The hidden interplay between sex and COVID-19 mortality: the role of cardiovascular calcification

Abstract

Recent clinical and demographical studies on COVID-19 patients have demonstrated that men experience worse outcomes than women. However, in most cases, the data were not stratified according to gender, limiting the understanding of the real impact of gender on outcomes. This study aimed to evaluate the disaggregated in-hospital outcomes and explore the possible interactions between gender and cardiovascular calcifications. Data was derived from the sCORE-COVID-19 registry, an Italian multicentre registry that enrolled COVID-19 patients who had undergone a chest computer tomography scan on admission. A total of 1683 hospitalized patients (mean age 67±14 years) were included. Men had a higher prevalence of cardiovascular comorbidities, a higher pneumonia extension, more coronary calcifications (63% vs.50.9%, p<0.001), and a higher coronary calcium score (391±847 vs. 171±479 mm3, p<0.001). Men experienced a significantly higher mortality rate (24.4% vs. 17%, p=0.001), but the death event tended to occur earlier in women (15±7 vs. 8±7 days, p= 0.07). Non-survivors had a higher coronary, thoracic aorta, and aortic valve calcium score. Female sex, a known independent predictor of a favorable outcome in SARS-CoV2 infection, was not protective in women with a coronary calcification volume greater than 100 mm3. There were significant differences in cardiovascular comorbidities and vascular calcifications between men and women with SARS-CoV2 pneumonia. The differences in outcomes can be at least partially explained by the different cardiovascular profiles. However, women with poor outcomes had the same coronary calcific burden as men. The presumed favorable female sex bias in COVID-19 must therefore be reviewed in the context of comorbidities, especially cardiovascular ones.

Advanced cardiac imaging in the spectrum of COVID-19 related cardiovascular involvement

“…However, Stefanini et al found out that 39% of COVID-19 patients with STEMI had negative invasive coronary angiography (ICA) probably for the higher prevalence of type-2 MI in patients during the acute phase of COVID-19. These data further supported the use of CCTA in COVID-19 patients [47], also having the advantage to simultaneously rule-out coronary artery disease (CAD) and pulmonary embolism (PE) using a triple rule-out scanning protocol [23,24] and to refine risk stratification of COVID-19 patients with the quantification of coronary artery calcium score (CAC) [7,9,10,16,25,48].…”

“…Coronary artery calcium score (CAC) is an established biomarker for risk stratification in patients with suspected CAD and its value has been also documented in COVID-19 setting [25]. Several studies [9,10,16,25] showed that elevated CAC score, specially >400 AU, is associated to poor prognosis. Female patients showed lower mortality compared to men.…”

“…Pre-existing cardiovascular risk factors and the occurrence of acute cardiac injury are both predictors of adverse events [5,6], being associated to more severe disease and higher mortality rate [1,3,[7][8][9][10][11][12][13][14][15][16].…”

Coronary Heart Disease and Coronavirus Disease 2019: Pathogenesis, Epidemiology, Association with Myocardial Revascularization

“…Despite the relatively low prevalence of prior revascularization among patients with COVID-19, this event significantly increases the risk of short-term mortality, with odds ratios ranging from 1.8 to 12.8 [38]. This statement is supported by the results of several foreign studies, which demonstrated that clinical outcomes in patients with COVID-19 are closely related to comorbidities in patients [39]. Identification of risk factors associated with poor outcomes in patients with COVID-19 remains critical to identifying vulnerable populations [40].…”

COVID-19 Mortality in Italy Varies by Patient Age, Sex and Pandemic Wave

“…Most likely, several sex-related factors contribute to the higher risk of males for poorer COVID-19 outcomes. A study of 1,683 Italian patients who underwent chest computed tomography at admission showed that men had a higher prevalence of cardiovascular comorbidities, more coronary calci cations, and a higher coronary calcium score than females [22]. Notably, the higher coronary calci c burden of men appeared to be associated with higher mortality.…”