Mortality during the COVID-19 pandemic: findings from the CLINIMEX exercise cohort in the year of 2020

  1. Claudio Gil S. Araújo
  2. Christina Grüne de Souza e Silva
  3. Claudia Lucia Barros de Castro
  4. Jari A. Laukkanen
  5. Jonathan Myers
  6. Josef Niebauer
  7. Aline Sardinha
  8. João Felipe Franca

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Abstract

Background and Objective

The COVID-19 pandemic has heavily hit Brazil and, in particular, our Clinic’s current location in Copacabana – Rio de Janeiro city, where, as of mid-February 2021, it led to one death per 266 inhabitants. After having recently updated the vital status and mortality data in our exercise population (CLINIMEX exercise cohort), we hypothesized that the review of their evaluation reports would offer a unique opportunity to unearth some relevant information about the association between selected variables assessed in our comprehensive Exercise Medicine evaluation protocol, in particular, aerobic and musculoskeletal (MUSK) fitness, clinical variables, and death due to COVID-19.

Methods

We conducted a retrospective study using data from the CLINIMEX exercise cohort that included 6,101 non-athletic men and women aged >30 years who were alive as of March 12 th , 2020, and who’s vital status was followed up to December 14 th , 2020. For data analysis, two approaches were used: 1) comparison of frequency of deaths and relative % of underlying causes of death between the last 18-months pre-pandemic and 9-month pandemic periods; and 2) data from 51 variables from the participant’s most recent evaluation, including sex, age and clinical profile plus other variables obtained from physical examination, spirometry, (MUSK) fitness (e.g., sitting-rising test) and maximal cycling leg cardiopulmonary exercise testing (e.g. maximal VO2 and cardiorespiratory optimal point) were selected for comparison between groups of non-COVID-19 and COVID-19 deaths. Results: Age at death varied from 51 to 102 years [mean = 80 years]. Only 4 participants that died – 3 COVID-19 and 1 non-COVID-19 - were healthy at the time of their evaluation [p=.52]. COVID-19 was the most frequent (n=35; 36.5%) cause of death among the 96 deaths during this 9-month period. Comparing pre-pandemic and pandemic periods, there was a 35% increase in deaths and proportionately fewer deaths due to neoplasia and other causes other than cardiovascular or endocrine diseases. Results of aerobic and MUSK fitness tests indicated that the majority of the study participants were relatively unfit when compared to available age and sex-reference values. Indeed, there were few differences in the 51 selected variables between the two groups, suggesting a somewhat healthier profile among COVID-19 death participants: lower body mass index [p=.04], higher % of predicted forced vital capacity [p=.04], lower number of previous percutaneous coronary interventions [p=.04] and lower resting supine diastolic blood pressure [p=.03], with no differences for aerobic/MUSK fitness variables or past history of exercise/sports [p>.05].

Conclusion

Our data support that COVID-19 was a frequent and premature cause of death in a convenience sample of primarily white, unhealthy, middle-age and elderly individuals and that data from exercise/sport history and physical fitness testing obtained some years earlier were unable to distinguish non-COVID-19 and COVID-19 deaths.

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    SciScore for 10.1101/2021.03.17.21253138: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementConsent: All participants read and signed an informed consent form authorizing the use of their de-identified data for research purposes.
    IRB: – Plataforma Brasil number CAEE 40122320.8.0000.9433 and were formally reviewed and approved by an external Research Ethics Committee – Centro de Capacitação Física do Exército (reference number 4.459.555, December 13
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variableAfter having applied the exclusion criteria, there remained a total of 6,101 alive participants – 4,004 men (65.6%) and 2,097 women (34.4%), aged 52.2 ± 12.7 years (mean ± standard deviation) at the time of their first evaluation.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Prism software version 8.4.3 (GraphPad, San Diego, US) was used for all statistical calculations.
    Prism
    suggested: (PRISM, RRID:SCR_005375)
    GraphPad
    suggested: (GraphPad Prism, RRID:SCR_002798)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Limitations: This study has several relevant limitations: 1) The study has a retrospective design and there was a large range in the interval of time between the evaluations and the outcomes, i.e., death, as previously mentioned. While recent clinical data was available for some unhealthy and healthy participants that died, as in those that were attending onsite or remote exercise programs shortly before death, regarding many others, no recent information was available for the current study. However, this situation is similar for both COVID-19 and non-COVID-19 deaths in terms of the number of days elapsed between last evaluation and fatal outcomes (see table 2); 2) For this study, we relied on the information made available on the death certificates and no formal attempt was made to check their accuracy; 3) while this paper is being written (mid-February), the pandemic continues strong and Brazil is reaching new tragic records of 7-day rolling average of COVID-19 deaths/day; thus, we do not know if the findings herein would differ if a longer period of observation is considered; 4) A theoretical and logical possibility was that the participants dying from COVID-19 were more exposed and less “prudent” in regard to the virus infection. Unfortunately, there is no available information about how adherent the participants were to recommended sanitary precautions; however, as far as we could find out from information obtained from spouses, relatives and friends of the participants,...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

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  2. Version published to 10.1101/2021.03.17.21253138v1 on medRxiv