Prognostic impact of right ventricular dilatation and echocardiography use criteria in hospitalized COVID-19 patients
TL;DR
While AUC demonstrated high reliability, the significant and frequent changes in management suggest that the current guidelines may possess inherent limitations when addressing the unique, acute prognostic complexities of severe COVID-19 disease.
Abstract
Background
The surge of severe acute respiratory syndrome coronavirus 2 [coronavirus disease 2019 (COVID-19)] infection created unprecedented diagnostic and logistical pressures. Given the established potential for cardiac injury and the critical need to optimize scarce resources, establishing the clinical utility and prognostic value of transthoracic echocardiography (TTE) became imperative.
Aim
To evaluate the prognostic predictors and the adherence to appropriate use criteria (AUC) for TTE in a highly affected setting.
Methods
We performed a retrospective cohort study analyzing records from patients with confirmed COVID-19 who underwent TTE. Socio-demographic, biochemical, and echocardiographic parameters were collected. Mortality was the primary outcome. We assessed inter-observer agreement (Kappa statistic) for TTE indications (based on American College of Cardiology Foundation 2011 and American Society of Echocardiography 2020 guidelines) and the determination of clinical impact (a subsequent change in patient management).
Results
Total 149 patients were analyzed. Median age was 66 years [interquartile range (IQR): 56-73], median hospital stay was 13 days (IQR: 6-23). Overall and intensive care unit mortality rates were 39.6% and 60%, respectively. Elevated biochemical markers (leukocytes, neutrophils, lactate dehydrogenase, and C-reactive protein) were associated with mortality. Crucially, right ventricular (RV) dilatation and/or strain (P = 0.008) was identified as the sole echocardiographic finding significantly predictive of mortality. Inter-observer agreement for classifying AUC was high (κ ≥ 0.798). Furthermore, TTE prompted a change in clinical management in 79.7% of the cases.
Conclusion
RV pathology is a potent, quantifiable prognostic indicator. While AUC demonstrated high reliability, the significant and frequent changes in management suggest that the current guidelines may possess inherent limitations when addressing the unique, acute prognostic complexities of severe COVID-19 disease.