Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Abstract

Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. MethodsIn this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratoryconfirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients).Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03-1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61-12·23; p<0·0001), and d-dimer greater than 1 µg/mL (18·42, 2·64-128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0-24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days.Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 µg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future.

Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the COVID-19 Pandemic

“…infection. Pending larger studies, several existing reports are suggestive of SARS-CoV2 infection leading to CV complications or exacerbation of preexisting CVD (6,15,21).…”

“…fever, cough, dyspnea, myalgias, fatigue, and diarrhea) as well as laboratory abnormalities such as lymphopenia (18), although knowledge of the clinical feature of the disease is evolving daily (1,19). In severe cases, COVID-19 may present as pneumonia, the acute respiratory distress syndrome (ARDS), with or without both distributive and cardiogenic shock, to which elderly populations with preexisting medical comorbidities are the most vulnerable (1,6,19,20). Notably while rates of concomitant infections with other viruses and bacterial superinfections in preliminary data appear low (15), patients with the most severe clinical presentations are likely still at risk for co-infections, and unsurprisingly, worse outcomes have been noted in such cases (20,21).…”

“…Myocardial injury, as defined by an increased troponin level, can occur due to myocardial ischemia or non-ischemic myocardial processes including myocarditis (6,42,43). With severe respiratory infection and hypoxia, especially in the setting of severe infection and ARDS due to COVID-19, it is likely that a number of patients will develop such injury.…”

“…Reports have also suggested that acute cardiac injury -which includes not only elevation of cardiac biomarkers to > 99 th percentile of the upper reference limit, but also electrocardiographic and echocardiographic abnormalities -is highly prevalent in patients with COVID-19 and is associated with more severe disease and worse prognosis. Cohort studies from hospitalized patients in China estimate that such injury occurs in 7-17% of hospitalized patients with the disease (1,6,19) and is significantly more common in patients admitted to the ICU (22.2% vs. 2.0%, p<0.001) and among those who died (59% vs.…”

“…Preexisting cardiovascular disease (CVD) may predispose to COVID-19 infection. Those with CVD who are infected by the virus have an elevated risk of adverse outcomes; and infection, itself, is associated with cardiovascular complications (4)(5)(6). Moreover, COVID-19 infection may also have numerous indirect effects relevant to CV health.…”