe that healthcare providers should be aware of both venous and arterial thrombotic complications associated with coronavirus disease 2019, including possible fatal outcome.
Subject(s)
Aortic Diseases , Arterial Occlusive Diseases , SARS-CoV-2 , Thrombosis , Ultrasonography/methods , Aorta, Abdominal/diagnostic imaging , Aortic Diseases/diagnosis , Aortic Diseases/etiology , Aortic Diseases/physiopathology , Arterial Occlusive Diseases/diagnosis , Arterial Occlusive Diseases/etiology , Arterial Occlusive Diseases/physiopathology , Blood Coagulation , COVID-19/blood , COVID-19/complications , COVID-19/physiopathology , COVID-19/therapy , COVID-19 Nucleic Acid Testing/methods , Clinical Deterioration , Fatal Outcome , Humans , Male , Middle Aged , Patient Comfort , Point-of-Care Testing , SARS-CoV-2/isolation & purification , SARS-CoV-2/pathogenicity , Thrombosis/diagnostic imaging , Thrombosis/etiology , Thrombosis/physiopathologySubject(s)
Aortic Diseases , Arterial Occlusive Diseases , Asymptomatic Infections , COVID-19/complications , Intracranial Thrombosis , Pulmonary Embolism , ST Elevation Myocardial Infarction , Thrombophilia , Adult , Aortic Diseases/diagnosis , Aortic Diseases/etiology , Aortic Diseases/physiopathology , Arterial Occlusive Diseases/blood , Arterial Occlusive Diseases/diagnosis , Arterial Occlusive Diseases/physiopathology , Arterial Occlusive Diseases/virology , COVID-19/blood , COVID-19/diagnosis , COVID-19/immunology , COVID-19/physiopathology , Computed Tomography Angiography/methods , Coronary Angiography/methods , Humans , Intracranial Thrombosis/diagnosis , Intracranial Thrombosis/etiology , Intracranial Thrombosis/physiopathology , Magnetic Resonance Imaging/methods , Male , Pulmonary Embolism/diagnosis , Pulmonary Embolism/etiology , Pulmonary Embolism/physiopathology , ST Elevation Myocardial Infarction/diagnosis , ST Elevation Myocardial Infarction/etiology , Seroconversion , Thrombophilia/blood , Thrombophilia/etiology , Thrombophilia/prevention & control , Post-Acute COVID-19 SyndromeABSTRACT
Coronavirus disease 2019 (COVID-19) could predispose to both venous and arterial thromboembolism, in an exaggerated immune response to the virus, especially in severe patients. Even though aortic clots are a rare entity, the pro-coagulant nature of COVID-19 is associated with thrombosis in atypical locations and should be considered in patients with severe abnormalities in coagulation parameters. We describe a series of three cases of aortic thrombi diagnosed by computerized tomography (CT) angiography in patients with confirmed SARS-CoV-2 infection.