Coronary Artery Calcification and Complications in Patients with COVID-19

Dr Ragini Sharma, MD reviewing Jean Guillaume Dillinger, Fatima Azzahra Benmessaoud, Théo Pezel, Sebastian Voicuet al, on behalf of COVID Research Group of Lariboisiere Hospital. Coronary Artery Calcification and Complications in Patients with COVID-19 J Am Coll Cardiol Img. 2020 Jul 15. Epublished DOI:10.1016/j.jcmg.2020.07.004

Study Questions:
Can coronary artery calcification as seen on non-contrast CT chest represent an easy integrative marker of worse prognosis in COVID-19 patients?

Methodology

  • Inclusion: Consecutive patients hospitalized with COVID-19 from 40 to 80 years of age with a non-contrast chest CT on the day of admission.
  • Exclusion: Patients with a history of CV disease were excluded.
  • CT assessment: The presence or absence of CAC (CAC+ and CAC- respectively) was noted. Agatston score was also measured despite technical limitations (no ECG gating and slice thickness 2.0 mm).
  • Primary outcomes evaluated: The first occurrence of mechanical noninvasive or invasive ventilation, extracorporeal membrane oxygenation or death (score of 5, 6 or 7 on the WHO Blueprint scale) within 30 days following hospital admission. As CAC is highly correlated to age, the primary outcome was segmented by median age group.

Results:

  • 356 patients screened, 147 were excluded (54 had previous CV disease, and 93 had no chest CT scan within 24 hours of admission). Finally, 209 consecutive patients were included.

    Median age was 62 years [interquartile range (IQR) 51-70], 72% were men, and all patients were grade 3 or 4 on the WHO Blueprint scale at entry (hospitalization without or with nasal oxygen).

    The primary outcome occurred in 50.0% CAC+ patients compared to 17.5% CAC- (p<0.0001).

    In patients <62 years, CAC was detected in 69%, and the primary outcome occurred in 48% CAC+ compared to 13% in CAC- patients.

    Using Kaplan Meier analysis, CAC was significantly associated with the primary outcome; hazard ratio (HR) 3.5

    Multivariate analysis with Cox proportional hazard model including age, sex, hypertension, smoking and diabetes showed that CAC was independently associated with the primary outcome.

    Crude hazards ratio (HR) for the primary outcome for Agatston score (per quartiles) was 1.6 and using the same Cox proportional hazard model, HR for Agatston score was 1.8.

    A significant increase in peak high-sensitivity cardiac troponin I was detected in 9.1% CAC+ compared to 3.4% CAC-.
Conclusions:
Presence and extent of coronary artery calcification are associated with a worse prognosis in hospitalized COVID-19 patients. The severity of immune response, endothelial dysfunction and myocardial stress due to COVID-19 could be exacerbated in patients with subclinical coronary atherosclerosis.