Acute cardiovascular events in patients with community acquired pneumonia: results from the observational prospective FADOI-ICECAP study

Prognostic value of the platelet, neutrophil, monocyte, basophil, and eosinophil to lymphocyte ratios in patients with severe community-acquired pneumonia (SCAP)

Severe community-acquired pneumonia (SCAP) is a serious respiratory inflammation disease with high morbidity and mortality. This study aimed to evaluate the prognostic value of the platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), basophil-to-lymphocyte ratio (BLR) and eosinophil-to-lymphocyte ratio (ELR) in patients with SCAP. The study retrospectively included 554 patients with SCAP, and the clinical data were obtained from the electronic patient record (EMR) system. The primary outcome was in-hospital mortality, and the secondary outcomes included hospital length of stay (LOS), overall survival (OS), admission to ICU, ICU LOS, and ICU mortality. The results showed that both NLR and BLR were significant but not independent prognostic factors for in-hospital mortality; NLR was negatively correlated with hospital LOS while ELR was positively correlated with hospital LOS; both increased NLR and increased BLR were associated with reduced OS, while increased ELR was associated with improved OS; increased PLR, NLR, MLR, and BLR were all correlated with elevated ICU admission rates, while increased ELR was correlated with a reduced ICU admission rate; ELR was positively correlated with ICU LOS; both higher NLR and higher BLR were associated with increased ICU mortality. In summary, NLR and BLR were useful prognostic factors for clinical outcomes in patients with SCAP.

Arterial Thrombosis in Acute Respiratory Infections: An Underestimated but Clinically Relevant Problem

During the COVID-19 pandemic, there was increased interest in the issue of thrombotic complications of acute respiratory infections. Clinical reports and pathological studies have revealed that thrombus formation in COVID-19 may involve the venous and arterial vasculature. As thrombotic complications of infectious respiratory diseases are increasingly considered in the context of COVID-19, the fact that thrombosis in lung diseases of viral and bacterial etiology was described long before the pandemic is overlooked. Pre-pandemic studies show that bacterial and viral respiratory infections are associated with an increased risk of thrombotic complications such as myocardial infarction, ischemic stroke, pulmonary embolism, and other critical illnesses caused by arterial and venous thrombosis. This narrative review article aims to summarize the current evidence regarding thrombotic complications and their pathogenesis in acute lower respiratory tract infections.

Prediction of new-onset atrial fibrillation with the C2HEST score in patients admitted with community-acquired pneumonia

PURPOSE

Patients hospitalized for community-acquired pneumonia (CAP) may have a higher risk of new-onset atrial fibrillation (NOAF). The C2HEST score was developed to evaluate the NOAF risk in the general population. Data on the value of the C2HEST score in acute patients admitted with CAP are lacking. We want to establish the predictive value of C2HEST score for NOAF in patients with CAP.

METHODS

Patients with CAP enrolled in the SIXTUS cohort were enrolled. C2HEST score was calculated at baseline. In-hospital NOAF was recorded. Receiver-operating Characteristic (ROC) curve and multivariable Cox proportional hazard regression analysis were performed.

RESULTS

We enrolled 473 patients (36% women, mean age 70.6 ± 16.5 years), and 54 NOAF occurred. Patients with NOAF were elderly, more frequently affected by hypertension, heart failure, previous stroke/transient ischemic attack, peripheral artery disease and hyperthyroidism. NOAF patients had also higher CURB-65, PSI class and CHA2DS2-VASc score. The C-index of C2HEST score for NOAF was 0.747 (95% confidence interval [95%CI] 0.705-0.786), higher compared to CURB-65 (0.611, 95%CI 0.566-0.655, p = 0.0016), PSI (0.665, 95%CI 0.621-0.708, p = 0.0199) and CHA2DS2-VASc score (0.696, 95%CI 0.652-0.737, p = 0.0762). The best combination of sensitivity (67%) and specificity (70%) was observed with a C2HEST score ≥ 4. This result was confirmed by the multivariable Cox analysis (Hazard Ratio [HR] for C2HEST score ≥ 4 was 10.7, 95%CI 2.0-57.9; p = 0.006), independently from the severity of pneumonia.

CONCLUSION

The C2HEST score was a useful predictive tool to identify patients at higher risk for NOAF during hospitalization for CAP.

CLINICAL TRIAL REGISTRATION

www.

CLINICALTRIALS

gov (NCT01773863).

The association of antiplatelet agents with mortality among patients with non-COVID-19 community-acquired pneumonia: a systematic review and meta-analysis

Background

Community-acquired pneumonia (CAP) triggers inflammatory and thrombotic host responses driving morbidity and mortality. Antiplatelet agents may favorably modulate these pathways; however, their role in non-COVID-19 CAP remains uncertain.

Objectives

To evaluate the association of antiplatelet agents with mortality in hospitalized patients with non-COVID-19 CAP.

Methods

We conducted a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs) of adult patients hospitalized for non-COVID-19 CAP exposed to antiplatelet agents (acetylsalicylic acid or P2Y12 inhibitors). We searched MEDLINE, Embase, and CENTRAL from inception to August 2023. Our primary outcome was all-cause mortality: meta-analyzed (random-effects models) separately for observational studies and RCTs. For observational studies, we used adjusted mortality estimates.

Results

We included 13 observational studies (123,012 patients; 6 reported adjusted mortality estimates) and 2 RCTs (225 patients; both high risk of bias). In observational studies reporting hazard ratio, antiplatelet agents were associated with lower mortality (hazard ratio, 0.65; 95% CI, 0.46-0.91; I 2  = 85%; 4 studies, 91,430 patients). In studies reporting adjusted odds ratio, antiplatelet agent exposure was associated with reduced odds of mortality (odds ratio, 0.67; 95% CI, 0.45-1.00; I 2  = 0%; 2 studies, 24,889 patients). Among RCTs, there was a nonsignificant association with mortality (risk ratio, 0.66; 95% CI, 0.20-2.25; I 2  = 54%; 2 studies, 225 patients). By the Grading of Recommendations, Assessment, Development, and Evaluation criteria, the certainty of the evidence was low, primarily due to risk of bias.

Conclusion

In hospitalized patients with non-COVID-19 CAP, antiplatelet agents may be associated with reduced mortality compared with usual care or placebo, but the certainty of evidence is low.

Predicting adverse outcomes in adults with a community-acquired lower respiratory tract infection: a protocol for the development and validation of two prediction models for (i) all-cause hospitalisation and mortality and (ii) cardiovascular outcomes

BACKGROUND

Community-acquired lower respiratory tract infections (LRTI) are common in primary care and patients at particular risk of adverse outcomes, e.g., hospitalisation and mortality, are challenging to identify. LRTIs are also linked to an increased incidence of cardiovascular diseases (CVD) following the initial infection, whereas concurrent CVD might negatively impact overall prognosis in LRTI patients. Accurate risk prediction of adverse outcomes in LRTI patients, while considering the interplay with CVD, can aid general practitioners (GP) in the clinical decision-making process, and may allow for early detection of deterioration. This paper therefore presents the design of the development and external validation of two models for predicting individual risk of all-cause hospitalisation or mortality (model 1) and short-term incidence of CVD (model 2) in adults presenting to primary care with LRTI.

METHODS

Both models will be developed using linked routine electronic health records (EHR) data from Dutch primary and secondary care, and the mortality registry. Adults aged ≥ 40 years with a GP-diagnosis of LRTI between 2016 and 2019 are eligible for inclusion. Relevant patient demographics, medical history, medication use, presenting signs and symptoms, and vital and laboratory measurements will be considered as candidate predictors. Outcomes of interest include 30-day all-cause hospitalisation or mortality (model 1) and 90-day CVD (model 2). Multivariable elastic net regression techniques will be used for model development. During the modelling process, the incremental predictive value of CVD for hospitalisation or all-cause mortality (model 1) will also be assessed. The models will be validated through internal-external cross-validation and external validation in an equivalent cohort of primary care LRTI patients.

DISCUSSION

Implementation of currently available prediction models for primary care LRTI patients is hampered by limited assessment of model performance. While considering the role of CVD in LRTI prognosis, we aim to develop and externally validate two models that predict clinically relevant outcomes to aid GPs in clinical decision-making. Challenges that we anticipate include the possibility of low event rates and common problems related to the use of EHR data, such as candidate predictor measurement and missingness, how best to retrieve information from free text fields, and potential misclassification of outcome events.

Cardiovascular Complications Are the Primary Drivers of Mortality in Hospitalized Patients With SARS-CoV-2 Community-Acquired Pneumonia

BACKGROUND

Hospitalized patients with SARS-CoV-2 community-acquired pneumonia (CAP) and associated comorbidities are at increased risk of cardiovascular complications. The magnitude of effect of cardiovascular complications and the role of prior comorbidities on clinical outcomes are not well defined.

RESEARCH QUESTION

What is the impact of cardiovascular complications on mortality in hospitalized patients with SARS-CoV-2 CAP? What is the impact of comorbidities and other risk factors on the risk of developing cardiovascular complications and mortality in these patients?

STUDY DESIGN AND METHODS

This cohort study included 1,645 hospitalized patients with SARS-CoV-2 CAP. Cardiovascular complications were evaluated. The clinical course during hospitalization was described by using a multistate model with four states: (1) hospitalized with no cardiovascular complications; (2) hospitalized with cardiovascular complications; (3) discharged alive; (4) and dead. Cox proportional hazards regression was used to analyze the impact of prior comorbid conditions on transitions between these states. Hazard ratios (HRs) and 95% CIs are reported.

RESULTS

Cardiovascular complications occurred in 18% of patients hospitalized with SARS-CoV-2 CAP. The mortality rate in this group was 45% vs 13% in patients without cardiovascular complications. Male subjects (HR, 1.32; 95% CI, 1.03-1.68), older adults (HR, 1.34; 95% CI, 1.03-1.75), and patients with congestive heart failure (HR, 1.59; 95% CI, 1.18-2.15), coronary artery disease (HR, 1.34; 95% CI, 1.00-1.79), atrial fibrillation (HR, 1.43; 95% CI, 1.06-1.95), direct admissions to the ICU (HR, 1.77; 95% CI, 1.36-2.32), and Pao2/Fio2 < 200 (HR, 1.46; 95% CI, 1.11-1.92) were more likely to develop cardiovascular complications following hospitalization for SARS-CoV-2 CAP; however, these factors are not associated with increased risk of death following a cardiovascular complication.

INTERPRETATION

Prior comorbidities, older age, male sex, severity of illness, and hypoxemia are associated with increased risk of cardiovascular complications. Once patients develop cardiovascular complications, the risk of death is extremely high. Cardiovascular complications are the primary drivers of mortality in hospitalized patients with SARS-CoV-2 CAP.

Prevalence of new-onset atrial fibrillation in hospitalized patients with community-acquired pneumonia: a systematic review and meta-analysis

Community-acquired pneumonia (CAP) is a common lower respiratory tract infection, often complicated by cardiovascular events, including cardiac arrhythmias. New-onset atrial fibrillation (newAF) has been associated with increased mortality in CAP patients, especially in those critically ill; however, limited data on the prevalence of newAF in patients with CAP are available. We aim to estimate the pooled prevalence of newAF and its impact on adverse outcomes in patients with CAP, through a systematic review and meta-analysis. MEDLINE and EMBASE were systematically searched from inception to 27 January 2022. All studies reporting the prevalence of newAF in CAP patients were included and all-cause mortality was extracted when available. The pooled prevalence of newAF, 95% Confidence Intervals (CI), and 95% Prediction Intervals (PI) were computed. The inconsistency index (I2) was calculated to measure heterogeneity. Subgroup analyses were also performed. A protocol for this study was registered on PROSPERO (CRD42022307422). Among 7,655 records retrieved, 10 studies were included, with a total of 280,589 CAP patients. Pooled prevalence of newAF in CAP patients was 7.6% (95% CI 6.4-9.0%, 95% PI 4.3-13.1%, I2 = 95%). Subgroup analyses showed no significant differences according to geographical location or study design. Patients with newAF had a higher risk of mortality among the studies included in the systematic review. NewAF is a common complication, occurring in 7.6% of CAP patients, with prediction intervals suggesting an even higher burden. CAP patients who develop newAF during hospitalization may be at higher risk of mortality in both short- and long-term follow-up.

CHA2DS2-VASc Score for Major Adverse Cardiovascular Events Stratification in Patients with Pneumonia with and without Atrial Fibrillation

BACKGROUND

Recent studies have shown an association between CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, sex category) score and outcome of acute myocardial infarction, stroke, and chest pain. As pneumonia can affect the cardiovascular system, this study aimed to investigate the performance of the CHA2DS2-VASc score for major adverse cardiovascular events (MACEs) risk stratification in patients with pneumonia.

METHODS

A retrospective population-based cohort study including 61,843 patients with pneumonia. These patients were divided into two cohorts that were stratified based on the presence or absence of underlying atrial fibrillation (AF). We calculated the CHA2DS2-VASc score and incidence density rates of MACEs in each cohort. Cox regression was conducted to calculate hazard ratio of MACEs in pneumonia patients. The diagnostic performance of CHA2DS2-VASc with regard to MACEs was tested using the receiver operator characteristic curve.

RESULTS

Pneumonia patients with higher CHA2DS2-VASc score were more likely develop MACEs in both the AF and non-AF groups. In the AF group, the areas under the curve (AUC), sensitivity, and specificity were 0.824 (0.7773-0.8708), 0.7, and 0.84 respectively. In the non-AF group, the AUC, sensitivity, and specificity were 0.8185 (0.8152-0.8217), 0.75, and 0.83 respectively.

CONCLUSIONS

The CHA2DS2-VASc score showed good performance in the prediction of MACE in patients with pneumonia.