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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Since it was first reported in China in 2019&#44; COVID-19&#44; the infection caused by the new coronavirus SARS-CoV-2&#44; has become a global pandemic&#44; with more than 500 million confirmed cases worldwide as of June 2022&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Health care systems around the world have been placed under tremendous strain by COVID-19&#44; and the virus will likely leave lasting effects for years to come&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Fortunately&#44; most people infected with the virus experience mild to moderate respiratory illness and recover without needing hospital admission&#46; Some&#44; however&#44; become seriously ill with severe or critical disease following the development of an acute respiratory distress syndrome caused by systemic hyperinflammation and cytokine release&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Vaccination has had a major impact in reducing morbidity and mortality resulting from COVID-19 infection&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> with billions of vaccine doses administered since the first approval in December 2020&#46; Its long-term protection against severe infection is still not established&#44; especially with the advent of new mutated strains&#44; and there will likely be a need for regular vaccine boosts in years to come&#44; particularly for higher-risk groups&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Multiple studies have demonstrated that comorbid cardiovascular disease and cardiovascular risk factors are linked to a more severe course and higher mortality from COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Obesity&#44; in particular&#44; has been established as a risk factor for COVID-19 disease severity&#44; with higher risk for hospitalization&#44; intensive care unit &#40;ICU&#41; admission&#44; invasive mechanical ventilation and death&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> This may be due not only to the stronger association of obesity with cardiovascular risk factors &#40;such as hypertension and type 2 diabetes&#41; and cardiovascular disease &#40;coronary artery disease and heart failure&#41; &#8211; which by themselves are a risk factor for COVID-19 disease severity &#8211; but also to the proinflammatory state associated with obesity resulting from the release of various inflammatory molecules&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;5</span></a> In the setting of COVID-19&#44; obesity can therefore result in further inflammation and subsequent cytokine storm&#44; increasing the risk of severe disease&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Epicardial adipose tissue is increased in obese people&#44; and might also play a role in adverse outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In their article published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Erd&#246;l et al&#46; report a single-center retrospective study that took place at Ankara City Hospital in Turkey&#44; with data collected during an unspecified period&#46; A total of 101 consecutive patients diagnosed with COVID-19 infection were enrolled &#40;26 of them with severe or critical disease and admitted to the ICU&#41;&#46; Clinical&#44; laboratory and imaging &#40;computed tomography &#91;CT&#93; scan&#41; data were collected&#46; The main objective was to assess the association between epicardial fat volume &#40;EFV&#41;&#44; inflammatory biomarkers &#40;C-reactive protein&#44; procalcitonin&#44; serum ferritin&#44; and interleukin-6&#41; and prognosis &#40;composite endpoint of death or admission to the ICU&#41;&#46; Patients admitted to the ICU were significantly older and had a higher prevalence of comorbidities such as coronary artery disease and chronic obstructive pulmonary disease&#44; compared to those with milder disease admitted to the ward &#40;n&#61;75&#41;&#46; Demographic and clinical characteristics such as gender&#44; body mass index&#44; smoking and diabetes were not different between the groups&#46; Inflammatory biomarkers were significantly more elevated in patients admitted to the ICU&#44; and so was EFV&#46; The authors<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> also found a moderate correlation between each of the inflammatory biomarkers and EFV &#40;r&#61;0&#46;26-0&#46;49&#41;&#46; A cut-off value of 102 cm<span class="elsevierStyleSup">3</span> for EFV was found to have a 94&#37; negative predictive value for predicting more severe disease&#46; On multivariate logistic regression analysis&#44; EFV and age independently predicted admission to the ICU&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A recently published study by Mehta et al&#46; also found that epicardial adipose tissue is a risk factor for severe COVID-19&#44; independently of age&#44; body mass index and comorbid conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Angiotensin-converting enzyme 2&#44; recognized as a key receptor in the cell entry of SARS-CoV-2&#44; has also been found in epicardial adipose tissue&#44; further confirming this fat depot as a potential player in the pathophysiology of the disease&#46; In the setting of COVID-19&#44; epicardial adipose tissue may play a role in generating an imbalance between pro- and anti-inflammatory adipokines&#44; potentially leading to the cytokine storm described in patients with severe COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Since most patients with severe COVID-19 will undergo a CT scan&#44; with no need for gating&#44; it is an easily accessible parameter that further helps in the risk stratification of these patients&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">This paper has several limitations&#44; mainly that it reports a single-center retrospective study with a small sample size&#46; Furthermore&#44; the results might have been different in the post-vaccination era&#44; with many of the vaccinated patients admitted to the ICU with severe COVID-19 nowadays being those under chronic immunosuppression&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">This study&#44; however&#44; contributes to current knowledge of the role of EFV in adverse outcomes&#44; and to further risk stratification of COVID-19 patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Epicardial fat as a predictor of COVID-19 disease severity: Just a surrogate for obesity or a true independent predictor?
A gordura epicárdica como fator preditivo da gravidade da doença COVID-19: apenas um marcador de obesidade ou um verdadeiro fator preditivo independente?
Christopher Strong
Serviço de Cardiologia, CHLO, Hospital de Santa Cruz, Carnaxide, Portugal
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    "titulo" => "Epicardial fat as a predictor of COVID-19 disease severity&#58; Just a surrogate for obesity or a true independent predictor&#63;"
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        "autoresLista" => "Christopher Strong"
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        "titulo" => "A gordura epic&#225;rdica como fator preditivo da gravidade da doen&#231;a COVID-19&#58; apenas um marcador de obesidade ou um verdadeiro fator preditivo independente&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Since it was first reported in China in 2019&#44; COVID-19&#44; the infection caused by the new coronavirus SARS-CoV-2&#44; has become a global pandemic&#44; with more than 500 million confirmed cases worldwide as of June 2022&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Health care systems around the world have been placed under tremendous strain by COVID-19&#44; and the virus will likely leave lasting effects for years to come&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Fortunately&#44; most people infected with the virus experience mild to moderate respiratory illness and recover without needing hospital admission&#46; Some&#44; however&#44; become seriously ill with severe or critical disease following the development of an acute respiratory distress syndrome caused by systemic hyperinflammation and cytokine release&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Vaccination has had a major impact in reducing morbidity and mortality resulting from COVID-19 infection&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> with billions of vaccine doses administered since the first approval in December 2020&#46; Its long-term protection against severe infection is still not established&#44; especially with the advent of new mutated strains&#44; and there will likely be a need for regular vaccine boosts in years to come&#44; particularly for higher-risk groups&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Multiple studies have demonstrated that comorbid cardiovascular disease and cardiovascular risk factors are linked to a more severe course and higher mortality from COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Obesity&#44; in particular&#44; has been established as a risk factor for COVID-19 disease severity&#44; with higher risk for hospitalization&#44; intensive care unit &#40;ICU&#41; admission&#44; invasive mechanical ventilation and death&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> This may be due not only to the stronger association of obesity with cardiovascular risk factors &#40;such as hypertension and type 2 diabetes&#41; and cardiovascular disease &#40;coronary artery disease and heart failure&#41; &#8211; which by themselves are a risk factor for COVID-19 disease severity &#8211; but also to the proinflammatory state associated with obesity resulting from the release of various inflammatory molecules&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;5</span></a> In the setting of COVID-19&#44; obesity can therefore result in further inflammation and subsequent cytokine storm&#44; increasing the risk of severe disease&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Epicardial adipose tissue is increased in obese people&#44; and might also play a role in adverse outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In their article published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Erd&#246;l et al&#46; report a single-center retrospective study that took place at Ankara City Hospital in Turkey&#44; with data collected during an unspecified period&#46; A total of 101 consecutive patients diagnosed with COVID-19 infection were enrolled &#40;26 of them with severe or critical disease and admitted to the ICU&#41;&#46; Clinical&#44; laboratory and imaging &#40;computed tomography &#91;CT&#93; scan&#41; data were collected&#46; The main objective was to assess the association between epicardial fat volume &#40;EFV&#41;&#44; inflammatory biomarkers &#40;C-reactive protein&#44; procalcitonin&#44; serum ferritin&#44; and interleukin-6&#41; and prognosis &#40;composite endpoint of death or admission to the ICU&#41;&#46; Patients admitted to the ICU were significantly older and had a higher prevalence of comorbidities such as coronary artery disease and chronic obstructive pulmonary disease&#44; compared to those with milder disease admitted to the ward &#40;n&#61;75&#41;&#46; Demographic and clinical characteristics such as gender&#44; body mass index&#44; smoking and diabetes were not different between the groups&#46; Inflammatory biomarkers were significantly more elevated in patients admitted to the ICU&#44; and so was EFV&#46; The authors<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> also found a moderate correlation between each of the inflammatory biomarkers and EFV &#40;r&#61;0&#46;26-0&#46;49&#41;&#46; A cut-off value of 102 cm<span class="elsevierStyleSup">3</span> for EFV was found to have a 94&#37; negative predictive value for predicting more severe disease&#46; On multivariate logistic regression analysis&#44; EFV and age independently predicted admission to the ICU&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A recently published study by Mehta et al&#46; also found that epicardial adipose tissue is a risk factor for severe COVID-19&#44; independently of age&#44; body mass index and comorbid conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Angiotensin-converting enzyme 2&#44; recognized as a key receptor in the cell entry of SARS-CoV-2&#44; has also been found in epicardial adipose tissue&#44; further confirming this fat depot as a potential player in the pathophysiology of the disease&#46; In the setting of COVID-19&#44; epicardial adipose tissue may play a role in generating an imbalance between pro- and anti-inflammatory adipokines&#44; potentially leading to the cytokine storm described in patients with severe COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Since most patients with severe COVID-19 will undergo a CT scan&#44; with no need for gating&#44; it is an easily accessible parameter that further helps in the risk stratification of these patients&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">This paper has several limitations&#44; mainly that it reports a single-center retrospective study with a small sample size&#46; Furthermore&#44; the results might have been different in the post-vaccination era&#44; with many of the vaccinated patients admitted to the ICU with severe COVID-19 nowadays being those under chronic immunosuppression&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">This study&#44; however&#44; contributes to current knowledge of the role of EFV in adverse outcomes&#44; and to further risk stratification of COVID-19 patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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