COVID-19 patients with acute pulmonary embolism have a higher mortality risk: systematic review and meta-analysis based on Italian cohorts

A COVID-19 specific multiparametric and ECG-based score for the prediction of in-hospital mortality: ELCOVID score

We aimed to develop and validate a COVID-19 specific scoring system, also including some ECG features, to predict all-cause in-hospital mortality at admission. Patients were retrieved from the ELCOVID study (ClinicalTrials.gov identifier: NCT04367129), a prospective, multicenter Italian study enrolling COVID-19 patients between May to September 2020. For the model validation, we randomly selected two-thirds of participants to create a derivation dataset and we used the remaining one-third of participants as the validation set. Over the study period, 1014 hospitalized COVID-19 patients (mean age 74 years, 61% males) met the inclusion criteria and were included in this analysis. During a median follow-up of 12 (IQR 7-22) days, 359 (35%) patients died. Age (HR 2.25 [95%CI 1.72-2.94], p < 0.001), delirium (HR 2.03 [2.14-3.61], p = 0.012), platelets (HR 0.91 [0.83-0.98], p = 0.018), D-dimer level (HR 1.18 [1.01-1.31], p = 0.002), signs of right ventricular strain (RVS) (HR 1.47 [1.02-2.13], p = 0.039) and ECG signs of previous myocardial necrosis (HR 2.28 [1.23-4.21], p = 0.009) were independently associated to in-hospital all-cause mortality. The derived risk-scoring system, namely EL COVID score, showed a moderate discriminatory capacity and good calibration. A cut-off score of ≥ 4 had a sensitivity of 78.4% and 65.2% specificity in predicting all-cause in-hospital mortality. ELCOVID score represents a valid, reliable, sensitive, and inexpensive scoring system that can be used for the prognostication of COVID-19 patients at admission and may allow the earlier identification of patients having a higher mortality risk who may be benefit from more aggressive treatments and closer monitoring.

Pulmonary embolism impacts clinical outcomes of intubated patients with acute respiratory distress syndrome related to COVID-19

BACKGROUND

Pulmonary embolism (PE) in critically ill patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 is a major complication which might impact survival. We aimed to determine the prevalence of PE and assess its impact of PE on clinical outcomes in intubated patients with ARDS due to COVID-19.

METHODS

All intubated patients with ARDS due to COVID-19 admitted to the intensive care unit (ICU) of Geneva University Hospitals between March 9, 2020, and May 31, 2022, were included. A retrospective analysis was conducted on the occurrence of PE and its association with clinical outcomes. The primary outcome was ventilator-free days during the first 28 days after ICU admission. Linear regressions were performed to investigate the association between PE and outcomes.

RESULTS

Among the 370 intubated patients with ARDS related to COVID-19, 58 (15.7%) presented with PE. Patients with PE had significantly fewer ventilator-free days than patients without PE (median (IQR) of 3 (0-11) days versus 12 (0-19) days; p < 0.001). Mortality did not differ significantly between groups (12/58 [20.7%] of patients with PE versus 71/312 [22.8%] of patients without PE; p = 0.72). Duration of IMV, and ICU and hospital LOS were significantly longer among patients with PE. The need for ECMO support was similar among both groups.

CONCLUSIONS

The occurrence of PE in patients with ARDS due to COVID-19 had a significant impact on clinical outcomes. They had fewer ventilator-free days, longer duration of IMV, and longer ICU and hospital lengths of stay. However, pulmonary embolism was not associated with higher mortality.

ETHICS APPROVAL

Ethical committee of Geneva (BASEC #: 2020-00917).

Edoxaban and/or colchicine in outpatients with COVID-19: rationale and design of the CONVINCE trial

BACKGROUND

An excessive inflammatory response and a hypercoagulable state are not infrequent in patients with coronavirus disease-2019 (COVID-19) and are associated with adverse clinical outcomes. However, the optimal treatment strategy for COVID-19 patients managed in the out-of-hospital setting is still uncertain.

DESIGN

The CONVINCE (NCT04516941) is an investigator-initiated, open-label, blinded-endpoint, 2 × 2 factorial design randomized trial aimed at assessing two independently tested hypotheses (anticoagulation and anti-inflammatory ones) in COVID-19 patients. Adult symptomatic patients (≥18 years of age) within 7 days from reverse transcription-PCR (RT-PCR) diagnosis of SARS-CoV-2 infection managed at home or in nursery settings were considered for eligibility. Eligible patients fulfilling all inclusion and no exclusion criteria were randomized to edoxaban versus no treatment (anticoagulation hypothesis) and colchicine versus no treatment (anti-inflammatory hypothesis) in a 1 : 1:1 : 1 ratio. The study had two co-primary endpoints (one for each randomization), including the composite of major vascular thrombotic events at 25 ± 3 days for the anticoagulation hypothesis and the composite of SARS-CoV-2 detection rates at 14 ± 3 days by RT-PCR or freedom from death or hospitalizations (anti-inflammatory hypothesis). Study endpoints will be adjudicated by a blinded Clinical Events Committee. With a final sample size of 420 patients, this study projects an 80% power for each of the two primary endpoints appraised separately.

CONCLUSION

The CONVINCE trial aims at determining whether targeting anticoagulation and/or anti-inflammatory pathways may confer benefit in COVID-19 patients managed in the out-of-hospital setting.

TRIAL REGISTRATION

ClinicalTrials.gov number, NCT04516941.

Impact of Alteplase on Mortality in Critically Ill Patients with COVID-19 and Pulmonary Embolism

COVID-19 is an independent risk factor for pulmonary embolism (PE). Little is known about alteplase therapy in this patient group. A retrospective study analyzed 74 patients with PE and acute respiratory distress syndrome (ARDS) due to COVID-19 who were hospitalized in the intensive care unit in 2021. Patients with or without confirmed right heart thrombi (RHT) were treated with unfractionated heparin or alteplase. The mortality rate in patients with RHT treated with heparin was 100% compared to 37.9% and 55.2% in those treated with alteplase without RHT and alteplase with RHT, respectively. The risk of death in the alteplase group increased with delayed thrombolysis (p = 0.009, odds ratio (OR) = 1.73 95% CI (confidence interval) 1.14-2.62), increased D-dimer concentration (p = 0.02, OR = 1.43 95% CI 1.06-1.93), and decreased PaO₂/FiO₂ ratio (p = 0.001, OR = 0.56 95% CI 0.41-0.78). The receiver operating characteristic method determined that a 1-day delay in thrombolytic treatment, D-dimer concentration >5.844 mg/L, and PaO₂/FiO₂ <144 mmHg predicted a fatal outcome. The risk of death in patients with severe COVID-19 with ARDS and PE increases with higher D-dimer levels, decreased PaO₂/FiO₂, and delayed thrombolytic treatment. Thrombolysis seems to be treatment of choice in severe COVID-19 with PE and RHT. It should be carried out as soon as possible after the diagnosis is established.

Outcomes among heart failure patients hospitalized for acute pulmonary embolism and COVID-19 infection: Insight from the National Inpatient Sample

There is paucity of data regarding the outcomes of hospitalized acute pulmonary embolism (PE) patients with heart failure (HF) and Coronavirus Disease 2019 (COVID-19) infection. We utilized the 2020 National Inpatient Sample (NIS) Database in conducting a retrospective cohort study to investigate the outcomes of hospitalized acute PE patients with HF and COVID-19, looking at its impact on in-hospital mortality, thrombolysis, and thrombectomy utilization as well as hospital length of stay (LOS). A total of 23,413 hospitalized acute PE patients with HF were identified in our study, of which 1.26% (n = 295/23,413) had COVID-19 infection. Utilizing a stepwise survey multivariable logistic regression model that adjusted for confounders, COVID-19 infection among acute PE patients with HF was found to be an independent predictor of overall in-hospital mortality (adjusted odds ratio [aOR]: 2.77; 95% confidence interval [CI], 1.15-6.67; p = 0.023) and thrombolysis utilization (aOR: 5.52; 95% CI, 2.57-11.84; p ≤ 0.001) compared to those without COVID-19. However, there were comparable rates of thrombectomy utilization and LOS among acute PE patients with HF regardless of the COVID-19 infection status. On subgroup analysis, patients with HF with reduced ejection fraction was found to be associated with increased risk for in-hospital mortality (aOR: 3.89; 95% CI, 1.33-11.39; p = 0.013) and thrombectomy utilization (aOR: 4.58; 95% CI, 1.08-19.41; p = 0.042), whereas both HF subtypes were associated with increased thrombolysis utilization. COVID-19 infection among acute PE patients with HF was associated with higher over-all in-hospital mortality and increased thrombolysis utilization but had comparable hospital LOS as well as thrombectomy utilization.