Lymphopenia in severe coronavirus disease-2019 (COVID-19): systematic review and meta-analysis

OBJECTIVE

Clinical and laboratory biomarkers to predict the severity of coronavirus disease 2019 (COVID-19) are essential in this pandemic situation of which resource allocation must be urgently prepared especially in the context of respiratory support readiness. Lymphocyte count has been a marker of interest since the first COVID-19 publication. We conducted a systematic review and meta-analysis in order to investigate the association of lymphocyte count on admission and the severity of COVID-19. We would also like to analyze whether patient characteristics such as age and comorbidities affect the relationship between lymphocyte count and COVID-19.

METHODS

Comprehensive and systematic literature search was performed from PubMed, SCOPUS, EuropePMC, ProQuest, Cochrane Central Databases, and Google Scholar. Research articles in adult patients diagnosed with COVID-19 with information on lymphocyte count and several outcomes of interest, including mortality, acute respiratory distress syndrome (ARDS), intensive care unit (ICU) care, and severe COVID-19, were included in the analysis. Inverse variance method was used to obtain mean differences and its standard deviations. Maentel-Haenszel formula was used to calculate dichotomous variables to obtain odds ratios (ORs) along with its 95% confidence intervals. Random-effect models were used for meta-analysis regardless of heterogeneity. Restricted-maximum likelihood random-effects meta-regression was performed for age, gender, cardiac comorbidity, hypertension, diabetes mellitus, COPD, and smoking.

RESULTS

There were a total of 3099 patients from 24 studies. Meta-analysis showed that patients with poor outcome have a lower lymphocyte count (mean difference - 361.06 μL [- 439.18, - 282.95], p < 0.001; I 2 84%) compared to those with good outcome. Subgroup analysis showed lower lymphocyte count in patients who died (mean difference - 395.35 μL [- 165.64, - 625.07], p < 0.001; I 2 87%), experienced ARDS (mean difference - 377.56 μL [- 271.89, - 483.22], p < 0.001; I 2 0%), received ICU care (mean difference - 376.53 μL [- 682.84, - 70.22], p = 0.02; I 2 89%), and have severe COVID-19 (mean difference - 353.34 μL [- 250.94, - 455.73], p < 0.001; I 2 85%). Lymphopenia was associated with severe COVID-19 (OR 3.70 [2.44, 5.63], p < 0.001; I 2 40%). Meta-regression showed that the association between lymphocyte count and composite poor outcome was affected by age (p = 0.034).

CONCLUSION

This meta-analysis showed that lymphopenia on admission was associated with poor outcome in patients with COVID-19.

C-reactive protein, procalcitonin, D-dimer, and ferritin in severe coronavirus disease-2019: a meta-analysis

BACKGROUND

Patients critically ill with coronavirus disease-2019 (COVID-19) feature hyperinflammation, and the associated biomarkers may be beneficial for risk stratification. We aimed to investigate the association between several biomarkers, including serum C-reactive protein (CRP), procalcitonin (PCT), D-dimer, and serum ferritin, and COVID-19 severity.

METHODS

We performed a comprehensive systematic literature search through electronic databases. The outcome of interest for this study was the composite poor outcome, which comprises mortality, acute respiratory distress syndrome, need for care in an intensive care unit, and severe COVID-19.

RESULTS

A total of 5350 patients were pooled from 25 studies. Elevated CRP was associated with an increased composite poor outcome [risk ratio (RR) 1.84 (1.45, 2.33), p < 0.001; I2: 96%] and its severe COVID-19 (RR 1.41; I2: 93%) subgroup. A CRP ⩾10 mg/L has a 51% sensitivity, 88% specificity, likelihood ratio (LR) + of 4.1, LR- of 0.5, and an area under curve (AUC) of 0.84. An elevated PCT was associated with an increased composite poor outcome [RR 3.92 (2.42, 6.35), p < 0.001; I2: 85%] and its mortality (RR 6.26; I2: 96%) and severe COVID-19 (RR 3.93; I2: 63%) subgroups. A PCT ⩾0.5 ng/ml has an 88% sensitivity, 68% specificity, LR+ of 2.7, LR- of 0.2, and an AUC of 0.88. An elevated D-dimer was associated with an increased composite poor outcome [RR 2.93 (2.14, 4.01), p < 0.001; I2: 77%], including its mortality (RR 4.15; I2: 83%) and severe COVID-19 (RR 2.42; I2: 58%) subgroups. A D-dimer >0.5 mg/L has a 58% sensitivity, 69% specificity, LR+ of 1.8, LR- of 0.6, and an AUC of 0.69. Patients with a composite poor outcome had a higher serum ferritin with a standardized mean difference of 0.90 (0.64, 1.15), p < 0.0001; I2: 76%.

CONCLUSION

This meta-analysis showed that an elevated serum CRP, PCT, D-dimer, and ferritin were associated with a poor outcome in COVID-19. The reviews of this paper are available via the supplemental material section.

Impact of cerebrovascular and cardiovascular diseases on mortality and severity of COVID-19-systematic review, meta-analysis, and meta-regression

BACKGROUND

We conducted a systematic review and meta-analysis to evaluate the latest evidence on the association between cerebrovascular, and cardiovascular diseases and poor outcome in patients with Coronavirus Disease 2019 (COVID-19) pneumonia.

METHODS

A comprehensive systematic literature search was performed using PubMed, SCOPUS, EuropePMC, and Cochrane Central Database. The outcome of interest was composite poor outcome that comprised of mortality and severe COVID-19.

RESULTS

A total of 4448 patients were obtained from 16 studies. Cerebrovascular disease was associated with an increased composite poor outcome (RR 2.04 [1.43,2.91], p<0.001; I2: 77%). Subgroup analysis revealed that cerebrovascular disease was associated with mortality (RR 2.38 [1.92,2.96], p<0.001; I2: 0%) and showed borderline significance for severe COVID-19 (RR 1.88 [1.00,3.51], p = 0.05; I2: 87%). Cardiovascular disease was associated with increased composite poor outcome (RR 2.23 [1.71,2.91], p<0.001; I2: 60%), mortality (RR 2.25 [1.53,3.29], p<0.001; I2: 33%) and severe COVID-19 (RR 2.25 [1.51,3.36], p<0.001; I2: 76%). Meta-regression demonstrate that the association was not influenced by gender, age, hypertension, diabetes, and respiratory comorbidities. Furthermore, the association between cerebrovascular disease and poor outcome was not affected by cardiovascular diseases and vice versa.

CONCLUSION

Cerebrovascular and cardiovascular diseases were associated with an increased risk for poor outcome in patients with COVID-19.

Hypertension is associated with increased mortality and severity of disease in COVID-19 pneumonia: A systematic review, meta-analysis and meta-regression

OBJECTIVE

To investigate the association between hypertension and outcome in patients with Coronavirus Disease 2019 (COVID-19) pneumonia.

METHODS

We performed a systematic literature search from several databases on studies that assess hypertension and outcome in COVID-19. Composite of poor outcome, comprising of mortality, severe COVID-19, acute respiratory distress syndrome (ARDS), need for intensive care unit (ICU) care and disease progression were the outcomes of interest.

RESULTS

A total of 6560 patients were pooled from 30 studies. Hypertension was associated with increased composite poor outcome (risk ratio (RR) 2.11 (95% confidence interval (CI) 1.85, 2.40), p < 0.001; I2, 44%) and its sub-group, including mortality (RR 2.21 (1.74, 2.81), p < 0.001; I2, 66%), severe COVID-19 (RR 2.04 (1.69, 2.47), p < 0.001; I2 31%), ARDS (RR 1.64 (1.11, 2.43), p = 0.01; I2,0%, p = 0.35), ICU care (RR 2.11 (1.34, 3.33), p = 0.001; I2 18%, p = 0.30), and disease progression (RR 3.01 (1.51, 5.99), p = 0.002; I2 0%, p = 0.55). Meta-regression analysis showed that gender (p = 0.013) was a covariate that affects the association. The association was stronger in studies with a percentage of males < 55% compared to ⩾ 55% (RR 2.32 v. RR 1.79).

CONCLUSION

Hypertension was associated with increased composite poor outcome, including mortality, severe COVID-19, ARDS, need for ICU care and disease progression in patients with COVID-19.

Clinical frailty scale and mortality in COVID-19: A systematic review and dose-response meta-analysis

INTRODUCTION

National Institute for Health and Care Excellence (NICE) endorsed clinical frailty scale (CFS) to help with decision-making. However, this recommendation lacks an evidence basis and is controversial. This meta-analysis aims to quantify the dose-response relationship between CFS and mortality in COVID-19 patients, with a goal of supplementing the evidence of its use.

METHODS

We performed a systematic literature search from several electronic databases up until 8 September 2020. We searched for studies investigating COVID-19 patients and reported both (1) CFS and its distribution (2) CFS and its association with mortality. The outcome of interest was mortality, defined as clinically validated death or non-survivor. The odds ratio (ORs) will be reported per 1% increase in CFS. The potential for a non-linear relationship based on ORs of each quantitative CFS was examined using restricted cubic splines with a three-knots model.

RESULTS

There were a total of 3817 patients from seven studies. Mean age was 80.3 (SD 8.2), and 53% (48-58%) were males. The pooled prevalence for CFS 1-3 was 34% (32-36%), CFS 4-6 was 42% (40-45%), and CFS 7-9 was 23% (21-25%). Each 1-point increase in CFS was associated with 12% increase in mortality (OR 1.12 (1.04, 1.20), p = 0.003; I2: 77.3%). The dose-response relationship was linear (Pnon-linearity=0.116). The funnel-plot analysis was asymmetrical; Trim-and-fill analysis by the imputation of two studies on the left side resulted in OR of 1.10 [1.03, 1.19].

CONCLUSION

This meta-analysis showed that increase in CFS was associated with increase in mortality in a linear fashion.

Multiorgan Failure With Emphasis on Acute Kidney Injury and Severity of COVID-19: Systematic Review and Meta-Analysis

BACKGROUND

Abnormalities in hematologic, biochemical, and immunologic biomarkers have been shown to be associated with severity and mortality in Coronavirus Disease 2019 (COVID-19). Therefore, early evaluation and monitoring of both liver and kidney functions, as well as hematologic parameters, are pivotal to forecast the progression of COVID-19.

OBJECTIVES

In this study, we performed a systematic review and meta-analysis to investigate the association between several complications, including acute kidney injury (AKI), acute liver injury (ALI), and coagulopathy, with poor outcomes in COVID-19.

DESIGN

Systematic review and meta-analysis.

SETTING

Observational studies reporting AKI, ALI, and coagulopathy along with the outcomes of clinically validated death, severe COVID-19, or intensive care unit (ICU) care were included in this study. The exclusion criteria were abstract-only publications, review articles, commentaries, letters, case reports, non-English language articles, and studies that did not report key exposures or outcomes of interest.

PATIENTS

Adult patients diagnosed with COVID-19.

MEASUREMENTS

Data extracted included author, year, study design, age, sex, cardiovascular diseases, hypertension, diabetes mellitus, respiratory comorbidities, chronic kidney disease, mortality, severe COVID-19, and need for ICU care.

METHODS

We performed a systematic literature search from PubMed, SCOPUS, EuropePMC, and the Cochrane Central Database. AKI and ALI follow the definition of the included studies. Coagulopathy refers to the coagulopathy or disseminated intravascular coagulation defined in the included studies. The outcome of interest was a composite of mortality, need for ICU care, and severe COVID-19. We used random-effects models regardless of heterogeneity to calculate risk ratios (RRs) for dichotomous variables. Heterogeneity was assessed using I 2. Random effects meta-regression was conducted for comorbidities and the analysis was performed for one covariate at a time.

RESULTS

There were 3615 patients from 15 studies. The mean Newcastle-Ottawa scale of the included studies was 7.3 ± 1.2. The AKI was associated with an increased the composite outcome (RR: 10.55 [7.68, 14.50], P < .001; I 2: 0%). Subgroup analysis showed that AKI was associated with increased mortality (RR: 13.38 [8.15, 21.95], P < .001; I 2: 24%), severe COVID-19 (RR: 8.12 [4.43, 14.86], P < .001; I 2: 0%), and the need for ICU care (RR: 5.90 [1.32, 26.35], P = .02; I 2: 0%). The ALI was associated with increased mortality (RR: 4.02 [1.51, 10.68], P = .005; I 2: 88%) in COVID-19. Mortality was higher in COVID-19 with coagulopathy (RR: 7.55 [3.24, 17.59], P < .001; I 2: 69%). The AKI was associated with the composite outcome and was not influenced by age (P = .182), sex (P = .104), hypertension (P = .788), cardiovascular diseases (P = .068), diabetes (P = .097), respiratory comorbidity (P = .762), and chronic kidney disease (P = .77).

LIMITATIONS

There are several limitations of this study. Many of these studies did not define the extent of AKI (grade), which may affect the outcome. Acute liver injury and coagulopathy were not defined in most of the studies. The definition of severe COVID-19 differed across studies. Several articles included in the study were published at preprint servers and are not yet peer-reviewed. Most of the studies were from China; thus, some patients might overlap across the reports. Most of the included studies were retrospective in design.

CONCLUSIONS

This meta-analysis showed that the presence of AKI, ALI, and coagulopathy was associated with poor outcomes in patients with COVID-19.

Elevated N-terminal pro-brain natriuretic peptide is associated with increased mortality in patients with COVID-19: systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to assess the association between N-terminal pro-brain natriuretic peptide (NT-proBNP) and mortality in patients with COVID-19.

METHODS

Systematic literature search from several electronic databases were performed. The outcome was mortality (non-survivor) in patients with COVID-19 pneumonia. NT-proBNP data were in continuous variable (pg/mL), dichotomous data (elevated/non-elevated) and effect estimate adjusted to cardiac injury/elevated biomarkers of cardiac injury.

RESULTS

A total of 967 patients from six studies were included in this analysis. NT-proBNP was higher in non-survivor group (standardised mean difference 0.75 (0.44, 1.07), p<0.001; I2: 61%). Elevated NT-proBNP was associated with increased mortality (RR 3.63 (92.21, 5.95), p<0.001; I2: 60%). Sensitivity analysis by removing a study reduces heterogeneity (risk ratio 3.47 (2.36, 5.11), p<0.001; I2: 49%). Pooled adjusted HR (adjusted to cardiac injury/elevated biomarkers of cardiac injury) showed that elevated NT-proBNP was independently associated with mortality (HR 1.37 (1.19, 1.57), p<0.001; I2: 0%, p=0.77). Pooled analysis of multiple cut-off point resulted in a sensitivity of 76% (46%-92%) and specificity of 88% (71%-96%). Summary receiver operating characteristic curve analysis demonstrates an area under curve of 0.90 (0.87-0.93). Elevated NT-proBNP has a likelihood ratio (LR) +6.4 and LR -0.3.

CONCLUSION

Elevated NT-proBNP level was associated with increased mortality in COVID-19 pneumonia.

The use of renin angiotensin system inhibitor on mortality in patients with coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis

BACKGROUND

and Aims; To investigate the association between use of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin-receptor blocker (ARB) and outcomes of hypertensive COVID-19 patients, a systematic review and meta-analysis were performed.

METHODS

We systematically searched PubMed, EuropePMC, ProQuest, and Cochrane Central Databases using the terms "(COVID-19 OR SARS-CoV-2) AND (angiotensin converting enzyme OR angiotensin receptor blocker)". The primary and second outcomes were mortality (non-survivor) and severe COVID-19, respectively.

RESULTS

Totally, 7410 patients were included from 15 studies. Pooled analysis showed that the use of ACEI/ARB was not associated with mortality (OR 0.73 [0.38, 1.40], p = 0.34; I2: 81%) and severity (OR 1.03 [0.73, 1.45], p = 0.87; I2: 65%). Pooled adjusted OR showed no risk/benefit associated with ACEI/ARB use in terms of mortality (OR 0.83 [0.54, 1.27], p = 0.38; I2: 0%). Subgroup analysis showed that the use of ARB was associated with reduced mortality (OR 0.51 [0.29, 0.90], p = 0.02; I2: 22%) but not ACEI subgroup (OR 0.68 [0.39, 1.17], p = 0.16; I2: 0%). Meta-regression showed that the association between ACEI/ARB use and mortality in patients with COVID-19 do not varies by gender (p = 0.104). GRADE showed a very low certainty of evidence for effect of ACEI/ARB on mortality and severity. The certainty of evidence was very low for both ACEI and ARB subgroups.

CONCLUSION

Administration of a renin angiotensin system (RAS) inhibitor, was not associated with increased mortality or severity of COVID-19 in patients with hypertension. Specifically, ARB and not ACEI use, was associated with lower mortality.

Delirium and Mortality in Coronavirus Disease 2019 (COVID-19) - A Systematic Review and Meta-analysis

INTRODUCTION

Older adults are indisputably struck hard by the coronavirus disease 2019 (COVID-19) pandemic. The main objective of this meta-analysis is to establish the association between delirium and mortality in older adults with COVID-19.

METHODS

Systematic literature searches of PubMed, Embase, and Scopus databases were performed up until 28 November 2020. The exposure in this study was the diagnosis of delirium using clinically validated criteria. Delirium might be in-hospital, at admission, or both. The main outcome was mortality defined as clinically validated non-survivor/death. The effect estimates were reported as odds ratios (ORs) and adjusted odds ratios (aORs).

RESULTS

A total of 3,868 patients from 9 studies were included in this systematic review and meta-analysis. The percentage of patients with delirium was 27% [20%, 34%]. Every 1 mg/L increase in CRP was significantly associated with 1% increased delirium risk (OR 1.01 [1.00. 1.02], p=0.033). Delirium was associated with mortality (OR 2.39 [1.64, 3.49], p<0.001; I2: 82.88%). Subgroup analysis on delirium assessed at admission indicate independent association (OR 2.12 [1.39, 3.25], p<0.001; I2: 82.67%). Pooled adjusted analysis indicated that delirium was independently associated with mortality (aOR 1.50 [1.16, 1.94], p=0.002; I2: 31.02%). Subgroup analysis on delirium assessed at admission indicate independent association (OR 1.40 [1.03, 1.90], p=0.030; I2: 35.19%). Meta-regression indicates that the association between delirium and mortality were not significantly influenced by study-level variations in age, sex [reference: male], hypertension, diabetes, and dementia.

CONCLUSION

The presence of delirium is associated with increased risk of mortality in hospitalized older adults with COVID-19.

Diabetes and COVID-19: The past, the present, and the future

Diabetes, one of the most prevalent chronic diseases in the world, is strongly associated with a poor prognosis in COVID-19. Scrupulous blood sugar management is crucial, since the worse outcomes are closely associated with higher blood sugar levels in COVID-19 infection. Although recent observational studies showed that insulin was associated with mortality, it should not deter insulin use in hospitalized patients requiring tight glucose control. Back and forth dilemma in the past with regards to continue/discontinue certain medications used in diabetes have been mostly resolved. The initial fears of consequences related to continuing certain medications have been largely dispelled. COVID-19 also necessitates the transformation in diabetes care through the integration of technologies. Recent advances in health-related technologies, notably telemedicine and remote continuous glucose monitoring, have become essential in the management of diabetes during the pandemic. Today, these technologies have changed the landscape of medicine and become more important than ever. Being a high-risk population, patients with type 1 or type 2 diabetes, should be prioritized for vaccination. In the future, as the pandemic fades, the prevalence of non-communicable diseases is expected to rise due to lifestyle changes and medical issues/dilemma encountered during the pandemic.

Prolonged P-wave duration in sinus rhythm pre-ablation is associated with atrial fibrillation recurrence after pulmonary vein isolation-A systematic review and meta-analysis

INTRODUCTION

A prolonged P-wave duration (PWD) in sinus rhythm pre-ablation has been hypothesized to be a non-invasive ECG marker associated with increased atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI). This systematic review and meta-analysis will assess the latest evidence on the association of prolonged PWD pre-ablation with AF recurrence after PVI.

HYPOTHESIS

Prolonged PWD pre-ablation is associated with AF recurrence after PVI.

METHODS

The inclusion criteria for this study are all cohort studies that assess prolonged PWD on ECG during sinus rhythm pre-ablation and its association with AF recurrence in post-PVI patients.

RESULTS

There were 1,482 patients with AF post-PVI from twelve cohort studies. The cut-off points for prolonged PWD ranges from >120 ms to >150 ms. Meta-analysis on six studies showed a pooled mean difference of PWD in subjects with recurrent AF and non-recurring AF was 12.54 ms [8.76-16.31], p < 0.001; I2 78%. Pooled odds ratio was 4.17 [2.10-8.31], p < 0.001; I2 72% and pooled hazard ratio was 1.93 [1.10-3.39], p = 0.02; I2 80%. Upon subgroup analysis, the association between prolonged PWD and AF recurrence was significant in signal-averaged ECG, 12-lead ECG, paroxysmal AF, >120-130 ms, and >140-150 ms PWD cut-off point subgroups.

CONCLUSION

These findings suggest that prolonged PWD with a cutoff of >120 ms to >150 ms in sinus rhythm before ablation may be associated with AF recurrence after PVI regardless of age, gender, left atrial size, and the presence of structural heart disease. We also encouraged further studies that investigate predicting models to include prolonged PWD as one of their parameters.

Visceral adiposity, subcutaneous adiposity, and severe coronavirus disease-2019 (COVID-19): Systematic review and meta-analysis

BACKGROUND AND AIMS

Body mass index (BMI) has previously been shown to increase mortality and disease severity in patients with COVID-19, but the pooled effect estimate was heterogeneous. Although BMI is widely used as an indicator, it cannot distinguish visceral from subcutaneous fat. This systematic review and meta-analysis aimed to investigate the association between visceral adiposity, subcutaneous fat, and severe COVID-19.

METHODS

We performed a systematic literature search using the databases: PubMed, Embase, and EuropePMC. Data on visceral fat area (VTA), subcutaneous fat area (SFA), and total fat area (TFA) were collected. The outcome of interest was severe COVID-19. We used a REML random-effects model to pool the mean differences and odds ratio (OR).

RESULTS

There were 5 studies comprising of 539 patients. Patients with severe COVID-19 have a higher VTA (mean difference 41.7 cm2 [27.0, 56.4], p < 0.001; I2: 0%) and TFA (mean difference 64.6 cm2 [26.2, 103.1], p = 0.001; I2: 0%). There was no significant difference in terms of SFA between patients with severe and non-severe COVID-19 (mean difference 9.3 cm2 [-4.9, 23.4], p = 0.199; I2: 1.2%). Pooled ORs showed that VTA was associated with severe COVID-19 (OR 1.9 [1.1, 2.2], p = 0.002; I2: 49.3%).

CONCLUSION

Visceral adiposity was associated with increased COVID-19 severity, while subcutaneous adiposity was not.

PROSPERO ID

CRD42020215876.

Ablation-index guided versus conventional contact-force guided ablation in pulmonary vein isolation - Systematic review and meta-analysis

BACKGROUND

Contact-force sensing catheter is widely used for catheter ablation, however, it did not take account of radiofrequency power. Ablation index (AI) is a novel marker incorporating contact force-time-power, was shown to be reliable in predicting lesion size and depth for radiofrequency delivery. We aimed to assess the latest evidence on ablation index guided procedure versus conventional ablation procedure.

METHODS

We performed a comprehensive search on topic that assesses ablation index guided procedure versus conventional procedures from inception up until February 2019 through PubMed, EuropePMC, EBSCOhost, Cochrane Central Database, and ClinicalTrials.gov.

RESULTS

A total of 1727 subjects from five studies were included. 12 months' incidence of AF/AT/AFL was lower in ablation index guided with an OR of 0.35 [0.17, 0.73], p = 0.005; I2 58%. Upon sensitivity analysis by removing a study, heterogeneity decreased to 0% with OR of 0.26 [0.15, 0.46], p < 0.001. First-pass isolation has a pooled OR of 11.29 [4.68, 27.20], p < 0.001; I2 58%. Pooled OR for acute pulmonary vein reconnection was 0.43 [0.29, 0.64], p < 0.001; I2 46%. AI group has a shorter fluoroscopy time of MD -1.62 [-2.62, -0.62] minutes, p = 0.001; I2 51% and total ablation time MD -9.96 [-17.16, -2.76] minutes, p < 0.001; I2 95%. Total procedural time and complication rate were similar.

CONCLUSION

Ablation index guided procedure resulted in a significantly lower incidence of AF/AT/AFL, shorter fluoroscopy time, and total ablation time. First-pass isolation was higher in AI group and acute PVR was lower in AI group. Ablation-index guided procedure has a similar safety profile to conventional ablation.

Incidence and impact of cardiac arrhythmias in coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis

BACKGROUND

Studies have shown that cardiac arrhythmias may occur in up to 44% of patients with severe coronavirus disease 2019 (COVID-19) and has been associated with an increased risk of death. This systematic review and meta-analysis aimed to evaluate the incidence of cardiac arrhythmias in patients with COVID-19 and their implications on patient prognosis.

METHODS

We performed a systematic literature search from PubMed, SCOPUS, Europe PMC, Cochrane Central Databases, and Google Scholar + Preprint Servers. The primary endpoint of the study was poor outcomes including mortality, severe COVID-19, and the need for ICU care.

RESULTS

A total of 4 studies including 784 patients were analyzed. The incidence of arrhythmia in patients with COVID-19 was 19% (9-28%; I2: 91.45). Arrhythmia occurred in 48% (38-57%; I2: 48.08) of patients with poor outcome and 6% (1-12%; I2: 85.33%) of patients without poor outcome. Patients with COVID-19 experiencing arrhythmia had an increased risk of poor outcome (RR 7.96 [3.77, 16.81], p < 0.001; I2: 71.1%). The funnel-plot analysis showed an asymmetrical funnel plot with most of the studies on the right side of the effect estimate. The regression-based Egger's test showed indication of small-study effects (p = 0.001).

CONCLUSION

Cardiac arrhythmias were significantly associated with an increased risk of poor outcome in COVID-19. Arrhythmias were observed in 19% of patients with COVID-19 and in 48% of patients with COVID-19 and poor outcomes.

Thrombocytopenia as a prognostic marker in COVID-19 patients: diagnostic test accuracy meta-analysis

This systematic review and meta-analysis aimed to evaluate thrombocytopenia as a prognostic biomarker in patients with coronavirus disease 2019 (COVID-19). We performed a systematic literature search using PubMed, Embase and EuropePMC. The main outcome was composite poor outcome, a composite of mortality, severity, need for intensive care unit care and invasive mechanical ventilation. There were 8963 patients from 23 studies. Thrombocytopenia occurred in 18% of the patients. Male gender (P = 0.037) significantly reduce the incidence. Thrombocytopenia was associated with composite poor outcome (RR 1.90 (1.43-2.52), P < 0.001; I2: 92.3%). Subgroup analysis showed that thrombocytopenia was associated with mortality (RR 2.34 (1.23-4.45), P < 0.001; I2: 96.8%) and severity (RR 1.61 (1.33-1.96), P < 0.001; I2: 62.4%). Subgroup analysis for cut-off <100 × 109/l showed RR of 1.93 (1.37-2.72), P < 0.001; I2: 83.2%). Thrombocytopenia had a sensitivity of 0.26 (0.18-0.36), specificity of 0.89 (0.84-0.92), positive likelihood ratio of 2.3 (1.6-3.2), negative likelihood ratio of 0.83 (0.75-0.93), diagnostic odds ratio of 3 (2, 4) and area under curve of 0.70 (0.66-0.74) for composite poor outcome. Meta-regression analysis showed that the association between thrombocytopenia and poor outcome did not vary significantly with age, male, lymphocyte, d-dimer, hypertension, diabetes and CKD. Fagan's nomogram showed that the posterior probability of poor outcome was 50% in patients with thrombocytopenia, and 26% in those without thrombocytopenia. The Deek's funnel plot was relatively symmetrical and the quantitative asymmetry test was non-significant (P = 0.14). This study indicates that thrombocytopenia was associated with poor outcome in patients with COVID-19.PROSPERO ID: CRD42020213974.

Efficacy and safety of PulseRider for treatment of wide-necked intracranial aneurysm-A systematic review and meta-analysis

OBJECTIVE

PulseRider is a novel self-expanding nickel-titanium (nitinol) stent for treatment of wide-necked aneurysms, which is commonly located at the arterial branches in the brain. This systematic review and meta-analysis aims to assess the efficacy and safety of PulseRider for treatment of wide-necked intracranial aneurysm.

METHOD

We performed a systematic literature search on articles that evaluate the efficacy and safety of PulseRider-assisted coiling of the wide-necked aneurysm from several electronic databases. The primary endpoint was adequate occlusion, defined as Raymond-Roy Class I + Raymond-Roy Class II upon immediate angiography and at six-month follow-up.

RESULTS

There were a total of 157 subjects from six studies. The rate of adequate occlusion on immediate angiography was 90% (95% CI, 85%-94%) and 91% (95% CI, 85%-96%) at six-month follow-up. Of these, Raymond-Roy Class I can be observed in 48% (95% CI, 41%-56%) of aneurysms immediately after coiling, and 64% (95% CI, 55%-72%) of aneurysms on six-month follow-up. Raymond-Roy Class II was found in 30% (95% CI, 23%-37%) of aneurysms immediately after coiling, and 25% (17-33) after six-month follow-up. Complications occur in 5% (95% CI, 1%-8%) of the patients. There were three intraoperative aneurysm rupture, three thrombus formation, three procedure-related posterior cerebral artery strokes, one vessel dissection, and one delayed device thrombosis. There was no procedure/device-related death.

CONCLUSIONS

PulseRider-assisted coiling for treatment of patients with wide-necked aneurysm reached 90% adequate occlusion rate that rises up to 91% at sixth month with 5% complication rate.

Fibrosis-4 index and mortality in coronavirus disease 2019: a meta-analysis

BACKGROUND/AIMS

In this meta-analysis, we aimed to evaluate the prognostic value of fibrosis-4 index (FIB-4) in COVID-19.

METHODS

We performed a comprehensive literature search of PubMed, Embase, and Scopus databases on 26 November 2020. FIB-4 was calculated by [age (years) × AST (IU/L)]/[platelet count (109/L) × √ALT (U/L)]. A value above cutoff point was considered high and a value below cutoff point was considered low. The main outcome was mortality, the association between high FIB-4 and mortality was reported in odds ratio (OR). Sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic OR (DOR), area under the curve (AUC) were generated.

RESULTS

There were 963 patients from five studies included in this systematic review and meta-analysis. Meta-analysis showed that high FIB-4 was associated with increased mortality [OR 3.96 (2.16-7.27), P < 0.001; I2: 41.3%]. High FIB-4 was associated mortality with a sensitivity of 0.56 (0.40-0.70), specificity of 0.80 (0.72-0.86), PLR 2.8 (1.8-4.2), NLR 0.55 (0.39-0.78), DOR 5 (2-10), and AUC of 0.77 (0.73-0.81). Fagan's nomogram indicated that for a pre-test probability (mortality) of 30%, a high FIB-4 was associated with 54% post-test probability and a low FIB-4 was associated with 19%, respectively. The funnel-plot analysis was asymmetrical, trim-and-fill analysis by imputation of a study on the left side using linear estimator resulted in an OR of 3.48 (1.97-6.14). Egger's test showed no indication of small-study effects (P = 0.881).

CONCLUSION

High FIB-4 was associated with mortality in patients with COVID-19.

Elevated De Ritis Ratio Is Associated With Poor Prognosis in COVID-19: A Systematic Review and Meta-Analysis

Objective: This meta-analysis aims to assess whether elevated De Ritis ratio is associated with poor prognosis in patients with coronavirus 2019 (COVID-19). Methods: A systematic literature search was performed using PubMed, Embase, and EuropePMC databases up until September 17, 2021. De Ritis ratio is also known as Aspartate aminotransferase/alanine transaminase (AST/ALT) ratio. The main outcome was poor prognosis, a composite of mortality, severity, the need for ICU care, and intubation. The effect measure was odds ratios (ORs) and mean differences. We generated sensitivity and specificity, negative and positive likelihood ratio (NLR and PLR), diagnostic odds ratio (DOR), and area under curve (AUC). Results: There were eight studies with 4,606 patients. De Ritis ratio was elevated in 44% of the patients. Patients with poor prognosis have higher De Ritis ratio [mean difference 0.41 (0.31, 0.50), p < 0.001; I 2: 81.0%] and subgroup analysis showed that non-survivors also have higher De Ritis Ratio [mean difference 0.47 (0.46, 0.48), p < 0.001; I 2: 0%]. Elevated De Ritis ratio was associated with poor prognosis [OR 3.28 (2.39, 4.52), p < 0.001; I 2: 35.8%]. It has a sensitivity of 55% (36-73), specificity of 71% (52-85), PLR 1.9, NLR.63, DOR of 3 (2-4), and AUC of.67 (0.63-0.71). The posterior probability of poor prognosis was 38% if De Ritis is elevated, while 17% if De Ritis is not elevated. Conclusion: Elevated De Ritis ratio is associated with poor prognosis in patients with COVID-19. Systematic Review Registration: PROSPERO ID: CRD42020216634.

Clinical Characteristics of De Novo Heart Failure and Acute Decompensated Chronic Heart Failure: Are They Distinctive Phenotypes That Contribute to Different Outcomes?

Heart failure is currently one of the leading causes of morbidity and mortality. Patients with heart failure often present with acute symptoms and may have a poor prognosis. Recent evidence shows differences in clinical characteristics and outcomes between de novo heart failure (DNHF) and acute decompensated chronic heart failure (ADCHF). Based on a better understanding of the distinct pathophysiology of these two conditions, new strategies may be considered to treat heart failure patients and improve outcomes. In this review, the authors elaborate distinctions regarding the clinical characteristics and outcomes of DNHF and ADCHF and their respective pathophysiology. Future clinical trials of therapies should address the potentially different phenotypes between DNHF and ADCHF if meaningful discoveries are to be made.

Antibiotic envelope is associated with reduction in cardiac implantable electronic devices infections especially for high-power device-Systematic review and meta-analysis

BACKGROUND

Infections after cardiac implantable electronic device (CIED) placement are associated with significant morbidity and mortality. The incidence of CIED is increasing overtime despite the optimal use of antimicrobial agents. This systematic review and meta-analysis will address the latest evidence on the use of AE to mitigate the risk of CIED infection, and which subset of patients will they benefit the most.

METHODS

We performed a comprehensive search on topics that assesses antibiotic envelope and implantable cardiac electronic device up until August 2019.

RESULTS

There were a total of 32,329 subjects from six studies. Antibiotic envelope was associated with a lower risk of major infection with OR 0.42 [0.19, 0.97], P = .04; I2: 58% and HR 0.52 [0.32, 0.85], P = .009; I2: 80%. Upon sensitivity analysis by removing a study, the OR became 0.40 [0.27, 0.59], P < .001; I2: 46%. Subgroup analysis for 12 months' infection was OR 0.65 [0.43, 0.99], P = .04; I2: 49%. Meta-analysis of propensity-matched cohort showed a reduced risk of infection with AE (OR of 0.14 [0.05, 0.41], P < .001; I2:0%). Mortality was similar in both AE and control groups. Antibiotic envelope reduced the incidence of infection in patients receiving high-power device (OR 0.44 [0.27, 0.73], P = .001; I2:0%) but not low-power device.

CONCLUSION

Antibiotic envelope (TYRX) was found to be safe and effective in reducing the risk of major infections in high-risk patients receiving CIED implantation, especially in those receiving high-power CIED.

Longer diagnosis-to-ablation time is associated with recurrence of atrial fibrillation after catheter ablation-Systematic review and meta-analysis

BACKGROUND

Diagnosis-to-ablation time (DTAT) has been postulated to be one of the predictors of atrial fibrillation (AF) recurrence, and it is a "modifiable" risk factor unlike that of many electrocardiographic or echocardiographic parameters. This development may change our consideration for ablation. In this systematic review and meta-analysis, we aim to analyze the latest evidence on the importance of DTAT and whether they predict the AF recurrence after catheter ablation.

METHODS

We performed a comprehensive search on topics that assess diagnosis-to-ablation time (DTAT) and AF recurrence from inception up until August 2019 through PubMed, EuropePMC, Cochrane Central Database, and http://ClinicalTrials.gov.

RESULTS

There was a total of 3548 patients from six studies. Longer DTAT was associated with increased risk for AF recurrence in all studies included. Meta-analysis of these studies showed that DTAT had a hazard ratio (HR) of 1.19 [1.02, 1.39], P = .03; I 2: 92% for AF recurrence. Upon sensitivity analysis by removing a study, HR became 1.24 [1.16, 1.32], P < .001; I 2: 29%. Meta-analysis on DTAT time >3 years had HR 1.73 [1.54, 1.93], P < .001; I 2: 45% for the recurrence of AF. Upon subgroup analysis of data that compared >6 years to <1 year, the HR was 1.93 [1.62, 2.29], P < .001; I 2: 0%.

CONCLUSION

Longer DTAT time is associated with an increased risk of AF recurrence. Hence, determining management at the earliest possible moment to avoid delay is of utmost importance.