key: cord-337163-i8ysgucd
authors: Desai, Rupak; Singh, Sandeep; Parekh, Tarang; Sachdeva, Sonali; Kumar, Lekshmi; Sachdeva, Rajesh; Kumar, Gautam
title: COVID-19 and Shock: A Cautionary Tale for Elderly Patients from a Pooled Analysis
date: 2020-04-10
journal: Ann Emerg Med
DOI: 10.1016/j.annemergmed.2020.04.014
sha: 
doc_id: 337163
cord_uid: i8ysgucd

nan

To the Editor,

The shocking scale of coronavirus disease 2019(COVID-19) infections is worrisome with more than 1 million confirmed cases and over 50,000 reported deaths across the globe by the end of March 2020. The unprecedented challenges brought by the COVID-19 pandemic have overwhelmed the healthcare system, strained healthcare workers and raised a dire need to collect, analyze and interpret real-time data to expedite understanding the etiopathogenesis, risk factors and prognosis of COVID-19 and ways to curtail overall mortality rate.

Although the awareness of the natural progression of COVID-19 is increasing with cardiovascular risk factors and older age being frequently identified as major risk factors for poor survival in COVID-19 patients, our knowledge remains limited on the pooled prevalence of shock and its impact on predicting mortality in COVID-19 infection. While the predominant complication of COVID-19 is an acute respiratory illness which could lead to acute respiratory distress syndrome, COVID-19 patients with cardiovascular complications and sepsis have a heightened risk of developing shock with potential in-hospital mortality during the disease course. Acute cardiac injury has been reported to be ranging from 12% to 16.7% in COVID-19 patients.

To our knowledge, this is the first pooled estimates of the prevalence of shock in COVID-19 patients with age-based (mean age<50 vs >50-years) variation. Random effects models were obtained to perform a meta-analysis, and I 2 statistics were used to measure inter-study heterogeneity. After a thorough review of the literature from PubMed, Scopus and Google Scholar, data were collected from 5 studies (4/5 septic shock) reported from China until March 2020. Among 1578 COVID-19 patients, the pooled prevalence of shock was 6.3%(95CI 4.0%-2 16.8%), I 2 =96%, with the cohort greater than 50-years of mean age showing significantly higher prevalence of shock [9.5%(2.4%-20.5%)] compared to younger cohort (mean age<50 years) [3.3% (95CI 0-11.4%)].

In this meta-analysis, the elderly population had a higher burden of shock compared to the younger cohort. The predilection of elderly patients toward sepsis and a higher burden of cardiovascular diseases owing to higher comorbidities could be a major reason for the observed age-related disparity in the prevalence of shock. This warrants stricter precautions and social distancing for the geriatric population.

A potential link for shock in COVID-19 could be due to elevated cytokine levels. During a viral illness, the up-regulation of cytokines like IFN-γ and IL-10 potentiates the vasodilation leading to shock. Similarly, IL-1β/6/8, MCP-1 and PAI-1 levels are increased in acute phase of sepsis, reflecting endothelial injury. Viral infections could trigger a hyper-inflammatory state, like cytokine-storm syndrome, as featured in COVID-19 patients, which could contribute to developing shock with a potential of multiorgan dysfunction.

Concisely, this meta-analysis highlights the worse impact of COVID-19 in older age group (9.5% vs. 3.3%) as compared to the younger cohort. More data are required on the prevalence of shock, its predictors and their impact on the survival of elderly COVID-19 patients to effectively maneuver supportive resuscitation measures on time. Furthermore, elderly survivors requiring prolonged nursing care and ventilator support might also add up to the magnitude of complications and economic liability during this global healthcare crisis.

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China

coronavirus disease 2019: retrospective study

Clinical Characteristics of Coronavirus Disease

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study