COVID-19 and Shock: A Cautionary Tale for Elderly Patients From a Pooled Analysis

To the Editor:

The shocking scale of coronavirus disease 2019 (COVID-19) infections is worrisome, with more than 1 million confirmed cases and greater than 50,000 reported deaths across the globe by the end of March 2020. The unprecedented challenges brought by the COVID-19 pandemic have overwhelmed the health care system, strained health care workers, and raised a dire need to collect, analyze, and interpret real-time data to expedite understanding the etiopathogenesis, risk factors, and prognosis of COVID-19 and ways to curtail overall mortality rate.

Although the awareness of the natural progression of COVID-19 is increasing, with cardiovascular risk factors and older age being frequently identified as major risk factors for poor survival in COVID-19 patients, our knowledge remains limited on the pooled prevalence of shock and its effect on predicting mortality in COVID-19 infection. Although the predominant complication of COVID-19 is acute respiratory illness that could lead to acute respiratory distress syndrome, COVID-19 patients with cardiovascular complications and sepsis have a heightened risk of developing shock with potential inhospital mortality during the disease course. Acute cardiac injury has been reported to range from 12% to 16.7% in COVID-19 patients.

To our knowledge, this is the first pooled estimate of the prevalence of shock in COVID-19 patients with age-based variation (mean age <50 versus >50 years). Random-effects models were obtained to perform a meta-analysis, and I ² statistics were used to measure interstudy heterogeneity. After a thorough review of the literature from PubMed, Scopus, and Google Scholar, data were collected from 5 studies (4/5 septic shock) reported from China until March 2020.1, 2, 3, 4, 5 Among 1,578 COVID-19 patients, the pooled prevalence of shock was 6.3% (95% confidence interval 4.0% to 16.8%) and I ²=96%, with the cohort older than 50 years (mean age) showing significantly higher prevalence of shock (9.5%; 95% confidence interval 2.4% to 20.5%) compared with the younger cohort (mean age <50 years) (3.3%; 95% confidence interval 0% to 11.4%) (Figure ).

Figure.

Random-effects pooled prevalence of shock among COVID-19 patients stratified by mean age.

In this meta-analysis, the elderly population had a higher burden of shock compared with the younger cohort. The predilection of elderly patients toward sepsis and a higher burden of cardiovascular diseases owing to higher comorbidities could be a major reason for the observed age-related disparity in the prevalence of shock. This warrants stricter precautions and social distancing for the geriatric population.

A potential link for shock in COVID-19 could be due to elevated cytokine levels. During a viral illness, the up-regulation of cytokines such as interferon gamma and interleukin (IL)-10 potentiates the vasodilation leading to shock. Similarly, IL-1β, 6, and 8; monocyte chemoattractant protein-1; and plasminogen activator inhibitor-1 levels are increased in the acute phase of sepsis, reflecting endothelial injury. Viral infections could trigger a hyperinflammatory state, such as cytokine-storm syndrome, as featured in COVID-19 patients, which could contribute to developing shock with a potential for multiorgan dysfunction.

Concisely, this meta-analysis highlights the worse effect of COVID-19 in an older age group (9.5% versus 3.3%) compared with the younger cohort. More data are required on the prevalence of shock, its predictors, and their effect on the survival of elderly COVID-19 patients to effectively maneuver supportive resuscitation measures on time. Furthermore, elderly survivors requiring prolonged nursing care and ventilator support might add to the magnitude of complications and economic liability during this global health care crisis.