Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China

Abstract

Dear Editor, The rapid emergence of COVID-19 in Wuhan city, Hubei Province, China, has resulted in thousands of deaths [1]. Many infected patients, however, presented mild flu-like symptoms and quickly recover [2]. To effectively prioritize resources for patients with the highest risk, we identified clinical predictors of mild and severe patient outcomes.Using the database of Jin Yin-tan Hospital and Tongji Hospital, we conducted a retrospective multicenter study of 68 death cases (68/150, 45%) and 82 discharged cases (82/150, 55%) with laboratory-confirmed infection of SARS-CoV-2. Patients met the discharge criteria if they had no fever for at least 3 days, significantly improved respiratory function, and had negative SARS-CoV-2 laboratory test results twice in succession. Case data included demographics, clinical characteristics, laboratory results, treatment options and outcomes. For statistical analysis, we represented continuous measurements as means (SDs) or as medians (IQRs) which compared with Student's t test or the Mann-Whitney-Wilcoxon test. Categorical variables were expressed as numbers (%) and compared by the χ 2 test or Fisher's exact test.The distribution of the enrolled patients' age is shown in Fig. 1a. There was a significant difference in age between the death group and the discharge group (p < 0.001) but no difference in the sex ratio (p = 0.43). A total of 63% (43/68) of patients in the death group and 41% (34/82) in the discharge group had underlying diseases (p = 0.0069). It should be noted that patients with cardiovascular diseases have a significantly increased risk of death when they are infected with SARS-CoV-2 (p < 0.001). A total of 16% (11/68) of the patients in the death group had secondary infections, and 1% (1/82) of the patients in the discharge group had secondary infections (p = 0.0018). Laboratory results showed that there were significant differences in white blood cell counts, absolute values of lymphocytes, platelets, albumin, total bilirubin, blood urea nitrogen, blood creatinine, myoglobin, cardiac troponin, C-reactive protein (CRP) and interleukin-6 (IL-6) between the two groups ( Fig. 1b and Supplementary Table 1).The survival times of the enrolled patients in the death group were analyzed. The distribution of survival time from disease onset to death showed two peaks, with the first one at approximately 14 days (22 cases) and the second one at approximately 22 days (17 cases) (Fig. 1c). An analysis of the cause of death was performed. Among the 68 fatal cases, 36 patients (53%) died of respiratory failure, five patients (7%) with myocardial damage died of circulatory failure, 22 patients (33%) died of both, and five remaining died of an unknown cause (Fig. 1d). Based on the analysis of the clinical data, we confirmed that some patients died of fulminant myocarditis. In this study, we first reported that the infection of SARS-CoV-2 may cause fulminant myocarditis. Given that fulminant myocarditis is characterized by a rapid progress and a severe state of illness [3], o...

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

“…Prior studies in other coronavirus species (MERS-CoV) have demonstrated evidence of acute myocarditis using cardiac magnetic resonance imaging (46), and myocardial inflammation and damage have been reported with COVID-19 infection. Among 68 deaths in a case series of 150 patients with COVID-19, 7% were attributed to myocarditis with circulatory failure and in 33% of cases which myocarditis may have played a contributing role to the patient's demise (21). Other reports have described fulminant myocarditis in the setting of high viral load with autopsy findings of inflammatory mononuclear infiltrate in myocardial tissue (26,47,48).…”

“…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).…”

“…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). Children account for the minority of laboratory-confirmed cases of COVID-19 in China and appear to be less susceptible to severe disease, possibly due to stronger innate immunity, fewer comorbidities, differences in maturation of viral receptors, and/or prior exposure to other coronavirus species (22).…”

“…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. Elevated serum troponin levels have been described in many patients infected with COVID-19, with significant differences noted between patients who died and those who survived to discharge (21,44). In a meta-analysis of 4 studies including a total of 341 patients, standardized mean difference of cardiac troponin I levels were significantly higher in those with severe COVID-19 related illness compared to those with non-severe disease (25.6, 95% CI 6.8-44.5) (45).…”

Clinical considerations for patients with diabetes in times of COVID-19 epidemic

“…In a study in 140 patients with COVID-19 in Wuhan, China, diabetes was not a risk factor for severe disease course [9]. However, another study in 150 patients (68 deaths and 82 recovered patients) in Wuhan showed that the number of co-morbidities to be a significant predictor of mortality [10]. Analysis of 11 studies regarding laboratory abnormalities in patients with COVID-19 did not mention raised blood glucose or diabetes as predictor of severe disease [11].…”