April 21, 2020

Patients with COVID-19 and ST-segment elevation have poor prognosis, D‐dimer levels on admission predict in‐hospital mortality, case study suggests possible vertical transmission of SARS-CoV-2

By Denise Baez

NEW YORK -- April 21, 2020 -- In today’s DG Alert, we cover ST-segment elevation in patients with coronavirus disease 2019 (COVID-19), the prognostic utility of D-dimer levels on in-hospital mortality, and a possible case of vertical transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 

According to a case series published in The New England Journal of Medicine, patients with COVID-19 who had ST-segment elevation had a poor prognosis.

Sripal Bangalore, MD, New York University Grossman School of Medicine, New York, New York, and colleagues identified 18 patients with COVID-19 and ST-segment elevation treated at 6 New York City hospitals. 

The median age of the patients was 63 years, 83% were men, 33% had chest pain around the time of ST-segment elevation, 65% had hypertension, 41% had hypercholesterolemia, 35% had diabetes, and 18% had a history of coronary artery disease. Of the patients, 10 (56%) had ST-segment elevation at the time of presentation, and in the other 8 patients, it developed during hospitalisation (median, 6 days). 

Of 14 (78%) patients with focal ST-segment elevation, 5 (36%) had a normal left ventricular ejection fraction (1 with regional wall-motion abnormality) and 8 (57%) patients had a reduced left ventricular ejection fraction (5 with regional wall-motion abnormalities). One patient did not have an echocardiogram. Of the 4 patients with diffuse ST-segment elevation, 3 (75%) had a normal left ventricular ejection fraction and normal wall motion and 1 patient had a left ventricular ejection fraction of 10% with global hypokinesis.

Half of the patients underwent coronary angiography; 6 of these patients had obstructive disease and 5 (56%) underwent percutaneous coronary intervention (1 after the administration of fibrinolytic agents). 

The 8 patients (44%) who received a clinical diagnosis of myocardial infarction had higher median peak troponin and d-dimer levels (1,909 vs 858 ng/ml) than the 10 (56%) patients with noncoronary myocardial injury.

A total of 13 (72%) patients died in the hospital -- 4 with myocardial infarction and 9 with noncoronary myocardial injury.

“In this series of patients with COVID-19 who had ST-segment elevation, there was variability in presentation, a high prevalence of nonobstructive disease, and a poor prognosis,” the authors wrote. “Half the patients underwent coronary angiography, of whom two thirds had obstructive disease. Of note, all 18 patients had elevated d-dimer levels. In contrast, in a previous study involving patients who presented with ST-segment elevation myocardial infarction, 64% had normal d-dimer levels. Myocardial injury in patients with COVID-19 could be due to plaque rupture, cytokine storm, hypoxic injury, coronary spasm, microthrombi, or direct endothelial or vascular injury.”

Another study, published in Journal of Thrombosis and Haemostasis, showed that D‐dimer levels on admission predict in‐hospital mortality in patients with COVID-19. 

Litao Zhang, and Xinsheng Yan, Wuhan Asia Heart Hospital, Wuhan, China, and colleagues analysed data from 343 patients with COVID-19 treated at Wuhan Asia General Hospital from January 12, 2020, to March 15, 2020. Of the patients, 67 had D-dimer levels ≥2.0 µg/ml and 267 had D‐dimer levels <2.0 µg/ml on admission. 

A total of 13 deaths occurred during hospitalisation -- 12 deaths among patients with D-dimer levels ≥2.0 µg/ml and 1 in a patient with D-dimer levels <2.0 µg/ml (hazard ratio = 51.5; P < 0.001).

The optimum cut-off value of D‐dimer to predict in‐hospital mortality was 2.0 µg/ml with a sensitivity of 92.3% and a specificity of 83.3%. 

Compared with patients with D-dimer levels <2.0 µg/ml, patients with D-dimer levels ≥2.0 µg/ml had a higher incidence of underlying disease, such as diabetes, hypertension, coronary heart disease, and history of stroke. They also had lower levels of lymphocyte, haemoglobin, platelet count, and higher levels of neutrophil, C-reactive protein, and prothrombin time.

“D‐dimer on admission greater than 2.0µg/mL could effectively predict in‐hospital mortality… [And] improve management in patients with COVID-19,” the authors concluded.

Lastly, a case report published in the American Journal of Perinatology suggests possible vertical transmission of SARS-CoV-2. 

Maria Claudia Alzamora, MD, British American Hospital, Lima, Peru, and colleagues describe the case of a pregnant woman aged 41 years with diabetes presenting with a 4-day history of malaise, low-grade fever, and progressive shortness of breath. A nasopharyngeal swab was positive for COVID-19, but serology was negative. The patient developed respiratory failure requiring mechanical ventilation on day 5 of disease onset. 

The patient underwent a caesarean delivery, and neonatal isolation was implemented immediately after birth, without delayed cord clamping or skin-to-skin contact. 

The neonatal nasopharyngeal swab, 16 hours after delivery, was positive SARS-CoV-2 and immunoglobulin (Ig)-M and IgG for SARS-CoV-2 were negative. Maternal IgM and IgG were positive on postpartum day 4 (day 9 after symptom onset). 

“We report a severe presentation of COVID-19 during pregnancy,” the authors wrote. “To our knowledge, this is the earliest reported positive polymerase chain reaction in the neonate, raising the concern for vertical transmission. We suggest pregnant women should be considered as a high-risk group and minimise exposures for these reasons.”

SOURCE: The New England Journal of Medicine, Journal of Thrombosis and Haemostasis, and American Journal of Perinatology
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