RT Journal Article SR Electronic T1 The trajectory of COVID-19 cardiopulmonary disease: insights from an autopsy study of community-based, pre-hospital deaths JF ERJ Open Research JO erjor FD European Respiratory Society SP 00303-2022 DO 10.1183/23120541.00303-2022 A1 Luke Milross A1 Joaquim Majo A1 Julian Pulle A1 Sam Hoggard A1 Nigel Cooper A1 Bethany Hunter A1 Christopher JA Duncan A1 Andrew Filby A1 Andrew J. Fisher YR 2022 UL http://openres.ersjournals.com/content/early/2022/10/06/23120541.00303-2022.abstract AB Background Post-mortem examination of lung and heart tissue has been vital to developing an understanding of COVID-19 pathophysiology, however studies to date have almost uniformly used tissue obtained from hospital-based deaths where individuals have been exposed to major medical and pharmacological interventions.Methods In this study we investigated patterns of lung and heart injury from 46 community-based, pre-hospital COVID-19-attributable deaths who underwent autopsy.Results The cohort comprised 22 females and 24 males, median age 64 years (range 19–91) at time of death with illness duration range 0–23 days. Comorbidities associated with poor outcomes in COVID-19 were represented with obesity (BMI>30 kg·m−2) in 19/46 cases (41.3%). Diffuse alveolar damage (DAD) in its early exudative phase was the most common pattern of lung injury, however significant heterogeneity was identified with bronchopneumonia, pulmonary oedema consistent with acute cardiac failure, pulmonary thromboembolism and microthombosis also identified and often in overlapping patterns. Review of clinical records and next of kin accounts suggested a combination of unexpectedly low symptom burden, rapidly progressive disease and psychosocial factors may have contributed to a failure of hospital presentation prior to death.Conclusions Identifying such advanced acute lung injury in community-based deaths is extremely unusual and raises the question why some with severe COVID-19 pneumonitis were not hospitalised. Multiple factors that include low symptom burden, rapidly progressive disease trajectories and psychosocial factors provide possible explanations.FootnotesThis manuscript has recently been accepted for publication in the ERJ Open Research. It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJOR online. Please open or download the PDF to view this article.Conflicts of interest: The authors declare no conflict of interest.