Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Point-of-care lung ultrasound in the assessment of COVID-19: results of a UK multicentre service evaluation

BACKGROUND

Coronavirus disease 2019 has had a dramatic impact on the delivery of acute care globally. Accurate risk stratification is fundamental to the efficient organisation of care. Point-of-care lung ultrasound offers practical advantages over conventional imaging with potential to improve the operational performance of acute care pathways during periods of high demand. The Society for Acute Medicine and the Intensive Care Society undertook a collaborative evaluation of point-of-care imaging in the UK to describe the scope of current practice and explore performance during real-world application.

METHODS

A retrospective service evaluation was undertaken of the use of point-of-care lung ultrasound during the initial wave of coronavirus infection in the UK. We report an evaluation of all imaging studies performed outside the intensive care unit. An ordinal scale was used to measure the severity of loss of lung aeration. The relationship between lung ultrasound, polymerase chain reaction for SARS-CoV-2 and 30-day outcomes were described using logistic regression models.

RESULTS

Data were collected from 7 hospitals between February and September 2020. In total, 297 ultrasound examinations from 295 patients were recorded. Nasopharyngeal swab samples were positive in 145 patients (49.2% 95%CI 43.5-54.8). A multivariate model combining three ultrasound variables showed reasonable discrimination in relation to the polymerase chain reaction reference (AUC 0.77 95%CI 0.71-0.82). The composite outcome of death or intensive care admission at 30 days occurred in 83 (28.1%, 95%CI 23.3-33.5). Lung ultrasound was able to discriminate the composite outcome with a reasonable level of accuracy (AUC 0.76 95%CI 0.69-0.83) in univariate analysis. The relationship remained statistically significant in a multivariate model controlled for age, sex and the time interval from admission to scan Conclusion: Point-of-care lung ultrasound is able to discriminate patients at increased risk of deterioration allowing more informed clinical decision making.

Indwelling pleural catheters for malignancy related pleural effusions

OBJECTIVE

Malignant Pleural Effusion (MPE) carries significant morbidity and mortality. Indwelling pleural catheters (IPCs) are established in the management pathway. Large case reviews add to the evidence base regarding safety and efficacy.

PATIENTS AND METHODS

168 patients had an IPC inserted between January 2012 and December 2018 in a large pleural centre. Data on outcomes and complications were obtained from the patients' notes, laboratory and radiographic findings. A descriptive statistical methodology was applied.

RESULTS

168 IPCs were inserted in a predominantly male population. The overall complication rate is 13%. The incidence of any individual complication such as infection, metastatic seeding, drain displacement, and loculations are all less than previously described.

CONCLUSIONS

This case review adds to the large body of evidence that IPCs are safe and have minimal complications. Specific factors enabling this are the use of pre-operative antibiotics, the use of theatre space, and the experience of the pleural interventional physicians.

Idiopathic systemic capillary leak syndrome (Clarkson's disease) presenting with recurrent hypovolemic shock

A 49-year old male with a past medical history of myocardial infarction and compartment syndromes requiring fasciotomies presented on five occasions with hypovolemic shock. We describe his admissions and presumptive diagnoses which required large volumes of intravenous fluids, admission to intensive care for vasopressors and renal replacement therapy. The presentations were always precipitated by a prodrome of fatigue and pre-syncopal episodes. On his last admission, a diagnosis of Idiopathic systemic capillary leak syndrome (ISCLS), also known as Clarkson's Disease, was reached. He is currently receiving high dose intravenous immunoglobulins on a monthly basis.

Heart failure from thyrotoxicosis due to Graves' disease

A 30-year-old female patient with a past medical history of pernicious anaemia presented with pleuritic chest pain, palpitations, fatigue, coryzal symptoms and a high temperature. She was hypoxic and tachycardic and was extensively investigated as well as aggressively treated. A type 1 'gut feeling' assessment by the admitting medical registrar made the diagnosis possible as thyroid function tests were grossly deranged and pointed to Graves' disease causing heart failure, complicated by pneumonia. The patient was discharged on carbimazole, antibiotics and beta blockers. Due to a resultant thrombocytopaenia, she has now been swapped onto propylthiouracil and is under active follow up.

Ambulatory drainage and management of a pleural empyema

A 61 year old male presented to chest clinic with a lung abscess. This ruptured and resulted in an empyema that required a small bore chest drain. Pus started bypassing the drain, spilling out subcutaneously. This was probably due to the impending formation of an empyema necessitans. To stem the flow, a large bore drain was inserted. An ambulatory bag was connected to the end of that drain which enabled outpatient management through the ambulatory care unit over a ten week period. The chest drain stayed in for nine weeks. Risk stratification using the RAPID score was applied. This is a routine medical presentation with well-known and accepted investigations with routine organisms (mixed aerobic and anaerobic microbiota) and treatment with classical broad spectrum antibiotics. The striking feature of the case is that with strict supervision, patient education and motivation, ambulatory management is perfectly feasible and safe.

A review of a pleural service

This paper reviews the organisation and outcomes of a pleural service, specifically geared towards the management of malignant pleural effusions, in a district general hospital in the north east of England. We summarise the evidence behind local anaesthetic thoracoscopy and indwelling pleural catheters. We then summarise the review of our service, including a discussion around complications.

Malignant mesothelioma presenting as a breast mass

We present a case of a male patient with a breast mass, found to be a malignant mesothelioma. We discuss the diagnostic challenges, the need for heightened awareness in suspected cases, the histological classification of mesotheliomas and the treatments available. We believe this to be the second reported case of a mesothelioma presenting as a breast mass.