key: cord-0764159-ngnac7ys
authors: Nam, Janice; D'Andrea, Melissa; O’Hara, Alexander; Staszewski, Lindsey; Pozin, Jacob; Wozniak, Amy; Korepta, Lindsey; Halandras, Pegge; Soult, Michael; Aulivola, Bernadette
title: Racial Disparities in the Risk for Thromboembolic Events in COVID-19 Patients during the Height of the SARS-CoV-2 Pandemic and Impact on Outcomes
date: 2022-05-16
journal: Ann Vasc Surg
DOI: 10.1016/j.avsg.2022.04.048
sha: b534f9b3cb896b5bf0abbf0274e7f78ce6d9df86
doc_id: 764159
cord_uid: ngnac7ys

OBJECTIVE: The primary objective of this study is to assess the risk of thromboembolic events in hospitalized patients with COVID-19 and study the impact of thromboembolic events on hospital course and mortality risk during the initial height of the SARS-CoV-2 pandemic. METHODS: A retrospective review of all adult inpatients (≥18 years old) with COVID-19 infection at a single academic institution from March 15, 2020 – July 1, 2020 was performed. Collected data included patient demographics, comorbidities, hospital admission type, thromboembolic events, laboratory values, use of anticoagulants/antiplatelet agents, hospital length of stay, and in-hospital mortality. Logistic regression was used to estimate associations between risk factors and thromboembolic events. RESULTS: A total of 826 inpatients with COVID-19 were identified. Of these, 56% were male, average age was 60.9 years, and race/ethnicity was reported as % Hispanic in 51%, non-Hispanic Black in 25% and non-Hispanic White in 18%. A total of 98 thromboembolic events were documented in 87 patients (10.5%). Hypertension, coronary artery disease, and chronic limb threatening ischemia were associated with an increased incidence of thromboembolism (p < 0.05). Hispanic patients had higher incidence of thromboembolism compared to White non-Hispanic patients [OR (CI): 2.237 (1.053, 4.754), p = 0.036]. As D-dimer increased, the odds of thromboembolic event increased by 5.2% [OR (CI): 1.052 (1.027, 1.077), p < 0.001]. Patients with thromboembolic events had longer hospital stay (Median 13 vs. 6 days, p < 0.001), higher likelihood of ICU admission (63% vs 33%, p < 0.001), and higher in-hospital mortality (28% vs 16%, p = 0.006). Arterial thromboembolic events were associated with higher in-hospital mortality than venous thromboembolic events (37% vs 15%, p = 0.027). CONCLUSION: During the initial height of the SARS-CoV-2 pandemic, thromboembolic events were relatively frequent in hospitalized patients with COVID-19. Racial disparities were seen with an increased proportion of minority patients admitted with respect to percentages seen in the general population, There was also significantly increased incidence of thromboembolic events in Hispanic patients. Thromboembolic events were associated with significantly longer hospital stay and higher in-hospital mortality. Patients with arterial thromboembolic events fared worse with significantly higher mortality than those with venous events. Inconsistencies in anticoagulation management early in the pandemic may have contributed to poor outcomes and more contemporary management outcomes need to be investigated.

in-hospital mortality. 116 

Means (SD) were used to summarize normally distributed continuous variables and 118 medians (Q1, Q3) were used to summarize non-normally distributed continuous variables; counts 119 and frequencies were used to summarize categorical factors. Odds ratios (OR), confidence 120 intervals (CI), and p-values for associations with a TE were estimated using complete-case 121 univariable logistic regression models. Predictors with association of p < 0.10 at the univariable 122 level were used in multivariable regression models to estimate adjusted associations. If a variable 123 had significant missing data (>10%), an indicator for missing data was included in the 124 multivariable model. Standard diagnostics (variance inflation factors, linearity of continuous 125 predictors, and Akaike information criterion) were used to assess model fit for the final 126 multivariable model. If a continuous predictor was not linearly associated with the outcome, an 127 'abnormal threshold' was used to dichotomize the variable. If a variable had little variability, 128 and model estimates were unstable, it was not included in the final multivariable model.

Additionally, TEs were correlated with outcomes of LOS, ICU admission, and mortality.

Wilcoxon test was used to compare LOS between groups, and Chi-sq test was used to compare 131 ICU admission and mortality proportions between groups. Two-sided p-values < 0.05 were 132 considered statistically significant. All analyses were performed using SAS 9.4 (Cary, NC).

A total of 826 hospitalized COVID-19 positive patients were identified and included in 136 the analysis. The mean (SD) age at diagnosis was 60.9 (16.7) years and 56% of patients were male with 44% female. With respect to race and ethnicity, 51% were Hispanic, 25% were non-Hispanic Black, and 18% were non-Hispanic White. The most prevalent comorbidity was 139 hypertension (65%) followed by DM (44%), hyperlipidemia (HLD) (41%), and CAD (19%).

Hospitalized patients with COVID-19 infection had a median (IQR) admission D-dimer level of 141 948 (1521) ng/mL, median BUN level of 16 (17) mg/dL, and median creatinine level of 1 (0.7) 142 unit mg/dL at admission. (Table I) . Thromboembolic events were diagnosed in a total of 87 143 patients (11%). Seventy-six patients had one TE diagnosed while 11 patients were diagnosed 144 with 2 TEs for a total of 98 events noted during the study period. (Table II) . (Table III) . 

There are several limitations in this study. First, it is a retrospective study intended to 244 describe in-hospital events and outcomes. The study was not designed to include long-term 245 follow up. Second, we had a small sample size with realtively few TEs, which can lead to 246 selection bias. Third, this study only evaluated outcomes in patients hospitalized with COVID-247 19 and thus sicker than their outpatient counterparts. It is likely that minimally symptomatic 248 patients with venous TEs may have been managed as outpatients and thus this study would not 249 have captured all TEs. This patient cohort likely carries more comorbidities inherently which 250 could lead to increased mortality risk. Therefore, we cannot draw conclusions on COVID-19 251 patients with TE that did not meet hospital admission criteria. In addition, only patients with a high clinical suspicion of TE underwent diagnostic testing in an effort to protect staff, such as vascular technologists, from COVID-19 exposure. Patients who were too ill to undergo 254 diagnostic testing may have been treated empirically with therapeutic anticoagulation or 255 treatment may have been deferred in patients who were not expected to survive, and therefore 256 they were not captured in this analysis. The incidence of TE diagnosis may have been higher, if 257 more frequent diagnostic imaging was performed. Moreover, data from the initial stage of the 258 SARS-CoV-2 pandemic may not be applicable in the current era where vaccination is available, 

BUN, Median (Q1, Q3)