Coronary artery calcium before and after hospitalization with pneumonia: The MESA study

Unmet needs in pneumonia research: a comprehensive approach by the CAPNETZ study group

Introduction

Despite improvements in medical science and public health, mortality of community-acquired pneumonia (CAP) has barely changed throughout the last 15 years. The current SARS-CoV-2 pandemic has once again highlighted the central importance of acute respiratory infections to human health. The “network of excellence on Community Acquired Pneumonia” (CAPNETZ) hosts the most comprehensive CAP database worldwide including more than 12,000 patients. CAPNETZ connects physicians, microbiologists, virologists, epidemiologists, and computer scientists throughout Europe. Our aim was to summarize the current situation in CAP research and identify the most pressing unmet needs in CAP research.

Methods

To identify areas of future CAP research, CAPNETZ followed a multiple-step procedure. First, research members of CAPNETZ were individually asked to identify unmet needs. Second, the top 100 experts in the field of CAP research were asked for their insights about the unmet needs in CAP (Delphi approach). Third, internal and external experts discussed unmet needs in CAP at a scientific retreat.

Results

Eleven topics for future CAP research were identified: detection of causative pathogens, next generation sequencing for antimicrobial treatment guidance, imaging diagnostics, biomarkers, risk stratification, antiviral and antibiotic treatment, adjunctive therapy, vaccines and prevention, systemic and local immune response, comorbidities, and long-term cardio-vascular complications.

Conclusion

Pneumonia is a complex disease where the interplay between pathogens, immune system and comorbidities not only impose an immediate risk of mortality but also affect the patients’ risk of developing comorbidities as well as mortality for up to a decade after pneumonia has resolved. Our review of unmet needs in CAP research has shown that there are still major shortcomings in our knowledge of CAP.

In-hospital prognostic role of coronary atherosclerotic burden in COVID-19 patients

AIMS

Currently, there are few available data regarding a possible role for subclinical atherosclerosis as a risk factor for mortality in Coronavirus Disease 19 (COVID-19) patients. We used coronary artery calcium (CAC) score derived from chest computed tomography (CT) scan to assess the in-hospital prognostic role of CAC in patients affected by COVID-19 pneumonia.

METHODS

Electronic medical records of patients with confirmed diagnosis of COVID-19 were retrospectively reviewed. Patients with known coronary artery disease (CAD) were excluded. A CAC score was calculated for each patient and was used to categorize them into one of four groups: 0, 1-299, 300-999 and at least 1000. The primary endpoint was in-hospital mortality for any cause.

RESULTS

The final population consisted of 282 patients. Fifty-seven patients (20%) died over a follow-up time of 40 days. The presence of CAC was detected in 144 patients (51%). Higher CAC score values were observed in nonsurvivors [median: 87, interquartile range (IQR): 0.0-836] compared with survivors (median: 0, IQR: 0.0-136). The mortality rate in patients with a CAC score of at least 1000 was significantly higher than in patients without coronary calcifications (50 vs. 11%) and CAC score 1-299 (50 vs. 23%), P < 0.05. After adjusting for clinical variables, the presence of any CAC categories was not an independent predictor of mortality; however, a trend for increased risk of mortality was observed in patients with CAC of at least 1000.

CONCLUSION

The correlation between CAC score and COVID-19 is fascinating and under-explored. However, in multivariable analysis, the CAC score did not show an additional value over more robust clinical variables in predicting in-hospital mortality. Only patients with the highest atherosclerotic burden (CAC ≥1000) could represent a high-risk population, similarly to patients with known CAD.

Qualitative coronary artery calcification scores and risk of all cause, COPD and pneumonia hospital admission in a large CT lung cancer screening cohort

BACKGROUND

Patients at high-risk for lung cancer and qualified for CT lung cancer screening (CTLS) are at risk for numerous cardio-pulmonary comorbidities. We sought to examine if qualitatively assessed coronary artery calcifications (CAC) on CTLS exams could identify patients at increased risk for non-cardiovascular events such as all cause, COPD and pneumonia related hospitalization and to verify previously reported associations between CAC and mortality and cardiovascular events.

STUDY DESIGN AND METHODS

Patients (n = 4673) from Lahey Hospital and Medical Center who underwent CTLS from January 12, 2012 through September 30, 2017 were included with clinical follow-up through September 30, 2019. CTLS exams were qualitatively scored for the presence and severity of CAC at the time of exam interpretation using a four point scale: none, mild, moderate, and marked. Multivariable Cox regression models were used to evaluate the association between CT qualitative CAC and all-cause, COPD-related, and pneumonia-related hospital admissions.

RESULTS

3631 (78%) of individuals undergoing CTLS had some degree of CAC on their baseline exam: 1308 (28.0%), 1128 (24.1%), and 1195 (25.6%) had mild, moderate and marked coronary calcification, respectively. Marked CAC was associated with all-cause hospital admission and pneumonia related admissions HR 1.48; 95% CI 1.23-1.78 and HR 2.19; 95% 1.30-3.71, respectively. Mild, moderate and marked CAC were associated with COPD-related admission HR 2.30; 95% CI 1.31-4.03, HR 2.17; 95% CI 1.20-3.91 and HR 2.27; 95% CI 1.24-4.15.

CONCLUSION

Qualitative CAC on CTLS exams identifies individuals at elevated risk for all cause, pneumonia and COPD-related hospital admissions.

Community-Acquired Pneumonia Patients at Risk for Early and Long-term Cardiovascular Events Are Identified by Cardiac Biomarkers

BACKGROUND

Community-acquired pneumonia (CAP) increases the risk of cardiovascular complications during and following the episode. The goal of this study was to determine the usefulness of cardiovascular and inflammatory biomarkers for assessing the risk of early (within 30 days) or long-term (1-year follow-up) cardiovascular events.

METHODS

A total of 730 hospitalized patients with CAP were prospectively followed up during 1 year. Cardiovascular (proadrenomedullin [proADM], pro-B-type natriuretic peptide (proBNP), proendothelin-1, and troponin T) and inflammatory (interleukin 6 [IL-6], C-reactive protein, and procalcitonin) biomarkers were measured on day 1, at day 4/5, and at day 30.

RESULTS

Ninety-two patients developed an early event, and 67 developed a long-term event. Significantly higher initial levels of proADM, proendothelin-1, troponin, proBNP, and IL-6 were recorded in patients who developed cardiovascular events. Despite a decrease at day 4/5, levels remained steady until day 30 in those who developed late events. Biomarkers (days 1 and 30) independently predicted cardiovascular events adjusted for age, previous cardiac disease, Pao₂/Fio₂ < 250 mm Hg, and sepsis: ORs (95% CIs), proendothelin-1, 2.25 (1.34-3.79); proADM, 2.53 (1.53-4.20); proBNP, 2.67 (1.59-4.49); and troponin T, 2.70 (1.62-4.49) for early events. For late events, the ORs (95% CIs) were: proendothelin-1, 3.13 (1.41-7.80); proADM, 2.29 (1.01-5.19); and proBNP, 2.34 (1.01-5.56). Addition of IL-6 levels at day 30 to proendothelin-1 or proADM increased the ORs to 3.53 and 2.80, respectively.

CONCLUSIONS

Cardiac biomarkers are useful for identifying patients with CAP at high risk for early and long-term cardiovascular events. They may aid personalized treatment optimization and for designing future interventional studies to reduce cardiovascular risk.