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Introduction: While COVID-19 is predominantly a lung infection, it can cause systemic viremia in susceptible patients and lead to cardiac involvement and myocarditis (MC);an inflammation of the myocardium characterized by arrhythmias, cardiogenic shock, acute heart failure, and death. Although rare, there is evidence of a surge in MC-related admissions during the COVID-19 pandemic, implying a correlation. However, the risk factors associated with MC susceptibility in these patients remain unclear. This study aims to assess the comorbidities and demographic features associated with the development of MC in adult patients with COVID-19. Method(s): Data were obtained from the PearlDiver database (PearlDiver Technologies, Fort Wayne, IN). The database provides all-payers administrative claims data on the patient level. Using ICD-10-CM codes, a cohort of patients hospitalized with a primary diagnosis of COVID-19 was identified. The study included only patients admitted to the hospital between January and October 2020 to minimize bias associated with vaccine-related MC. Within this cohort, patients diagnosed with MC during and up to one month after admission were identified and their demographic features and comorbidities to were compared to those without MC. We calculated Risk Ratios with their respective 95% CI. A p-value <0.05 was deemed significant. Result(s): We found 627,465 admissions due to COVID-19 from January to October 2020, with 506 (0.08 %) diagnosis of MC. Patients with MC were more likely to be males (60%), younger (mean age 48, SD= 23 vs. 60, SD =17 - p<0.01), and they had more comorbidities (mean Elixhauser Comorbidity Index: 7.52, SD= 5 vs. 6.9, SD = 5 - p<0.001). The development of MC was significantly associated with a history of coagulopathies [0.55(0.46-0.66);p<0.0001], asthma [1.20 (1.06-1.23);p= 0.01], deep venous thrombosis [1.54(1.38-1.68);p<0.0001], renal disease[1.15 (1.02-1.27);p= 0.03], congestive heart failure [1.24 (1.12-1.34);p=0.006], ischemic heart disease [1.25 (1.14-1.35);p=0.0001], and arrhythmias [1.24 (1.14-1.32);p< 0.0001]. However, a history of diabetes [0.89 (0.67-0.99);p=0.02], hypertension [0.71 (0.62-0.80);<0.000.1], depression [0.71(0.52-0.88);p=0.0001], and hypothyroidism [0.42(0.08-0.69);p<0.0001] was associated with lower risk of MC-related hospitalization. Other preexistent conditions including, psychosis, rheumatoid arthritis, cerebrovascular disease, obesity, tobacco use, alcohol abuse, HIV, anemia, peripheral vascular disease, and non-metastatic solid tumor were not significantly correlated with MC. Discussion(s): MC is a rare yet serious complication of COVID-19. Therefore, a better knowledge of the pathophysiology of COVID-19 and the patient factors associated with development to MC is crucial for prognostication and providing risk-adjusted treatment. Conclusion(s): Patients with a history of cardiovascular disease, renal and pulmonary disease were more likely to develop MC as a result of COVID-19. However, hypertension and diabetes were associated with lower risk of MC, which warrants further investigation.Copyright © 2022
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Background: Myocarditis (MC) is an inflammatory condition of the myocardium often caused by a virus and can lead to hospitalization, heart failure, or death. Although rare, data suggest an increased incidence associated with the COVID-19 virus. However, the risk for COVID-19-induced MC remains poorly understood and debated. We sought to evaluate the prevalence of pandemic MC-related inpatient encounters during 2020 through a descriptive approach and compare it to the pre-pandemic era. Given that the first COVID-19 vaccine doses were administered on December 14, 2020, a significant increase in MC prevalence could be attributable to COVID-19 exposure. Method(s): Data were obtained from the PearlDiver database (PearlDiver Technologies, Fort Wayne, IN). The database provides all-payers administrative claims data on the patient level. Using ICD-10-CM codes, a cohort of patients who had their first inpatient encounter with MC was identified and divided into pre-pandemic (January- October 2019) and pandemic (January-October 2020) groups and classified by age, gender, and month of hospitalization. We described these patients' demographics, calculated the prevalence ratio (PR) and 95% CI of MC-related encounters during the pandemic, and compared it with the same period in the pre-pandemic period. A p-value <0.05 was deemed significant. Result(s): The median age, length of stay in previous hospitalizations, mean gender and Elixhauser Comorbidity Index were similar between groups. The prevalence of MC was 22/100,000 cases in 2019 and 25/100,000 in 2020. The overall PR of hospitalization due to MC was 13% higher in 2020 than it was in 2019 (PR=1.13, p<0.0001), with a significantly higher risk in age groups 5-9 (PR=1.41 p=0.02), 60-64 (PR=1.24 p<0.0001), 65-69 (PR=1.14 p=0.01), 70-74 (PR=1.28 P<0.0001), and 80-85 (PR=1.36 p<0.0001). The risk was significantly higher in March (PR=1.27 p<0.0001), July (PR=1.41 p<0.0001, and September (PR=1.52 p<0.0001) in 2020. In 2020, the risk of MC in males with respect to females decreased by 3% compared to 2019. Discussion(s): Our results suggest a temporal correlation between increased prevalence of inpatient encounters for MC since COVID-19's inception. The risk was significantly higher in older adults and during months with a higher COVID-19 incidence. These findings do not demonstrate causation between the COVID-19 virus and MC and are limited by the typical biases associated with retrospective studies. Conclusion(s): Although MC is a less common hospitalization condition, our data supports a significantly increased prevalence of MC-related encounters during the initial year of the COVID-19 pandemic. We found risk variations according to age, gender, and month.Copyright © 2022
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Background: Advanced age and coronary artery disease (CAD) have been associated with a dismal prognosis in patients infected with COVID-19, most likely due to the virus's thrombogenic effects. Older adults with a history of CAD have routinely used low-dose Aspirin (LDA) as prevention due to their increased risk of cerebro-cardiovascular events. However, it is unclear if this population would benefit from LDA when infected with COVID-19. Methods: A retrospective study was conducted using the PearlDiver database (PearlDiver Technologies, Fort Wayne, IN). Using ICD codes, patients aged 65–75 and Elixhauser Comorbidity Score(ECI)>4 with a history of CAD admitted for COVID-19 were identified. The use of LDA for 1 month before the index event was used to split the cohort into two matched groups by age, gender, ECI, and other cardiovascular diseases. Records of groups were reviewed for multiple outcomes 30 days after admission. Pearson's chi-squared test was used to compare groups. The strength of association was reported as Risk Ratios (RR). Results: 4,017 patients with no difference in the mean age, gender, and ECI were included in each group. No differences present in 30-days all-cause readmission(RR=1.04, CI95% =0.92–1.17, p=0.49), mortality(RR=0.63, CI95%=0.30–1.29, p=0.28), ICU admission(RR=1.01, CI95%=0.89–1.15, p=0.79), gastrointestinal bleeding(RR=1.09, CI95% = 0.85–1.40, p=0.51), and intracranial hemorrhage(RR=0.69, CI95%=0.26–1.83, p=0.62) between groups. Conclusion: LDA didn't improve the evaluated outcomes in older persons 30 days after admission. A plausible explanation is that COVID-19's thrombogenic mechanism is likely atypical.
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Background: Older adults are afflicted more severely by COVID-19. SARS-CoV-2 can be complicated by myocarditis (MC), and the incidence of MC has been shown to correlate linearly with severity. However, data on comorbidities associated with MC in this population is scarce. Methods: Data were obtained from the PearlDiver database (PearlDiver Technologies, Fort Wayne, IN). The study used ICD codes to include patients hospitalized with a primary diagnosis of COVID-19, aged 65–75, and Elixhauser Comorbidity index(ECI)>4. Within this cohort, we identified patients diagnosed with MC 60 days after admission and compared their baseline comorbidities upon admission to those without MC. Pearson's chi-squared test was used to compare groups. The strength of association was reported by Risk Ratios (RR). A p-value < 0.05 was deemed significant. Results: 412,582 patients admitted with COVID-19 as the primary diagnosis were identified. 0.12% of this cohort developed MC over the following 60 days. The MC group was more likely to be male(57%, p=0.0001), with similar mean age(70.4, p=0.86) and mean ECI(9.4, p=0.07) to the no-MC group. Patients who developed MC have significantly higher rates of prior heart failure(RR= 1.30, CI95%=1.07–1.57, p=0.008). There was no difference between groups in terms of history of arrhythmias(p=0.36), cerebrovascular disease(p=0.09), chronic kidney disease(p=0.13), CAD(P=0.19), diabetes(p=0.48), ischemic heart disease(p=0.06), tobacco use(p=0.39), alcohol use(p=0.17), HIV(p=0.79), and severe liver disease(p=0.14). Conclusion: A history of heart failure increased the likelihood of developing MC in older adults.
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Background: Age, atrial fibrillation (AF), and COVID-19 infection predispose patients to hypercoagulability and poor outcomes. It is unclear if older adults with AF and COVID-19 infection would benefit from oral anticoagulants (OACs). Methods: A retrospective study was conducted using the PearlDiver database (PearlDiver Technologies, Fort Wayne, IN). Using ICD-10 codes, adults aged 65–75 and Elixhauser Comorbidity index(ECI) >4 with a history of AF admitted for COVID-19 were identified. The use of OACs for 6 months before the index event was used to split the cohort into two propensity score-matched groups considering age, gender, and ECI. Records from both groups were reviewed for multiple outcomes during the same admission. Pearson's chi-squared test was used to compare groups. The strength of association was reported using Risk Ratios (RR). A p-value < 0.05 was deemed significant. Results: We compared 16,967 individuals in both anticoagulated and non-anticoagulated groups. Anticoagulated patients had a lower risk of mortality (RR=0.11, p=0.026), and a higher risk of 30-day all-cause readmission(RR=1.12, p < 0.0001). However, there were no differences in ICU admission, gastrointestinal bleeding, intracranial hemorrhage, thromboembolic events, or length of hospitalization. Conclusion: Compared to non-anticoagulated patients, older adults with a history AF on chronic oral anticoagulants had a lower risk of all-cause mortality, and higher risk of 30-day all-cause readmission. This information would help clinicians decide whether to prescribe OACs to this population of patients.
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Background: Data suggest an increased incidence of myocarditis (MC) associated with the COVID-19 virus. However, the risk factors for COVID-19-related MC remains poorly understood and debated. Therefore, we sought to evaluate the correlation of a history of coronary artery disease (CAD) with MC in older adults admitted for COVID-19. Methods: Data were obtained from the PearlDiver database (PearlDiver Technologies, Fort Wayne, IN). The study included patients aged 65–75, hospitalized with a primary diagnosis of COVID-19, and Elixhauser Comorbidity index(ECI) >4. History of CAD upon admission was used to split the cohort into two propensity score-matched groups considering age, gender, other cardiovascular diseases, and ECI. Records from both groups were reviewed to identify patients diagnosed with MC during and up to one month after admission. Pearson's chi-squared test was used to compare groups. The strength of association was reported using Risk Ratios (RR). A p-value < 0.05 was deemed significant. Results: 182,556 patients with and 218,729 without a history of CAD admitted for COVID-19 were identified. Patients with a history of CAD were more likely to be male(54.7% vs. 42% p < 0.0001), older(mean age 70.62 vs. 70.30, p < 0.001), and had more comorbidities(ECI=11 vs. 8, p < 0.0001). After propensity score matching, 0.13% of patients with CAD and 0.12% without CAD developed MC within one month of admission(RR= 1.05, CI95%=0.87–1.26, p=0.61). Conclusion: One month following admission for COVID-19, the risk of MC was not significantly higher in older persons with a history of CAD.
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Background: According to the CDC, approximately 30% of hospitalizations for COVID-19 infection between the onset of the pandemic and November 2020 were attributed to obesity. However, there is limited data on how obesity affects the overall outcome of COVID-19 in hospitalized older adults. Methods: A retrospective study was conducted using the PearlDiver database (PearlDiver Technologies, Fort Wayne, IN). Using ICD-10 codes, a cohort of patients aged 65–75 and Elixhauser Comorbidity Index (ECI) >4 with a history of obesity admitted for COVID-19 was identified. This cohort was matched with a group of patients with no history of obesity, considering age, gender, and ECI. Records from both groups were reviewed for multiple outcomes over 30 days following admission. Pearson's chi-squared was used to compare groups. The strength of association was reported using Risk Ratios (RR). A p-value < 0.05 was deemed significant. Results: There were 151,429 members in each group. Obese individuals had a higher risk of 30-day all-cause readmission (RR=1.10, CI95% 1.07–1.11, p < 0.0001), ICU admission (RR=1.11, CI95% 1.08–1.15, p < 0.0001), acute thromboembolic events (RR=1.14, CI95% 1.07–1.2, p < 0.001), and deep venous thrombosis (RR=1.21, CI95% 1.12–1.32, p < 0.00001). There was no difference in length of hospitalization. Conclusion: Obesity is a modifiable risk factor that negatively affects COVID-19 outcomes in the older population. Given the prevalence of obesity in our population, primary and secondary obesity prevention is more important than ever.
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Background: Bladder-preserving combinedmodality therapies constitute an alternative to radical cystectomy for selected pts with MIBC. In preclinical studies, combination of radiation and dual checkpoint blockade appears to activate non-redundant immune mechanisms, potentiating antitumor activity. The purpose of the present study is to explore feasibility, toxicity and activity of this approach in MIBC. Methods: Pts with localized MIBC in clinical stages T2-4a N0 M0, ECOG 0-1, without contraindications to immunotherapy, who either wished for bladder preservation or were ineligible for cystectomy, were included in this phase II study. Treatment consisted of initial transurethral resection (TUR) of the tumor, followed by durvalumab 1,500 mg i.v. plus tremelimumab 75 mg i.v., every 4 weeks for 3 doses. Normofractionated external-beam RT was started 2 weeks later, at doses of 46 Gy to minor pelvis and 64-66 Gy to bladder. Pts with either residual or relapsed MIBC were offered salvage cystectomy. The primary endpoint was complete response (CR) defined as absence of MIBC at post-treatment tumor site biopsy. A 2- stage sequential design was used (CR rate P0=5, P1=0.7, α=0.10, β=0.20) requiring at least 6 CR in the first 12 pts to expand to a second cohort of 20 pts. Results: From 1/2019 to 8/2020, 32 pts were enrolled at 6 centers. Median age was 71 years (49-91). PS was 0 in 24 pts,1 in 8. 25 were males. Clinical stage was T2 in 28 pts, T3 in 3 and T4a in 1. All pts received at least two immunotherapy cycles. The median dose of RT administered was 64 Gy (60-65). CR at posttreatment biopsy was documented in 26 (81%) pts, 2 pts had residual MIBC and 4 pts were not evaluated due to rejection (1), clinical impairment (1), death from COVID 19 (1) and a suspected treatment-related death from peritonitis (1). After a median follow up of 6.1 months (2.5 - 20.1), 2 pts underwent salvage cystectomy because of MIBC and T1 relapses, respectively. The estimated 6-months rates for disease-free survival (DFS) with bladder intact, DFS and overall survival were 76% (95%CI, 61%-95%), 80% (95%CI, 66%-98%) and 93% (95%CI, 85%-100%), respectively. A total of 31 (97%) pts experienced adverse events related to RT and/or immunotherapy, with diarrhea (41%) and urinary disorders (37.5%) as the most frequent. Grade 3 or 4 adverse events related to therapy were reported in 31% pts, being the most frequent gastrointestinal toxicity (12.5%), acute kidney failure (6%) and hepatitis (6%). Conclusions: A combined-modality approach including durvalumab + tremelimumab with concurrent RT is feasible and safe, showing high efficacy in terms of response and eliciting bladder preservation in a large number of pts. Further research on this approach as an alternative to cystectomy is warranted.