Vascular complications in 305 severely ill patients with COVID-19
a cohort study
Keywords:
Mortality, COVID-19, Cohort studies, Peripheral vascular diseases, Critical careAbstract
BACKGROUND: Although an association has been made between coronavirus disease 2019 (COVID-19) and microvascular disease, data on vascular complications (other than venous thromboembolism) are sparse. OBJECTIVE: To investigate the vascular complications in severely ill patients hospitalized with COVID-19 and their association with all-cause mortality. DESIGN AND SETTING: This cohort study was conducted at the Universidade Federal de São Paulo, Brazil. METHODS: All 305 consecutive patients diagnosed with COVID-19 and hospitalized in the intensive care unit (ICU) of a tertiary university hospital from April 2 to July 17, 2021, were included and followed up for 30 days. RESULTS: Of these, 193 (63.3%) were male, and the mean age was 59.9 years (standard deviation = 14.34). The mortality rate was 56.3% (172 patients), and 72 (23.6%) patients developed at least one vascular complication during the follow-up period. Vascular complications were more prevalent in the non-survivors (28.5%) than in the survivors (17.3%) group and included disseminated intravascular coagulation (DIC, 10.8%), deep vein thrombosis (8.2%), acrocyanosis (7.5%), and necrosis of the extremities (2%). DIC (adjusted odds ratio (aOR) 2.30, 95% confidence interval (CI) 1.01–5.24, P = 0.046) and acrocyanosis (aOR 5.21, 95% CI 1.48–18.27, P = 0.009) were significantly more prevalent in the non-survivors than in the survivors group. CONCLUSION: Vascular complications in critically ill COVID-19 patients are common (23.6%) and can be closely related to the mortality rate (56.3%) until 30 days after ICU admission. Macrovascular complications have direct implications for mortality, which is the main outcome of the management of COVID-19. REGISTRATION: RBR-4qjzh7 (https://ensaiosclinicos.gov.br/rg/RBR-4qjzh7).
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References
Phelan AL, Katz R, Gostin LO. The Novel Coronavirus Originating in Wuhan, China: Challenges for Global Health Governance. JAMA. 2020;323(8):709-10. PMID: 31999307; https://doi.org/10.1001/jama.2020.1097.
Yeo C, Kaushal S, Yeo D. Enteric involvement of coronaviruses: is faecal–oral transmission of SARS-CoV-2 possible? Lancet Gastroenterol Hepatol. 2020;5(4):335-7. PMID: 32087098; https://doi.org/10.1016/S24681253(20)30048-0.
COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet Lond Engl. 2020;396(10243):27–38. PMID: 32479829; https://doi.org/10.1016/S0140-6736(20)31182-X.
Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O. Potential Effects of Coronaviruses on the Cardiovascular System: A Review. JAMA. 2020;5(7):831-40. PMID: 32219363; https://doi.org/10.1001/jamacardio.2020.1286.
Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844-7. PMID: 32073213; https://doi.org/10.1111/jth.14768.
Lowenstein CJ, Solomon SD. Severe COVID-19 Is a Microvascular Disease. Circulation. 2020;142(17):1609-11. PMID: 32877231; https://doi.org/10.1161/CIRCULATIONAHA.120.050354.
Kochav SM, Coromilas E, Nalbandian A, et al. Cardiac Arrhythmias in COVID-19 Infection. Circ Arrhythm Electrophysiol. 2020;13(6):e008719. PMID: 32434385; https://doi.org/10.1161/CIRCEP.120.008719.
Flumignan RL, Tinôco JD de S, Pascoal PI, et al. Prophylactic anticoagulants for people hospitalised with COVID-19. Cochrane Database Syst Rev. 2020;10(10):CD013739. PMID: 33502773; https://doi.org/10.1002/14651858.CD013739.
Flumignan RL, Tinôco JD de S, Pascoal PI, et al. Prophylactic anticoagulants for people hospitalized with COVID-19: systematic review. Br J Surg. 2021;108(9):e299-e300. PMID: 34109373; https://doi.org/10.1093/bjs/znab197.
Pagnesi M, Baldetti L, Beneduce A, et al. Pulmonary hypertension and right ventricular involvement in hospitalised patients with COVID-19. Heart. 2020;106(17):1324-31. PMID: 32675217; https://doi.org/10.1136/heartjnl2020-317355.
Flumignan RL, Civile VT, Tinôco JD de S, et al. Anticoagulants for people hospitalised with COVID-19. Cochrane Database Syst Rev. 2022;3(3):CD013739. PMID: 35244208; https://doi.org/10.1002/14651858.CD013739.pub2.
Piazza G, Campia U, Hurwitz S, et al. Registry of Arterial and Venous Thromboembolic Complications in Patients With COVID-19. J Am Coll Cardiol. 2020;76(18):2060-72. PMID: 33121712; https://doi.org/10.1016/j.jacc.2020.08.070.
Ribeiro SB, Domingos LF, Moreno J. Arterial thrombosis in COVID-19: keep in mind to stay vigilant. Postgrad Med J. 2022;98(e2):e69. PMID: 35232835; https://doi.org/10.1136/postgradmedj-2021-140364.
von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-9. PMID: 18313558; https://doi.org/10.1016/j.jclinepi.2007.11.008.
WHO. Protocol: Real-time RT-PCR assays for the detection of SARS-CoV-2. Published 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/real-time-rt-pcr-assays-for-the-detection-of-sars-cov-2-institut-pasteur-paris.pdfsfvrsn=3662fcb6_2. Accessed in 2022 (Oct 24).
Lim W, Le Gal G, Bates SM, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: Diagnosis of venous thromboembolism. Blood Adv. 2018;2(22):3226-56. PMID: 30482764; https://doi.org/10.1182/bloodadvances.2018024828.
COMET. Core outcome set developers’ response to COVID-19 (7th July 2020). Published 2020. Available from: https://cometinitiative.org/Studies/Details/1538. Accessed in 2022 (Oct 24).
Taylor J, Toh CH, Hoots WK, Wada H, Levi M. Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation: On behalf of the scientific subcommittee on Disseminated Intravascular Coagulation (DIC) of the International Society on Thrombosis and Haematostasis (ISTH). Thromb Haemost. 2001;86(5):1327-30. PMID: 11816725; https://doi.org/10.1055/s00371616068.
Channappanavar R, Fett C, Mack M, et al. Sex-Based Differences in Susceptibility to Severe Acute Respiratory Syndrome Coronavirus Infection. J Immunol. 2017;198(10):4046-53. PMID: 28373583; https://doi.org/10.4049/jimmunol.1601896.
Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507-13. PMID: 32007143; https://doi.org/10.1016/S0140-6736(20)30211-7.
Jin M, Tong Q. Rhabdomyolysis as Potential Late Complication Associated with COVID-19. Emerg Infect Dis. 2020;26(7):1618-20. PMID: 32197060; https://doi.org/10.3201/eid2607.200445.
Linschoten M, Peters S, van Smeden M, et al. Cardiac complications in patients hospitalised with COVID-19. Eur Heart J Acute Cardiovasc Care. 2020;9(8):817-823. PMID: 33222494; https://doi.org/10.1177/2048872620974605.
Khan MZ, Jamal Y, Sutton B, Rauf F. Venous thromboembolism in patients with COVID-19 and correlation with D-dimers: a single-centre experience. BMJ Open Respir Res. 2020;7(1):e000779. PMID: 33199402; https://doi.org/10.1136/bmjresp-2020-000779.
Klok FA, Kruip MJHA, van der Meer NJM, et al. Confirmation of the high cumulative incidence of thrombotic complications in critically ill ICU patients with COVID-19: An updated analysis. Thromb Res. 2020;191:148-50. PMID: 32381264; https://doi.org/10.1016/j.thromres.2020.04.041.
Lodigiani C, Iapichino G, Carenzo L, et al. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res. 2020;191:9-14. PMID: 32353746; https://doi.org/10.1016/j.thromres.2020.04.024.
Lopes RD, de Barros E Silva PGM, Furtado RHM, et al. Therapeutic versus prophylactic anticoagulation for patients admitted to hospital with COVID-19 and elevated D-dimer concentration (ACTION): an open-label, multicentre, randomised, controlled trial. Lancet Lond Engl. 2021;397(10291):2253-63. PMID: 34097856; https://doi.org/10.1016/S0140-6736(21)01203-4.
Shi W, Lv J, Lin L. Coagulopathy in COVID-19: Focus on vascular thrombotic events. J Mol Cell Cardiol. 2020;146(May):32-40. PMID: 32681845; https://doi.org/10.1016/j.yjmcc.2020.07.003.
Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract. 2012;120(4):c179-84. PMID: 22890468; https://doi.org/10.1159/000339789.
Cheng Y, Luo R, Wang K, et al. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney Int. 2020;97(5):829-38. PMID: 32247631; https://doi.org/10.1016/j.kint.2020.03.005.
Benson RA, Nandhra S; The Vascular and Endovascular Research Network (VERN) COVID-19 Vascular Service (COVER) Tier 2 Study. Outcomes of Vascular and Endovascular Interventions Performed During the Coronavirus Disease 2019 (COVID-19) Pandemic. Ann Surg. 2021;273(4):630-5. PMID: 33378307; https://doi.org/10.1097/SLA.0000000000004722.
COVIDSurg Collaborative; GlobalSurg Collaborative. SARS-CoV-2 infection and venous thromboembolism after surgery: an international prospective cohort study. Anaesthesia. 2022;77(1):28-39. PMID: 34428858; https://doi.org/10.1111/anae.15563.
Kollias A, Kyriakoulis KG, Lagou S, et al. Venous thromboembolism in COVID-19: A systematic review and meta-analysis. Vasc Med Lond Engl. 2021;26(4):415-25. PMID: 33818197; https://doi.org/10.1177/1358863X21995566.
Roth GA, Mensah GA, Johnson CO, et al. Global Burden of Cardiovascular Diseases and Risk Factors, 1990-2019: Update from the GBD 2019 Study. J Am Coll Cardiol. 2020;76(25):2982-3021. Erratum in: J Am Coll Cardiol. 2021;77(15):1958-9. PMID: 33309175; https://doi.org/10.1016/j.jacc.2020.11.010.
