Clinical Course and Risk Factors for Mortality of Inpatients With COVID-19

Study Questions:

What are the clinical course and risk factors for mortality in adult patients admitted with coronavirus disease 2019 (COVID-19) infection, based on the experience from Wuhan, China?

Methods:

This is a retrospective cohort study in which the authors included all adult patients (≥18 years) with confirmed COVID-19 who were hospitalized in Wuhan, China between December 29, 2019 and January 31, 2020 and had either been discharged or had expired. Demographic, clinical, treatment, and laboratory data were extracted from the electronic medical record and compared between survivors and nonsurvivors. Analyses using univariable and multivariable logistic regression methods explored the risk factors associated with in-hospital mortality.

Results:

In total, 813 adult patients were hospitalized with COVID-19 during the study period. After exclusion of 613 patients who remained hospitalized or not confirmed to have COVID-19 infection by RNA testing, and excluding nine patients with incomplete medical records, 191 patients were included in the final analysis. Of this population, 54 patients died and 137 were discharged from the hospital. The median age was 56.0 years (interquartile range [IQR], 46.0-67.0 years), and ranged from 18 to 87 years. Comorbidities were present in approximately 50% of patients, with hypertension (30%) being the most common, followed by diabetes (19%) and coronary artery disease (8%).

The most common symptoms on admission were fever (94%) and cough (79%). The majority (95%) of patients received antibiotics and 21% received antivirals (lopinavir/ritonavir). The median time from illness onset to discharge was 22.0 days (IQR, 18.0-25.0 days) and the median time to death was 18.5 days (IQR, 15.0-22.0 days). Mechanical ventilation was required in 32 patients (17%), of whom 31 (97%) died. Extracorporeal membrane oxygenation was used in three patients, all of whom died. Common complications included sepsis (59%), acute respiratory distress syndrome (31%), heart failure (23%), and septic shock (20%), coagulopathy (19%), and acute cardiac injury (17%).

For multivariable logistic regression analysis, 171 patients with complete data were included (53 nonsurvivors and 118 survivors). Increased odds of in-hospital death were associated with older age (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.03-1.17), higher Sequential Organ Failure Assessment (SOFA) score (OR, 5.65; 95% CI, 2.61-12.23), and d-Dimer >1 µg/ml (OR, 18.42; 95% CI, 2.64-128.55) at admission. For survivors, the mean duration of viral shedding was 20.0 days (IQR, 17.0-24.0 days) from illness onset.

Conclusions:

This retrospective cohort study of hospitalized patients with COVID-19 demonstrated an association of older age, higher SOFA score, and elevated d-Dimer at admission as risk factors for death in adult patients with COVID-19. A significant number of hospitalized patients had other medical comorbidities, and patients exhibited prolonged viral shedding.

Perspective:

This retrospective cohort study offers important information regarding risk factors for morality in adult patients hospitalized with COVID-19. Older age, elevated SOFA score, and elevated D-dimer levels could help providers identify patients infected with COVID-19 with increased risk for mortality. This study documented prolonged viral shedding, underscoring the importance of isolation of infected patients and social distancing.

Clinical Topics: Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Hypertension

Keywords: Anti-Bacterial Agents, Antiviral Agents, China, Coronary Artery Disease, Coronavirus, Cough, Diabetes Mellitus, Electronic Health Records, Extracorporeal Membrane Oxygenation, Heart Failure, Hospital Mortality, Hypertension, Inpatients, Organ Dysfunction Scores, Patient Discharge, Primary Prevention, Respiration, Artificial, Respiratory Distress Syndrome, Adult, Risk Factors, Sepsis, Shock, Septic, Virus Shedding


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