Bedside echocardiography to predict mortality of COVID-19 patients beyond clinical data: Data from the PROVAR-COVID study

Pimentel, Sander Luis Gomes; Nascimento, Bruno Ramos; Franco, Juliane; Oliveira, Kaciane Krauss Bruno; Fraga, Clara Leal; Macedo, Frederico Vargas Botinha de; Raso, Leonardo Arruda de Moraes; Ávila, Renata Eliane de; Santos, Luiza Pereira Afonso dos; Rocha, Rodrigo Tavares Lanna; Oliveira, Renan Mello; Barbosa, Márcia de Melo; Sable, Craig; Ribeiro, Antonio Luiz Pinho; Beaton, Andrea Zawacki; Nunes, Maria Carmo Pereira

doi:10.1590/0037-8682-0382-2021

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Major Article • Rev. Soc. Bras. Med. Trop. 54 • 2021 • https://doi.org/10.1590/0037-8682-0382-2021 linkcopy

Bedside echocardiography to predict mortality of COVID-19 patients beyond clinical data: Data from the PROVAR-COVID study

Authorship SCIMAGO INSTITUTIONS RANKINGS

INTRODUCTION: Cardiac involvement seems to impact prognosis of COVID-19, being more frequent in critically ill patients. We aimed to assess the prognostic value of right ventricular (RV) and left ventricular (LV) dysfunction, evaluated by bedside echocardiography (echo), in patients hospitalized with COVID-19.

METHODS: Patients admitted in 2 reference hospitals in Brazil from Jul to Sept/2020 with confirmed COVID-19 and moderate/severe presentations underwent clinical and laboratory evaluation, and focused bedside echo (GE Vivid-IQ), at the earliest convenience, with remote interpretation. The association between demographics, clinical comorbidities and echo variables with all-cause hospital mortality was assessed, and factors significant at p<0.10 were put into multivariable models.

RESULTS: Total 163 patients were enrolled, 59% were men, mean age 64±16 years, and 107 (66%) were admitted to intensive care. Comorbidities were present in 144 (88%) patients: hypertension 115 (71%), diabetes 61 (37%) and heart failure 22 (14%). In-hospital mortality was 34% (N=56). In univariate analysis, echo variables significantly associated with death were: LV ejection fraction (LVEF, OR=0.94), RV fractional area change (OR=0.96), tricuspid annular plane systolic excursion (TAPSE, OR=0.83) and RV dysfunction (OR=5.3). In multivariate analysis, after adjustment for clinical and demographic variables, independent predictors of mortality were age≥63 years (OR=5.53, 95%CI 1.52-20.17), LVEF<64% (OR=7.37, 95%CI 2.10-25.94) and TAPSE<18.5 mm (OR=9.43, 95% CI 2.57-35.03), and the final model had good discrimination, with C-statistic=0.83 (95%CI 0.75-0.91).

CONCLUSION: Markers of RV and LV dysfunction assessed by bedside echo are independent predictors of mortality in hospitalized COVID-19 patients, after adjustment for clinical variables.

Keywords:
COVID-19; Echocardiography; Prognosis; SARS-Cov-2; Mortality

Variable:	Survivors (N=107)	Hospital death (N=56)	P-value:
Demographics and risk factors:
Age (median, (IQR))	62.0 (52.2 - 71.5)	68.2 (61.8 - 78.8)	0.010*
Sex (male, N (%)):	63 (58.9)	33 (58.9)	0.402
Any clinical comorbidities (N, %)	93 (86.9)	51 (91.1)	0.608
Hypertension (N, %):	75 (70.1)	40 (71.4)	1.000
Diabetes (N, %):	36 (33.6)	25 (44.6)	0.217
Heart failure (N, %):	15 (14.1)	7 (12.5)	0.812
Obesity (N, %):	13 (12.1)	5 (8.9)	0.786
Asthma (N, %):	5 (4.7)	4 (7.1)	0.721
Smoking (N, %):	26 (24.3)	13 (23.2)	1.000
COVID-19 symptoms at admission:
Symptom onset to admission (days, median (IQR))	7.0 (4.0 - 9.0)	7.0 (5.0 - 11.0)	0.432
Fever at admission (>37.8 ^oC) (N, %):	65 (60.7)	34 (60.7)	0.739
Cough (N, %):	80 (74.8)	42 (75.0)	1.000
Dyspnea (N, %):	80 (74.7)	52 (92.9)	0.006*
Diarrhea (N, %):	19 (17.8)	4 (7.1)	0.096
Headache (N, %)	14 (13.1)	3 (5.4)	0.269
Abdominal pain (N, %):	5 (4.7)	3 (5.4)	1.000
Anosmia (N, %):	17 (15.9)	3 (5.4)	0.121
Taste loss (N, %):	18 (16.8)	2 (3.6)	0.036*
Respiratory support and vasopressors:
Noninvasive ventilation (N, %)	14 (13.1)	10 (17.9)	0.486
Mechanical ventilation (N, %)	28 (26.2)	53 (94.6)	<0.001*
Days in mechanical ventilation (median, (IQR))	13.0 (6.0 - 23.0)	10.0 (7.0 - 16.0)	0.525
Tracheostomy (N, %)	10 (9.3)	15 (26.8)	0.618
Use of vasopressors (N, %)	21 (19.6)	51 (91.1)	<0.001*
Echo variables:
Admission to echo (days, median (IQR))	6.0 (3.0 - 9.0)	7.0 (3 - 12)	0.200
LVEF (%)	65.0 (61.0 - 70.0)	61.0 (46.0 - 66.0)	<0.001*
LV diastolic diameter (mm, median (IQR))	45.0 (43.0 - 49.0)	45.0 (40.0 - 49.0)	0.212
LV systolic diameter (mm, median (IQR))	29.0 (26.0 - 32.0)	32 (28.0 - 36.0)	0.008*
RV dysfunction (any) (N, %)	11 (10.3)	21 (37.5)	<0.001*
LA diameter (mm) (mean±SD)	37.9±4.7	36.3±6.1	0.084
RV fractional area change (%)(mean±SD)	39.8±10.0	35.6±11.4	0.046*
TAPSE (mm, median (IQR))	20.0 (18.0 - 23.0)	16.0 (14.0 - 19.0)	<0.001*
RV basal dimension (mm, median (IQR))	34.0 ( 31.0 - 38.0)	38.0 (36.0 - 43.0)	<0.001*
Septal E/E’ (median (IQR))	9.3 (8.0 - 11.8)	10.3 (9.2 - 13.0)	0.079
Tricuspid velocity (m/s) (mean±SD)	2.8±0.4	3.0±0.4	0.188
Mitral regurgitation (moderate/severe) (N, %):	12 (11.2)	1 (1.8)	0.007*
LV wall-motion abnormalities (N, %):	7 (6.5)	6 (10.7)	0.369
Pericardial effusion (N, %):	15 (14.0)	10 (17.8)	0.493

Univariable analysis:
Variable	OR:	95% CI:	P-value:
Demographics and risk factors:
Age (each 1 year):	1.03	1.01 - 1.05	0.013*
Sex (male):	1.41	0.72 - 2.75	0.312
Hypertension:	0.98	0.41 - 2.28	0.926
Diabetes:	1.58	0.79 - 3.17	0.194
Heart failure:	0.85	0.32 - 2.24	0.737
Obesity:	0.73	0.24 - 2.24	0.587
Asthma:	1.50	0.38 - 5.85	0.561
Smoking:	0.94	0.44 - 2.02	0.877
COVID-19 symptoms at admission:
Fever:	0.89	0.46 - 1.72	0.732
Cough:	1.09	0.51 - 2.33	0.823
Dyspnea:	4.39	1.45 - 13.29	0.009*
Diarrhea:	0.80	0.11 - 1.13	0.080
Abdominal pain:	1.16	0.27 - 5.07	0.840
Anosmia:	0.35	0.10 - 1.28	0.112
Taste loss:	0.21	0.05 - 0.97	0.045*
Echo variables:
LVEF (%)	0.94	0.92 - 0.98	<0.001*
RV dysfunction (any)	5.33	2.33 - 12.21	<0.001*
LA diameter (mm)	0.94	0.88 - 1.00	0.062
RV fractional area change (%)	0.96	0.93 - 0.99	0.049*
TAPSE (mm)	0.83	0.74 - 0.93	0.001*
RV basal dimension (mm)	1.10	1.03 - 1.18	0.004*
Septal E/E’	1.07	0.97 - 1.17	0.202
Tricuspid velocity (m/s)	2.60	0.68 - 9.92	0.161
Multivariable analysis†:
Age (each 1 year):	1.05	1.01 - 1.10	0.023*
LVEF (%):	0.96	0.91 - 0.99	0.048*
TAPSE (mm)	0.76	0.63 - 0.91	0.005*

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[TFN1] Abbreviations: LA: left atrium; LV: left ventricle; LVEF: left ventricular ejection fraction; OR: odds-ratio; RV: right ventricle; TAPSE: tricuspid annular plane systolic excursion. *p<0,05.