Cardiovascular Journal of Africa: Vol 32 No 2 (MARCH/APRIL 2021)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 2, March/April 2021 80 AFRICA
guidance.8 Patients who had mild pneumonia and/or mild illness
such as uncomplicated upper respiratory tract viral infection,
had non-specific symptoms such as fever, fatigue, cough (with
or without sputum production), anorexia, malaise, muscle pain,
sore throat, dyspnoea, nasal congestion or headache and rarely
presented with diarrhoea, nausea and vomiting, were followed
without hospitalisation.
Patients were hospitalised if they had one of these listed below:
• patients with mild pneumonia (unilateral infiltration) but with
age older than 60 years and/or existence of co-morbidities
such as diabetes, hypertension, cardiovascular disease, cere-
brovascular disease, chronic renal disease, chronic obstructive
pulmonary disease and immune incompetence (for exclusion:
active malignancy, ongoing chemotherapy or radiotherapy,
HIV infection)
• patients with moderate/severe pneumonia (bilateral infiltra-
tion and/or multiple mottling and ground-glass opacity)
• patients with hypotension (< 90/60 mmHg) or tachypnoea
or hypoxaemia [arterial oxygen (O2) saturation below 93%
without O2 supply]
• patients with mild pneumonia (unilateral infiltration) but
having severe biochemical or haematological parameters such
as ferritin value above 1 000 ng/ml or high-sensitivity C-reactive
protein (hs-CRP) level above 40 mg/dl or lymphopaenia.
Patients were taken to the ICU if the following clinical and
laboratory parameters were involved:
• respiratory rate ≥ 30 breaths/minute
• dyspnoea
• SpO2 < 90% and PaO2 < 70 mmHg despite > 5 l/min nasal
oxygen supply
• PaO2/FiO2 ≤ 300
• lactate > 2 mmol/l
• hypotension (systolic blood pressure < 90 mmHg or drop > 40
mmHg in usual systolic blood pressure or mean arterial pres-
sure < 65 mmHg), tachycardia (> 100 beats/min)
• findings showing renal, hepatic, haematological (thrombocy-
topaenia) or cerebral (confusion) dysfunction (sepsis or septic
shock)
• skin findings of capillary return disorder such as cutis
marmaratus.
The demographic (age and gender) and clinical (symptoms,
co-morbidities, treatments, complications and outcomes)
characteristics, laboratory findings, and results of cardiac
examinations (cardiac biomarkers and electrocardiography) of
patients during hospitalisation were collected from their medical
records by two investigators (NS and AA). Cardiac biomarkers
measured on admission were collected, including high-sensitivity
troponin T (hs-TNT) and N-terminal proB-type natriuretic
peptide (NT-proBNP). The radiological assessments included
radiography, computed tomography or magnetic resonance
imaging. All data were independently reviewed and entered into
the computer database by two analysts (HK and GD).
To confirm COVID-19, the SARS-CoV-2 (2019-nCoV)
polymerase chain reaction (qPC) detection kit (Bio-Speedy®) was
used for detecting the epidemic virus SARS-CoV-2 (2019-nCoV)
causing COVID-19. The kit was applied to nucleic aid isolates
from nasopharyngeal aspirate/lavage, broncho-alveolar lavage,
nasopharyngeal swab, oropharyngeal swab and sputum samples.
Rapid diagnosis with the kit was achieved via one-step reverse
transcription (RT) and real-time qPCR (RT-qPCR) targeting
the SARS-CoV-2 (2019-nCoV)-specific RdRp (RNA-dependent
RNA polymerase) gene fragment.
Arterial and/or venous thrombosis were defined as
documented thrombosis with imagining modalities such
as magnetic resonance imaging, computed tomography or
Doppler ultrasound. Malignant arrhythmia was defined as rapid
ventricular tachycardia lasting more than 30 seconds, inducing
haemodynamic instability and/or ventricular fibrillation.
Patients were considered to have acute myocardial injury
if serum levels of TNT were above the 99th percentile upper
reference limit (hs-TNT ≥ 14 pg/ml). 9 Acute coronary syndrome
was defined as the presence of chest pain or ischaemic equivalent
at rest, lasting longer than 20 minutes, associated with one of
the following conditions: ECG showing ST-segment elevation
or depression ≥ 1.0 mm in two or more contiguous leads;
elevated biomarkers of myocardial necrosis (i.e. CK-MB > once
the upper limit of normal of the local laboratory, or hs-TNT
≥ 14 pg/ml). Cerebrovascular accident was defined as the
presence of neurological symptoms and proven ischaemic and/or
haemorrhagic focus by imaging modalities. The clinical outcomes
(discharges, mortality and length of stay) were monitored up to
10 April 2020, the final date of follow up.
Treatment algorithms in hospitalised patients
Infection-specific treatment
• Hydroxychloroquine + oseltamivir (if influenza could not be
excluded) + azithromycin were initiated in patients with pneu-
monia including normal blood values [leukocyte, lymphocyte,
lactate dehydrogenase (LDH), ferritin, troponin] and patients
with CRP < 20 mg/l.
• In cases of moderate (bilateral infiltration) pneumonia:
– Hydroxychloroquine was given for 7–10 days.
– Conditions for addition of favipravir were examined (clini-
cal deterioration under hydroxychloroquine or progression
of pneumonia).
– A patient-based decision was made about anti-inflamma-
tory treatments.
– High-flow nasal oxygen therapy (SpO2 < 93% or PaO2/FiO2
< 300 or respiratory rate > 24 breaths/min) was given.
• Patients with severe pneumonia (multiple mottling and
ground-glass opacity), including those who developed acute
respiratory distress syndrome, sepsis or myocarditis, and
those at risk of developing shock:
– Hydroxychloroquine and/or favipravir + azithromycin
(should be evaluated for its contra-indications) + oseltami-
vir (if influenza could not be excluded).
– Patients who developed myocarditis were treated like
patients with severe pneumonia.
Other specific treatments and prophylaxis regimens
Antithrombotic and anticoagulant therapy/prophylaxis were
initiated unless contra-indicated, to all patients admitted to the
hospital, with a regimen of subcutaneous enoxaparin 4 000 IU
once a day and oral dipyridamole 75 mg twice a day.
In patients with severe pneumonia, enoxaparin 100 IU/kg
twice a day (at the treatment dose) was used subcutaneously
if serum ferritin levels were > 1 000 ng/ml (or nearly two-fold
increase in follow up) or serum LDH levels were > 400 U/l (or
increase in follow up) or serum D-dimer levels were > 2 000 μg/l.