Bhavani Sivasubramanium V, Robichaux Chad, Verhoef Philip A, Churpek Matthew M, Coopersmith Craig M
Department of Medicine, Emory University, Atlanta, GA; Emory Critical Care Center, Atlanta, GA.
Department of Biomedical Informatics, Emory University, Atlanta, GA.
Chest. 2024 Mar;165(3):529-539. doi: 10.1016/j.chest.2023.09.020. Epub 2023 Sep 23.
Trajectories of bedside vital signs have been used to identify sepsis subphenotypes with distinct outcomes and treatment responses. The objective of this study was to validate the vitals trajectory model in a multicenter cohort of patients hospitalized with COVID-19 and to evaluate the clinical characteristics and outcomes of the resulting subphenotypes.
Can the trajectory of routine bedside vital signs identify COVID-19 subphenotypes with distinct clinical characteristics and outcomes?
The study included adult patients admitted with COVID-19 to four academic hospitals in the Emory Healthcare system between March 1, 2020, and May 31, 2022. Using a validated group-based trajectory model, we classified patients into previously defined vital sign trajectories using oral temperature, heart rate, respiratory rate, and systolic and diastolic BP measured in the first 8 h of hospitalization. Clinical characteristics, biomarkers, and outcomes were compared between subphenotypes. Heterogeneity of treatment effect to tocilizumab was evaluated.
The 7,065 patients with hospitalized COVID-19 were classified into four subphenotypes: group A (n = 1,429, 20%)-high temperature, heart rate, respiratory rate, and hypotensive; group B (1,454, 21%)-high temperature, heart rate, respiratory rate, and hypertensive; group C (2,996, 42%)-low temperature, heart rate, respiratory rate, and normotensive; and group D (1,186, 17%)-low temperature, heart rate, respiratory rate, and hypotensive. Groups A and D had higher ORs of mechanical ventilation, vasopressors, and 30-day inpatient mortality (P < .001). On comparing patients receiving tocilizumab (n = 55) with those who met criteria for tocilizumab but were admitted before its use (n = 461), there was significant heterogeneity of treatment effect across subphenotypes in the association of tocilizumab with 30-day mortality (P = .001).
By using bedside vital signs available in even low-resource settings, we found novel subphenotypes associated with distinct manifestations of COVID-19, which could lead to preemptive and targeted treatments.
床边生命体征轨迹已被用于识别具有不同结局和治疗反应的脓毒症亚表型。本研究的目的是在多中心新冠肺炎住院患者队列中验证生命体征轨迹模型，并评估由此产生的亚表型的临床特征和结局。
常规床边生命体征轨迹能否识别具有不同临床特征和结局的新冠肺炎亚表型？
该研究纳入了2020年3月1日至2022年5月31日期间在埃默里医疗系统的四家学术医院因新冠肺炎入院的成年患者。使用经过验证的基于群体的轨迹模型，我们根据住院后8小时内测量的口腔温度、心率、呼吸频率以及收缩压和舒张压，将患者分类为先前定义的生命体征轨迹。比较各亚表型之间的临床特征、生物标志物和结局。评估托珠单抗治疗效果的异质性。
7065例新冠肺炎住院患者被分为四种亚表型：A组（n = 1429，20%）——高温、心率快、呼吸频率快且低血压；B组（1454例，21%）——高温、心率快、呼吸频率快且高血压；C组（2996例，42%）——低温、心率慢、呼吸频率慢且血压正常；D组（1186例，17%）——低温、心率慢、呼吸频率慢且低血压。A组和D组机械通气、使用血管活性药物和30天住院死亡率的比值比更高（P <.001）。在比较接受托珠单抗治疗的患者（n = 55）和符合托珠单抗标准但在其使用前入院的患者（n = 461）时，托珠单抗与30天死亡率的关联在各亚表型之间存在显著的治疗效果异质性（P =.001）。
通过使用即使在资源匮乏环境中也可获得的床边生命体征，我们发现了与新冠肺炎不同表现相关的新亚表型，这可能会带来抢先和有针对性的治疗。
