The Usefulness of the C2HEST Risk Score in Predicting Clinical Outcomes among Hospitalized Subjects with COVID-19 and Coronary Artery Disease

Background: Even though coronary artery disease (CAD) is considered an independent risk factor of an unfavorable outcome of SARS-CoV-2-infection, the clinical course of COVID-19 in subjects with CAD is heterogeneous, ranging from clinically asymptomatic to fatal cases. Since the individual C₂HEST components are similar to the COVID-19 risk factors, we evaluated its predictive value in CAD subjects. Materials and Methods: In total, 2183 patients hospitalized due to confirmed COVID-19 were enrolled onto this study consecutively. Based on past medical history, subjects were assigned to one of two of the study arms (CAD vs. non-CAD) and allocated to different risk strata, based on the C₂HEST score. Results: The CAD cohort included 228 subjects, while the non-CAD cohort consisted of 1956 patients. In-hospital, 3-month and 6-month mortality was highest in the high-risk C₂HEST stratum in the CAD cohort, reaching 43.06%, 56.25% and 65.89%, respectively, whereas in the non-CAD cohort in the high-risk stratum, it reached: 26.92%, 50.77% and 64.55%. Significant differences in mortality between the C₂HEST stratum in the CAD arm were observed in post hoc analysis only for medium- vs. high-risk strata. The C₂HEST score in the CAD cohort could predict hypovolemic shock, pneumonia and acute heart failure during hospitalization, whereas in the non-CAD cohort, it could predict cardiovascular events (myocardial injury, acute heart failure, myocardial infract, carcinogenic shock), pneumonia, acute liver dysfunction and renal injury as well as bleedings. Conclusions: The C₂HEST score is a simple, easy-to-apply tool which might be useful in risk stratification, preferably in non-CAD subjects admitted to hospital due to COVID-19.

Usefulness of C2HEST Score in Predicting Clinical Outcomes of COVID-19 in Heart Failure and Non-Heart-Failure Cohorts

Background: Patients with heart failure represent a vulnerable population for COVID-19 and are prone to having worse prognoses and higher fatality rates. Still, the clinical course of the infection is dynamic, and complication occurrence in particular in patients with heart failure is fairly unpredictable. Considering that individual components of the C2HEST (C2: Coronary Artery Diseases (CAD)/Chronic obstructive pulmonary disease (COPD); H: Hypertension; E: Elderly (Age ≥ 75); S: Systolic HF; T: Thyroid disease) are parallel to COVID-19 mortality risk factors, we evaluate the predictive value of C2HEST score in patients with heart failure (HF) Material and Methods: The retrospective medical data analysis of 2184 COVID-19 patients hospitalized in the University Hospital in Wroclaw between February 2020 and June 2021 was the basis of the study. The measured outcomes included: in-hospital mortality, 3-month and 6-month all-cause-mortality, non-fatal end of hospitalization, and adverse in-hospital clinical events. Results: The heart failure cohort consists of 255 patients, while 1929 patients were assigned to the non-HF cohort. The in-hospital, 3-month, and 6-month mortality rates were highest in the HF cohort high-risk C2HEST stratum, reaching 38.61%, 53.96%, and 65.36%, respectively. In the non-HF cohort, in-hospital, 3-month, and 6-month mortalities were also highest in the high-risk C2HEST stratum and came to 26.39%, 52.78%, and 65.0%, respectively. An additional point in the C2HEST score increased the total death intensity in 10% of HF subjects (HR 1.100, 95% CI 0.968−1.250 p = 0.143) while in the non-HF cohort, the same value increased by 62.3% (HR 1.623, 95% CI 1.518−1.734 p < 0.0001). Conclusions: The C2HEST score risk in the HF cohort failed to show discriminatory performance in terms of mortality and other clinical adverse outcomes during hospitalization. C2HEST score in the non-HF cohort showed significantly better performance in terms of predicting in-hospital and 6-month mortality and other non-fatal clinical outcomes such as cardiovascular events (myocardial injury, acute heart failure, myocardial infarction, cardiogenic shock), pneumonia, sepsis, and acute renal injury.

Usefulness of the C2HEST Score in Predicting the Clinical Outcomes of COVID-19 in Diabetic and Non-Diabetic Cohorts

BACKGROUND

Diabetes mellitus is among the most frequent comorbidities worsening COVID-19 outcome. Nevertheless, there are no data regarding the optimal risk stratification of patients with diabetes and COVID-19. Since individual C₂HEST components reflect the comorbidities, we assumed that the score could predict COVID-19 outcomes.

MATERIAL AND METHODS

A total of 2184 medical records of patients hospitalized for COVID-19 at the medical university center were analyzed, including 473 diabetic patients and 1666 patients without any glucose or metabolic abnormalities. The variables of patients' baseline characteristics were retrieved to calculate the C₂HEST score and subsequently the diabetic and non-diabetic subjects were assigned to the following categories: low-, medium- or high-risk. The measured outcomes included: in-hospital mortality; 3-month and 6-month all-cause mortality; non-fatal end of hospitalization (discharged home/sudden-deterioration/rehabilitation) and adverse in-hospital clinical events.

RESULTS

A total of 194 deaths (41%) were reported in the diabetic cohort, including 115 in-hospital deaths (24.3%). The 3-month and 6-month in-hospital mortality was highest in the high-risk C₂HEST stratum. The C₂HEST score revealed to be more sensitive in non-diabetic-group. The estimated six-month survival probability for high-risk subjects reached 0.4 in both cohorts whereas for the low-risk group, the six-month survival probability was 0.7 in the diabetic vs. 0.85 in the non-diabetic group-levels which were maintained during whole observation period. In both cohorts, receiver operating characteristics revealed that C₂HEST predicts the following: cardiogenic shock; acute heart failure; myocardial injury; and in-hospital acute kidney injury.

CONCLUSIONS

We demonstrated the usefulness and performance of the C₂HEST score in predicting the adverse COVID-19 outcomes in hospitalized diabetic subjects.

C2HEST score for atrial fibrillation risk prediction models: a Diagnostic Accuracy Tests meta-analysis

BACKGROUND

This meta-analysis aimed to assess the value of the C₂HEST score to facilitate population screening and detection of AF risk in millions of populations and validate risk scores and their composition and discriminatory power for identifying people at high or low risk of AF. We searched major indexing databases, including Pubmed/Medline, ISI web of science, Scopus, Embase, and Cochrane central, using ("C2HEST" OR "risk scoring system" OR "risk score") AND ("atrial fibrillation (AF)" OR "atrial flutter" OR "tachycardia, supraventricular" OR "heart atrium flutter") without any language, study region or study type restrictions between 1990 and 2021 years. Analyses were done using Meta-DiSc. The title and abstract screening were conducted by two independent investigators.

RESULTS

Totally 679 records were found through the initial search, of which ultimately, nine articles were included in the qualitative and quantitative analyses. The risk of AF accompanied every one-point increase of C₂HEST score (OR 1.03, 95% CI 1.01-1.05, p < 0.00001), with a high heterogeneity across studies (I² = 100%). The SROC for C₂HEST score in the prediction of AF showed that the overall area under the curve (AUC) was 0.91 (95% CI 0.85-0.96), AUC in Asian population was 0.87 (95% CI: 0.78-0.95) versus non-Asian 0.95 (95% CI 0.91-0.99), and in general population was 0.92 (95% CI 0.85-0.99) versus those with chronic conditions 0.83 (95% CI 0.71-0.95), respectively.

CONCLUSIONS

The results of this research support the idea that this quick score has the opportunity for use as a risk assessment in patients' AF screening strategies.

HATCH Score and Left Atrial Size Predict Atrial High-Rate Episodes in Patients With Cardiac Implantable Electronic Devices

Background: Patients with sustained atrial high-rate episodes (AHRE) have a high risk of major adverse cardio/cerebrovascular events (MACCE). However, the prediction model and factors for the occurrence of AHRE are unknown. We aimed to identify independent factors and various risk models for predicting MACCE and AHRE.

Methods: We retrospectively enrolled 314 consecutive patients who had cardiac implantable electronic devices (CIEDs). The primary endpoint was MACCE after AHRE ≥3, 6 min, and 6 h. Atrial high-rate episodes was defined as >175 bpm (Medtronic^®) lasting ≥30 s. Multivariate Cox and logistic regression analysis with time-dependent covariates were used to determine variables associated with independent risk of MACCE and occurrence of AHRE ≥3 min, respectively.

Results: One hundred twenty-five patients (39.8%) developed AHRE ≥3 min, 103 (32.8%) ≥6 min, and 55 (17.5%) ≥6 h. During follow-up (median 32 months), 77 MACCE occurred (incidence 9.20/100 patient years, 95% CI 5.66–18.39). The optimal AHRE cutoff value was 3 min for MACCE, with highest Youden index 1.350 (AUC, 0.716; 95% CI, 0.638–0.793; p < 0.001). Atrial high-rate episodes ≥3 min−6 h were independently associated with MACCE. HATCH score and left atrial diameter were independently associated with AHRE ≥3 min. The optimal cutoff for HATCH score was 3 and for left atrial diameter was 4 cm for AHRE ≥3 min.

Conclusion: Patients with CIEDs who develop AHRE ≥3 min have an independently increased risk of MACCE. Comprehensive assessment using HATCH score and echocardiography of patients with CIEDs is warranted.

Identifying At-Risk Patients for Sustained Atrial High-Rate Episodes Using the C2HEST Score: The West Birmingham Atrial Fibrillation Project

Background Sustained atrial high-rate episodes (SAHREs) among individuals with a cardiac implantable electronic device are associated with an increased risk of adverse outcomes. Risk stratification for the development of SAHREs has never been investigated. We aimed to assess the performance of the C2HEST (coronary artery disease or chronic obstructive pulmonary disease [1 point each], hypertension [1 point], elderly [age ≥75 years, 2 points], systolic heart failure [2 points], thyroid disease [1 point]) score in predicting SAHREs in patients with cardiac implantable electronic devices without atrial fibrillation. Methods and Results Five Hundred consecutive patients with cardiac implantable electronic devices in the West Birmingham Atrial Fibrillation Project in the United Kingdom were followed since the procedure to observe the development of SAHREs, defined by atrial high-rate episodes lasting >24 hours. Risk factors and incidence of SAHREs were analyzed. The predictive value of the C2HEST score for SAHRE prediction was evaluated. Over a mean follow-up of 53.1 months, 44 (8.8%) patients developed SAHREs. SAHREs were associated with higher all-cause mortality (P<0.001) and ischemic stroke (P=0.001). Age and heart failure were associated with SAHRE occurrence. The incidence of SAHREs increased by the C2HEST score (39% higher risk per point increase). Among patients with a C2HEST score ≥4, the incidence of SAHREs was 3.62% per year (95% CI, 2.14-5.16). The C2HEST score had moderate predictive capability (area under the curve, 0.73; 95% CI, 0.64-0.81) and discriminative ability (log-rank P=0.003), which was better than other clinical scores (CHA2DS2-VASc, CHADS2, HATCH). Conclusions The C2HEST score predicted SAHRE incidence in patients without atrial fibrillation who had an cardiac implantable electronic device, with the highest risk seen in patients with a C2HEST score ≥4 The benefit of using the C2HEST score in clinical practice in this patient population needs further investigation.