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