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Vol. 222. Issue 5.
Pages 309-310 (May 2022)
Vol. 222. Issue 5.
Pages 309-310 (May 2022)
Correspondence
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Glucocorticoid therapy in patients with COVID-19 and concurrent heart failure
Tratamiento con glucocorticoides en pacientes con COVID-19 e insuficiencia cardíaca concurrente
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C.S. Kowa,
Corresponding author
chiasiang_93@hotmail.com

Corresponding author.
, D.S. Ramachandramb, S.S. Hasanc,d
a School of Postgraduate Studies, International Medical University, Kuala Lumpur, Malaysia
b School of Pharmacy, Monash University Malaysia, Bandar Sunway, Subang Jaya, Selangor, Malaysia
c School of Applied Sciences, University of Huddersfield, Huddersfield, United Kingdom
d School of Biomedical Sciences & Pharmacy, University of Newcastle, Callaghan, Australia
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Dear Director:

We read with interest the multicentre, retrospective study performed by Salinas-Botrán et al.1 to identify the risk factors associated with in-hospital mortality among patients with heart failure hospitalized due to coronavirus disease 2019 (COVID-19).

It was reported from their multivariate analysis that age (adjusted odds ratio [AOR]: 1.03; 95% confidence interval [95% CI] 1.02–1.05), severe dependence (AOR: 1.62; 95% CI 1.19–2.20), baseline tachycardia (AOR: 1.01; 95% CI 1.00–1.01), baseline C-reactive protein level (AOR: 1.004; 95% CI 1.002–1.004), baseline lactate dehydrogenase level (AOR: 1.001; 95% CI: 1.001–1.002), and baseline serum creatinine level (AOR: 1.35; 95% CI 1.18–1.54) were independently associated with in-hospital mortality in their cohort of patients with heart failure hospitalized due to COVID-19. In fact, these identified risk factors of mortality are common in patients with COVID-19, including those without heart failure2,3.

Nevertheless, based on their findings, it appears that the use of glucocorticoids, which was not incorporated into their multivariate analysis, could also be associated with in-hospital mortality in their cohort of patients. The study reported that the deceased patients had a significantly higher rate of glucocorticoid use than the patients who stayed alive during hospitalization (47.4% vs. 41.7%; p = .015). While this may be due to confounding bias, in which the use of glucocorticoids could have selected patients with higher disease severity, we took notice that the deceased patients had a significantly higher rate of development of acute decompensated heart failure than the patients who stayed alive during hospitalization (35.7% vs. 28.6%; p < .001).

Apart from their anti-inflammatory activity, glucocorticoids, especially hydrocortisone, prednisone, and prednisolone, can produce an appreciable mineralocorticoid effect, subsequently leading to fluid retention4. This may be clinically insignificant in otherwise normal subjects (without heart failure) due to the phenomenon of mineralocorticoid escape that prevents progressive fluid overload. Still, patients with underlying heart disease, particularly those with congestive heart failure, may not be able to tolerate the mineralocorticoid effect of glucocorticoids, which can worsen their pre-existing fluid overload and precipitate acute decompensation of heart failure, as well as subsequent morbidity and mortality. Indeed, a recent study5 (n = 1155) reported that the use of glucocorticoids was associated with higher rates of in-hospital death, acute decompensated heart failure, need for invasive and non-invasive mechanical ventilation, and in-hospital complications, in patients with heart failure hospitalized for COVID-19. The findings contrast with the widely recognized mortality benefits of glucocorticoid therapy in patients with severe course of COVID-19.

Therefore, pending more investigations, we believe that caution should be exercised in the administration of glucocorticoids in patients with heart failure hospitalized for COVID-19; glucocorticoids with appreciable mineralocorticoid effect such as hydrocortisone should be avoided, while dexamethasone6 and methylprednisolone7 with no clinically important mineralocorticoid activity should be preferred when clinically indicated. Indeed, hydrocortisone can also have lower potency compared to dexamethasone in terms of anti-inflammatory activities8. In addition, the short-term use of glucocorticoids with minimal mineralocorticoid action, when added to maximum diuretic therapy, can potentiate renal responsiveness to diuretic therapy in patients with congestive heart failure9. Alternatively, if glucocorticoids are deemed inappropriate, interleukin-6 antagonists can be administered10.

We look forward to the authors’ reply to report the types of glucocorticoids administered to their cohort of patients with heart failure hospitalized due to COVID-19. In addition, if feasible, the authors should incorporate the use of different types of glucocorticoids in their multivariate analysis to determine if the use of glucocorticoids was associated with in-hospital mortality in their cohort of patients.

References
[1]
A. Salinas-Botrán, J. Sanz-Cánovas, J. Pérez-Somarriba, L.M. Pérez-Belmonte, L. Cobos-Palacios, M. Rubio-Rivas, et al.
Características clínicas y factores de riesgo al ingreso de mortalidad en pacientes con insuficiencia cardíaca hospitalizados por COVID-19 en España.
Rev Clin Esp, 222 (2022), pp. 255-265
[2]
Z.G. Dessie, T. Zewotir.
Mortality-related risk factors of COVID-19: a systematic review and meta-analysis of 42 studies and 423,117 patients.
BMC Infect Dis, 21 (2021), pp. 855
[3]
L. Zhang, J. Hou, F.Z. Ma, J. Li, S. Xue, Z.G. Xu.
The common risk factors for progression and mortality in COVID-19 patients: a meta-analysis.
Arch Virol, 166 (2021), pp. 2071-2087
[4]
D.E. Becker.
Basic and clinical pharmacology of glucocorticosteroids.
Anesth Prog, 60 (2013), pp. 25-32
[5]
L.M. Pérez-Belmonte, J. Sanz-Cánovas, A. Salinas, I. Sagastagoitia Fornie, M. Méndez-Bailón, R. Gómez-Huelgas, et al.
Corticosteroid therapy in patients with heart failure hospitalized for COVID-19: a multicenter retrospective study.
Intern Emerg Med, 16 (2021), pp. 2301-2305
[6]
P. Horby, W.S. Lim, J.R. Emberson, M. Mafham, J.L. Bell, L. Linsell, et al.
RECOVERY Collaborative Group. Dexamethasone in hospitalized patients with Covid-19.
N Engl J Med, 384 (2021), pp. 693-704
[7]
S.S. Hasan, C.S. Kow, Z.U. Mustafa, H.A. Merchant.
Does methylprednisolone reduce the mortality risk in hospitalized COVID-19 patients? A meta-analysis of randomized control trials.
Expert Rev Respir Med, 15 (2021), pp. 1049-1055
[8]
C.S. Kow, S.S. Hasan.
Dexamethasone or hydrocortisone in COVID-19?.
Cleve Clin J Med, 87 (2020), pp. 715
[9]
C. Liu, K. Liu.
Effects of glucocorticoids in potentiating diuresis in heart failure patients with diuretic resistance.
J Card Fail, 20 (2014), pp. 625-629
[10]
C.S. Kow, A.F. Zaihan, D.S. Ramachandram, S.S. Hasan.
IL-6 antagonists to replace systemic corticosteroids as the preferred anti-inflammatory therapy in patients with COVID-19?.
Cytokine, 149 (2022), pp. 155730

Please cite this article as: Kow CS, Ramachandram DS, Hasan SS. Tratamiento con glucocorticoides en pacientes con COVID-19 e insuficiencia cardíaca concurrente. Rev Clin Esp. 2022;222:309–310.

Copyright © 2021. Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)
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