10 Mar 2020

Other coronary interventions COVID-19

Clinical Characteristics of Coronavirus Disease 2019 in China

Selected in New England Journal of Medicine by L. Biasco

Scarce and mostly unstructured data are currently available, and reports on clinical presentation, characteristics potential treatments and outcomes of this viral epidemic are still missing. This article published in NEJM provides structured data on 1099 patients with laboratory-confirmed Covid-19 from 552 Chinese hospitals, and represents to date, the largest published series.

References

Authors

Wei-jie Guan, Ph.D., Zheng-yi Ni, M.D., Yu Hu, M.D., Wen-hua Liang, Ph.D., Chun-quan Ou, Ph.D., Jian-xing He, M.D., Lei Liu, M.D., Hong Shan, M.D., Chun-liang Lei, M.D., David S.C. Hui, M.D., Bin Du, M.D., Lan-juan Li, M.D.

Reference

NEJM February 28, 2020

Published

February 2020

Link

Read the abstract

Reviewer

Luigi Biasco

@BiascoDr

Interventional cardiologist / Cardiologist

Ciriè, Italy

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My Comment

Why this study- the rationale/objective?

The World Health Organization (WHO) has recently declared coronavirus disease 2019 (Covid-19) as a public health emergency of international concern and as from 7 March, more than 100,000 cases of Covid have been confirmed worldwide.

Few, scarce and mostly unstructured data are currently available and reports on clinical presentation, characteristics potential treatments and outcomes of this viral epidemics are still missing. The article published in the current issue of the New England Journal of Medicine provides structured data on 1099 patients with laboratory-confirmed Covid-19 from 552 Chinese hospitals, and represents to date, the largest published series.

How was it executed – the methodology?

Retrospective analysis of medical records of outpatients and hospitalized cases.
Cases: Covid-19 cases defined as positive nasal or pharyngeal swab specimens (almost 14% of all Covid-19 patients hospitalized in China in the study period).
Study period between 11 December 2019 and 19 January 2020.
Primary endpoint: composite death, mechanical ventilation, admission to intensive care.

Major findings

Overall median age of cases was 47.0 years (IQR 35.0–58.0) while median age increased to 63.0 years (IQR 53.0–71.0) in those showing primary endpoint. Male sex was slightly predominant (58.1%).
Only less than 1% (9 patients) were aged < 15. Children and teenager mostly had a benign course.
Fever at admission was evident only in 43.8% of cases and 36.4% of those with primary endpoint, while present in almost 90% of cases during hospitalization.
Cough and fatigue the two prevalent complaints. Median incubation was 4 days (range 2-7, estimated in 291 patients).
Key lab findings were lymphocytopenia (700 lymphocites/mm3 in patients showing primary outcome) and mild increase in C reactive protein.
Chest X ray was abnormal in 59% of patients, while CT scan was abnormal in 86% of cases. Ground-glass opacities (56.4%) and bilateral patchy shadowing (51.8%) were the predominant alterations, with latter more frequent in patients showing primary outcome. Few severe cases with normal CT scan have been also reported (2.9%).
3.5% of hospitalized cases were health-care professionals.
Mean time from symptom onset to ventilatory support: 9.3 days
Mean time from symptom onset to death: 15.4 days.
Clinical evolution of hospitalized patients:
- Pneumonia diagnosed 91.1%.
- Acute respiratory distress syndrome: 3.4%
- Septic shock: 1.1%.
Primary endpoint: 67 patients (6.1%)
- Intensive care admission: 5.0%.
- Invasive mechanical ventilation: 2.3%, mechanical ventilation: 6.1%.
- ECMO support: 0.5%.
- 1.4% death rate overall, 22.4% in those admitted to the ICU or mechanically ventilated.
Oseltamivir was administered to 35.8% but no data about effectiveness.
Basic reproductive number R0: 2.2 (each infected person spreads the infection to an additional two persons)

Critical reading and the relevance for clinical practice

The manuscript by Guan et al. describes the largest case series available to date of Covid-19 patients.

Clinical parameters, presentations, treatments and outcomes of laboratory confirmed infections from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are reported. The authors should be congratulated for the clarity of their data and for the effort of collecting, analyzing and publishing this preliminary report in such a complex setting in less than one month.

The main message that can be drawn out from their data is that COVID-19 might have an unusual clinical presentation as compared to a traditional viral infection like flu. Fever is evident in less than 50% of cases at presentation while occurring later during the hospital stay. Fatigue and cough are the prevalent clinical symptoms and lymphopenia the main abnormality at lab tests.

The role of troponin was not assessed in this report, while others have clearly shown that high sensitivity troponin might show an increase during infection as a sign of myocardial involvement, thus representing a potential challenge in the differential diagnosis of acute coronary syndromes. Positive stool specimens for SARS-CoV-2 have been also described. While chest x-ray might show a significant percentage of false positive results, high resolution CT scan is positive in almost 90% of cases.

No clear indications regarding specific therapies are available so far, with supportive therapy with fluid ventilation and, in a few cases mechanical circulatory support, used. Reported case fatality rate was 1.4%. This estimation, however, can be influenced by selection bias due to exclusion of patients with incomplete medical records.

This new epidemic is rapidly unmasking how our societies, health care systems and economies are fragile and unprepared to this unforeseen emergency. Due to the global spread of this novel viral infection hitting not only Asia, but now in Europe and extending to all other continents, it is clear that as physicians and citizens we are now called to an enormous effort to contain these epidemics and provide the highest available care to patients. For the first time in modern medicine, this threat is challenging each specialist to cross the borders of medical subspecialties and acquire skills on this novel disease.