COVID-19, a tale of two peaks: patients' characteristics, treatments, and clinical outcomes

The added predictive role of echocardiography in patients with mild or moderate Coronavirus Disease 2019

AIMS

Recently, several therapeutic agents have decreased the progression to critical disease in patients with mild/moderate COVID-19. However, their use is limited to patients with ≥1 clinical risk factor. We aimed to evaluate echocardiographic features that may aid in risk stratification for patients with mild/moderate COVID-19.

METHODS

278 consecutive patients with mild/moderate COVID-19 underwent prospective clinical and echocardiographic examination, ≤7 days of symptoms, as part of a predefined protocol. Analysis to identify echocardiographic predictors of outcome was performed.

RESULTS

In the multivariable risk model, E/e', TAPSE, and pulmonary acceleration time (PAT) were associated with the composite outcome (p = 0.01, 0.005, 0.05, respectively). Stepwise analyses showed that the addition of echocardiography on top of having ≥1 clinical risk factor and even using each parameter separately improved the prediction of outcomes. If patients were re-categorized as high risk only if having both ≥1 clinical and ≥ 1 echocardiography risk parameter (E/e' > 8, TAPSE<1.8 cm, PAT<90 msec), or even one echo parameter separately, then specificity, positive predictive value, and accuracy improved. If patients were re-classified as high risk if having either ≥1 clinical risk factor or ≥ 1 high-risk echocardiography parameter, all five individuals who were missed by the ≥1 risk factor "rule", were correctly diagnosed as high risk. Similar analyses, including only patients with mild disease, showed that the addition of TAPSE improved the prediction of outcomes.

CONCLUSIONS

In patients with mild/moderate COVID-19, a very limited echocardiographic exam is sufficient for improved outcome prediction, and may improve resource allocation for new anti-COVID-19 agents.

TRANSLATIONAL ASPECT OF THE WORK

We show that among patients with mild/moderate COVID-19, several easily obtained echocardiographic findings are strongly correlated with mortality or progression to the need for invasive/non-invasive mechanical ventilation, even when adjusted for the presence or absence of ≥1 clinical risk factor. Furthermore, even a limited echocardiographic exam is sufficient to develop a strategy of risk stratification. We believe that our data have important implications for the clinicians involved in the acute treatment of patients with COVID-19.

The Comparison of Clinical Epidemiology of Hospitalized Patients with COVID-19 during the Third and Fourth Waves of the Pandemic in Gorgan

Background

COVID-19 has turned into a global public health crisis. This study intended to compare demographic characteristics, disease severity, treatment methods, and clinical outcomes in hospitalized patients with COVID-19 during the third and fourth waves of the pandemic in Golestan Province, Iran.

Methods

In this cross-sectional study, the clinical epidemiology of all COVID-19 patients, who were hospitalized in two educational hospitals in Golestan Province for 30 days from the start of the third and fourth waves of the coronavirus pandemic in 2021-2022, was assessed. Their electronic medical records were used to collect their epidemiological, demographic, laboratory, and clinical information and treatment outcome.

Results

In all, 930 electronic medical records of the hospitalized patients (351 in the third wave and 579 in the fourth wave) were studied. In the third and fourth waves, 29.06% and 13.13% of the patients had severe COVID-19, respectively (P = 0.001). The number of deaths in the third wave was larger compared to the fourth wave (P = 0.015). The mean duration of hospitalization was longer in the third wave than in the fourth wave (P = 0.001). The drugs administered most in these two waves were remdesivir, dexamethasone, and heparin, and the patients who received these drugs were compared in the third and fourth waves (P = 0.001).

Conclusion

The reduced rate of mortality in the fourth wave was compared to the third wave. This reduction can be attributed to the change in the national strategy adopted in terms of hospitalization criteria and treatment protocols taking into account the acquired experience, earlier hospitalization, and start of drug therapy.

Atrial Fibrillation in the Setting of Acute Pneumonia: Not a Secondary Arrhythmia

Atrial fibrillation (AF) is the most common arrhythmia in the setting of critically ill patients. Pneumonia, and in particular community-acquired pneumonia, is one of the most common causes of illness and hospital admission worldwide. This article aims to review the association between AF and acute diseases, with specific attention to pneumonia, from the pathophysiology to its clinical significance. Even though the relationship between pneumonia and AF has been known for years, it was once considered a transient bystander. In recent years there has been growing knowledge on the clinical significance of this arrhythmia in acute clinical settings, in which it holds a prognostic role which is not so different as compared to that of the so-called "primary" AF. AF is a distinct entity even in the setting of pneumonia, and acute critical illnesses in general, and it should therefore be managed with a guidelines-oriented approach, including prescription of anticoagulants in patients at thromboembolic risk, always considering patients' individuality. More data on the significance of the arrhythmia in this setting will help clinicians to give patients the best possible care.