Lung disease severity, Coronary Artery Calcium, Coronary inflammation and Mortality in Coronavirus Disease 2019.

IMPORTANCE The in-hospital mortality rate of the coronavirus disease 2019 (COVID-19) is higher in case of myocardial injury, but the underlying mechanism is not known and might depend on pre-existing coronary artery disease (CAD), coronary inflammation or others. OBJECTIVE To determine the association of the extent of lung disease or coronary artery chest computed tomography (HRCT) variables, the Agatston coronary calcium score (CCS) and peri-coronary adipose tissue attenuation (PCAT), representing CAD and coronary inflammation, with mortality in patients with COVID-19. DESIGN Retrospective case series. SETTING Single academic institution, Parma University Hospital, Italy, between March 5, 2020 and March 15, 2020. Final follow-up: March 30, 2020. PARTICIPANTS 500 consecutive patients with suspected COVID-19 who underwent HRCT as a gatekeeper were initially selected and the subgroup with laboratory-confirmed SARS-CoV-2 infection formed the final study group. EXPOSURES SARS-CoV-2 infection by real-time reverse transcriptase polymerase chain reaction (RT-PCR) assay of nasopharyngeal swabs. MAIN OUTCOMES AND MEASURES In-hospital mortality was the end point. Demographic, clinical, laboratory and HRCT data were collected from hospital electronic records, and HRCT features (CCS and PCAT) were measured post-hoc from HRCT images. RESULTS Among 500 patients with suspected COVID-19, 279 had laboratory-confirmed COVID-19 and formed the study group. Among them, 170 patients (61%) were discharged alive and 109 (39%) died. Comparing patients discharged alive with patients who died, the median age was 65 vs 77 (p<0.001), with males 56% vs 68% (p=0.061), prior cardiovascular disease 9% vs 24% (p=0.001), median D-dimer 723 vs 1083 ng/ml (p<0.001), median C-reactive protein 78 vs 148 mg/L (p<0.001), the mean CCS 17 vs 189 (p<0.001) and the median PCAT -76.4 HU vs -68.6 HU (p<0.001). In multivariable analysis, only age (p<0.001), D-dimer (p=0.041), C-reactive protein (p=0.002), extent of lung disease (p=0.002), and PCAT (p<0.001), remained associated with in-hospital death. CONCLUSIONS AND RELEVANCE Increased age, D-dimer, C-reactive protein and the HRCT image features of extent of lung disease and coronary inflammation by PCAT (but not the CCS) were independently associated with mortality in hospitalized COVID-19 patients. Our study suggests that higher mortality in COVID-19 may be at least partly mediated by coronary artery inflammation.