The Association of CT-measured Cardiac Indices with Lung Involvement and Clinical Outcome in Patients with COVID-19

Vahid Eslami, Alireza Abrishami, Ehsan Zarei, Nastaran Khalili, Zahra Baharvand, Morteza Sanei-Taheri, Vahid Eslami, Alireza Abrishami, Ehsan Zarei, Nastaran Khalili, Zahra Baharvand, Morteza Sanei-Taheri

Abstract

Rationale and objectives: Cardiac indices can predict disease severity and survival in a multitude of respiratory and cardiovascular diseases. Herein, we hypothesized that CT-measured cardiac indices are correlated with severity of lung involvement and can predict survival in patients with COVID-19.

Materials and methods: Eighty-seven patients with confirmed COVID-19 who underwent chest CT were enrolled. Cardiac indices including pulmonary artery-to-aorta ratio (PA/A), cardiothoracic ratio (CTR), epicardial adipose tissue (EAT) thickness and EAT density, inferior vena cava diameter, and transverse-to-anteroposterior trachea ratio were measured by non-enhanced CT. Logistic regression and Cox-regression analyses evaluated the association of cardiac indices with patients' outcome (death vs discharge). Linear regression analysis was used to assess the relationship between the extent of lung involvement (based on CT score) and cardiac indices.

Results: Mean (±SD) age of patients was 54.55 (±15.3) years old; 65.5% were male. Increased CTR (>0.49) was seen in 52.9% of patients and was significantly associated with increased odds and hazard of death (odds ratio [OR] = 12.5, p = 0.005; hazard ratio = 11.4, p = 0.006). PA/A >1 was present in 20.7% of patients and displayed a nonsignificant increase in odds of death (OR = 1.9, p = 0.36). Furthermore, extensive lung involvement was positively associated with elevated CTR and increased PA/A (p = 0.001).

Conclusion: CT-measured cardiac indices might have predictive value regarding survival and extent of lung involvement in hospitalized patients with COVID-19 and could possibly be used for the risk stratification of these patients and for guiding therapy decision-making. In particular, increased CTR is prevalent in patients with COVID-19 and is a powerful predictor of mortality.

Keywords: COVID-19; Cardiothoracic ratio; cardiac; computed tomography; prognosis; pulmonary artery.

Copyright © 2020 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1
Figure 1
(A and B). Axial images of chest computed tomography (CT) showing measurement of cardiac indices. (A) CT-derived cardiothoracic ratio: The short arrow depicts the greatest transverse cardiac diameter and the longer arrow indicates the greatest transverse thoracic diameter. The thoracic diameter would normally be taken few centimeters caudal to this image; at the level of the dome of the hemidiaphragm (It has been included at this level only to simulate the measurement and to complete the figure). (B) CT-derived pulmonary artery-to-aorta ratio (PA/A).
Figure 2
Figure 2
(A and B). EAT thickness and density measurements were made at three levels (A) Corresponding to measurements at 25%, 50%, and 75% level of the RV wall. Of these three measurements, (B) the mean value was considered as EAT thickness and was included in the analysis. EAT density was also measured at these three levels. The area of interest was defined by manual delineation of the pericardium and then density was calculated in a workstation by specific software. (Color version of figure is available online.)
Figure 3
Figure 3
(A and B). Cumulative hazard function of death in patients according to (A) pulmonary artery-to-aorta ratio and (B) cardiothoracic ratio. Outcome was defined as death or discharge and length of hospitalization was considered as time to outcome in the cox regression analysis. (Color version of figure is available online.)
Figure 4
Figure 4
(A–H). A 45-year-old man presented with dry cough, dyspnea (SpO2: 88%) and abdominal pain without history of any comorbidity. Computed tomography (CT) images (A and B) obtained 5 days after the onset of symptoms show patchy ground-glass opacity in both lungs with increased pulmonary artery-to-aorta ratio (1.07) and (C and D) normal cardiothoracic ratio (0.46). CT images (E and F) obtained 28 days after symptoms onset show evolution of the area of ground glass opacities with reticular pattern and normal pulmonary artery-to-aorta ratio (1.00) and (G and H) normal cardiothoracic ratio (0.43). The patient was discharged after 26 days.

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