Discussion
Using a simple scoring system at the time of admission during the
COVID-19 outbreak can be life-saving in terms of predicting patients who
will have a mortal progression. For this reason, with this study, using
only the host risk factors without the radiology and laboratory findings
of patients at the time of admission, we defined the risk factors of
five hosts consisting of age, male, smoking, comorbidity, using ACE
inhibitor and the risk score called Co-AMSCA to predict the risk of
Covid 19 mortality. It was predicted with this study that the risk of
mortality is 7.8 times higher in patients with a Co-AMSCA score above
3.5 points than in patients with a score below 3.5 points.
The demographic, radiological, laboratory data and treatment modalities
were investigated in many studies to determine the severity and
mortality risk of COVID-19 (3-6, 8, 9). However, in the literature, a
scoring system created with host risk factors was detected only in one
study (10). In this study, which was conducted by Shi et al., three risk
factors and a risk score were defined to detect severe COVID-19 cases.
These risk factors were determined as ≥ 50 years of age, male gender,
and hypertension as an additional disease (10). Our study also showed
that advanced age, which is the first risk factor we identified,
increases mortality, which is similar to other studies (11, 12, 13). The
second and third host risk factors, which determine mortality in our
study, were male gender and smoking history. In some previous studies,
male gender and smoking were reported as poor prognostic factors
according to socio-demographic data (8, 9). It was reported in other
studies that having one or more comorbid diseases was a risk factor in
estimating mortality, as in our study (8-10, 14). However, unlike our
study, it was observed in these studies that a mortality risk score was
created by adding laboratory parameters (lymphocyte, d-dimer, CRP, LDH)
to host risk factors (13, 14). Surely a single parameter will not be
enough for predicting severe patients and mortality. Therefore, there
are new scores developed for COVID severity (CALL) and also some
well-known scores which were adapted to COVID-19 (MuLBSTA, qSOFA,
CURB-65, and NEWS2) (13-17). However, these are difficult to apply in
clinical practice, and there are technical and laboratory-requiring
difficulties, and they are time-consuming in terms of scoring. In our
study, another host risk factor in determining mortality was the use of
ACE inhibitors by the patient. ACE2 plays a vital role in RAS. Ang II
promotes atherosclerosis in the cardiovascular system along with
inflammation, oxidative stress, migration of endothelial cells, and
vascular smooth muscle cells (18). ACE2 has a protective effect on many
diseases with reduced expression of ACE2, such as hypertension,
diabetes, and cardiovascular diseases, because it antagonizes the role
of Ang II (19).
Several studies reported that COVID-19 related mortality was higher in
men and the elderly than women and the young, but the level of ACE2 was
shown oppositely (20,21). Moreover, Zhang et al. have reported that
ACEI/ARB was associated with lower mortality in COVID-19 patients with
hypertension (22).
Ji et al. developed a novel scoring model for obtaining the severe
COVID-19 patients called CALL score (14). It was developed for
progressive risk estimation using four parameters; comorbidity, age,
lymphocyte number, and LDH. Using a cut-off value of 6 points, the
positive and negative predictive values were 50.7% (38.9%-62.4%) and
98.5% (94.7%-99.8%), respectively, in this model (14). Zang et al.
developed a scoring model for predicting severity for COVID-19 patients
using age, WBC, neutrophil, GFR, and myoglobin (16). Myrstad et al. in
their study found that A NEWS2 score ≥6 at admission predicted severe
disease with 80.0% sensitivity and 84.3% specificity (Area Under the
Curve (AUC) 0.822, 95% CI 0.690-0.953) and also found that NEWS2 was
superior to qSOFA score ≥2 (AUC 0.624, 95% CI 0.446-0.810, P< .05) and other clinical risk scores for this purpose (17).
The mortality score of the Co-AMSCA cut-off value was 3.5 and above in
our study, sensitivity, specificity, NPV, and PPV were 80.4%, 65.5%,
96.0%, 24.3%, respectively. The reason why PPV was partially low was
that laboratory and radiological findings were included in the scoring
in other studies. Varol et al. obtained the CoLACD mortality score by
adding the age, lymphopenia, and dyspnea parameters as well as the
Carlson Comorbidity Score. They showed that the mortality risk was 11.8
times higher in patients with a CoLACD mortality score that was higher
than 2.5 than patients with a score lower than 2.5 points (4).
Contrary to previous studies, no relations were detected in our study
between BMI, which is one of the host risk factors, and mortality. In
the study of Cai Q et al., it was observed that the risk of developing
severe pneumonia was 86% higher in overweight patients and 2.42 times
higher in obese patients (23). In the study conducted by Wu J et al.,
BMI values of patients with severe COVID-19 were statistically higher
than those with mild disease (24). Kalligeros M et al. also reported
that patients with BMI ≥35 kg/m2 had 5.4 times higher
risk of requiring ICU care (25). Unlike the results of our study, Mehra
MR et al. conducted a study and reported that those who developed
mortality had higher mean BMI scores (26). In another study by Docherty
Annemarie B et al., obesity was found to be associated with increased
hospital mortality (27). Because of the retrospective design of our
study, height and weight measurements were based on patient statements,
and it was considered that this may be the reason for the inability to
detect a relation between BMI and mortality.
No relations were detected between blood groups and mortality in our
study. However, when the incidence of COVID 19 infection in a
meta-analysis was evaluated, it was shown in our study that blood group
A is vulnerable to infections (28). In a donor cohort study with the
primary aim not to determine the relations between the ABO blood group
and COVID-19 infection, the mortality risk in COVID-19 patients with
blood group A was reported to be significantly higher than in those with
blood group O (29).
However, the present study had some limitations. First of all, it was a
single-center, retrospective cohort study; however, all COVID-19
patients, who were admitted to our hospital during the time period we
specified, from the onset of the pandemic, were included. Also, the
hospital where this study was conducted was a specific tertiary chest
diseases training and research hospital in the Aegean region. All of the
components of the Co-AMSCA score were obtained from hospital data.
As a conclusion, we created a simple mortality score, which is easily
calculated and does not require laboratory and time. This study also
showed that a novel model that included five parameters, age, male
gender, smoking, comorbidity, and using ACE inhibitor achieved a
prediction of mortality in COVID-19 patients who are hospitalized for
pneumonia. If the Co-AMSCA score is validated with prospective studies,
it can be used for decreasing mortality and effective utilization of
medical resources in the COVID-19 pandemic. Also, we believe that the
host risk score we found will be a useful tool for the prevention and
treatment of this disease, in its detection and more serious follow-up
of individuals with high risks.
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Table 1. Comparison of demographic findings of COVID-19 patients who
mortal and non-mortal