CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 1, January–April 2023 AFRICA 17 Methods A total of 246 patients who were hospitalised between 20 March and 5 May 2020, with a diagnosis of moderate-to-severe viral pneumonia with COVID-19 reverse transcription polymerase chain reaction (RT-PCR) nucleic acid-positive test results, were analysed retrospectively. The study included 205 patients, while 41 patients were excluded from the study due to lack of adequate data. Anamnesis and information on the physical examination of patients was recorded. A history of hypertension, diabetes mellitus, chronic renal failure, chronic obstructive pulmonary disease (COPD), dyslipidaemia, heart failure, atrial fibrillation, coronary artery disease and cerebrovascular disease were determined as demographic features and were recorded. On admission, all patients included in the study had oropharyngeal and nasal swab samples taken for COVID-19 RT-PCR nucleic acid test, developed with the virus sequence stated in the Ministry of Health guidelines. In addition to routine biochemical data, daily serum troponin I and D-dimer levels were recorded as the study data for at least 10 days. Inclusion criteria for the study were patients aged over 18 years and attending the Biruni University Medical Faculty Hospital, with a COVID-19 RT-PCR-positive test result and moderate-to-severe viral pneumonia. Exclusion criteria for the study were patients who immediately required mechanical ventilation. In-hospital mortality and the need for intensive care were identified as endpoints. The study complies with the Declaration of Helsinki. We confirm that all methods were carried out in accordance with relevant guidelines and regulations. This retrospective study was approved by the Ministry of Health (no: 2020-1022T14_52_17) as well as the Biruni University Faculty of Medicine non-interventional clinical research ethics committee (no: 2020/45-01). Five millilitres of venous blood were collected from each patient on admission and for 10 days during follow up. Troponin I, D-dimer, haemogram and routine biochemical tests were analysed in our hospital from the blood taken. We used an immunoassay (Architech i1000 SR, Abbott) for troponin I and immunofluorescence assay (IF2084 for Getein 1600, Getein Biotech, Inc. Nanjing, China) for D-dimer measurements. Cardiac injury was defined as serum cardiac troponin level above the 99th percentile upper reference limit in patients with COVID-19 disease. Non-mortality was defined as discharge. According to World Health Organisation interim guidance, the definitive diagnosis of COVID-19 is based on a real-time RT-PCR test. Statistical analysis Statistical analysis was done using SPSS version 21 software. Correlation and comparison tests were carried out to determine the relationship between all values before starting the multiparameter analysis. A t-test for the independent groups was used for comparisons of averages of quantitative properties. Similarly, t-tests were used for the comparisons of the averages of the features in the form of present–absent. While all intragroup correlations were evaluated using Pearson’s correlation test, chi-squared and Fisher’s exact tests were used to calculate the cross distributions of all categorical data relative to each other. A receiver operating characteristic (ROC) curve analysis was plotted to determine the power of troponin I, D-dimer and other inflammatory markers to determine mortality and requirement for intensive care. The area under the curve (AUC) was estimated with 95% confidence interval. Statistical significance level was accepted as p < 0.05 in all tests. Results The demographic parameters of the patients are shown in Table 1. The average age was 58.81 ± 18.07 years. The average age was higher in the patient group that died compared to the group that survived (67.79 ± 14.9 vs 56.87 ± 18.15 years, respectively, p < 0.001). No statistical relationship was detected between mortality and gender (p = 0.857). The presence of hypertension, diabetes mellitus, previous coronary artery bypass surgery, heart failure, chronic renal failure and COPD were higher in the group that died (p = 0.003, 0.004, 0.045, 0.02, 0.003, 0.007, respectively). Although the mortality rate of patients who had previously undergone percutaneous coronary intervention was higher, it was not statistically significant (p = 0.323). There was no statistically significant relationship detected between previous medication use (angiotensin converting enzyme inhibitor/angiotensin receptor blockers, beta-blockers, calcium channel blockers, anti-aggregant and anticoagulant drugs) and mortality (p > 0.05). When the laboratory data were analysed (Table 2), serum creatine kinase (CK), C-reactive protein (CRP), ferritin, urea, creatinine, aspartate dehydrogenase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH) and sodiumvalues in the group that diedwere statistically significantly higher than in the other group (p = 0.03, 0.01, < 0.001, 0.01, 0.01, 0.02, 0.082, < 0.001, 0.013, respectively). Serum troponin I and D-dimer values, which were regularly measured in the first 10 days of hospitalisation, were found to be relevant to both mortality rate and requirement for intensive care. Troponin I and D-dimer values measured daily are summarised in Tables 3 and 4. Troponin I and D-dimer values were found to be significantly higher in the group of patients who died and those requiring intensive care compared to the group who were discharged and patients that did not require intensive care. Both troponin I and D-dimer values were higher in the group that died compared to patients requiring intensive care. Table 1. Relationship between demographic characteristics and mortality rate Demographic characteristics All patients (n = 205) Discharge (n = 167) Mortality (n = 38) p-value Age (years) 58.81 ± 18.0756.87 ± 18.15 67.79 ± 14.9 < 0.001 Gender (female), n (%) 109 (52.9) 88 (52.1) 21 (55.3) 0.857 Hypertension, n (%) 65 45 (26.9) 20 (52.6) 0.003 Diabetes mellitus, n (%) 40 28 (16.8) 12 (31.6) 0.04 PCI, n (%) 17 12 (7.2) 5 (13.2) 0.323 CABG, n (%) 5 2 (1.2) 3 (7.9) 0.045 Heart failure, n (%) 12 5 (3.0) 7 (18.4) 0.02 Chronic renal failure, n (%) 7 2 (1.2) 5 (13.2) 0.003 Atrial fibrilation, n (%) 15 12 (7.2) 3 (7.9) 1 COPD/asthma, n (%) 18 10 (6) 8 (21.1) 0.07 Cerebrovascular disease, n (%) 3 2 (1.2) 1 (2.6) 0.46 PCI: percutaneous coronary intervention; CABG: coronary artery bypass grafting; COPD: chronic obstructive pulmonary disease.
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