Long-Term Cardiovascular Outcomes of COVID-19

Quick Takes

  • In a cohort of 153,760 US veterans who survived the first 30 days after COVID-19 diagnosis, risk of incident cardiovascular disease was increased over the ensuing 12 months (hazard ratio for any cardiovascular outcome was 1.63, as compared with contemporary controls; burden was 45.29/1,000 persons).
  • The population burdens of heart failure and atrial fibrillation were particularly increased among COVID-19 patients.
  • For all cardiovascular diagnoses, risk increased with greater severity of the acute infection.

Study Questions:

What are the long-term risks of incident cardiovascular disease following coronavirus disease 2019 (COVID-19)?

Methods:

The authors used US Department of Veterans Affairs (VA) databases to build a cohort of 153,760 US veterans who survived the first 30 days after COVID-19 diagnosis, as well as two control groups: a contemporary cohort of approximately 5.6 million VA users with no COVID-19 diagnosis, and a historical cohort of approximately 5.9 million users during 2017. Cohorts were followed longitudinally to estimate risks (hazard ratios [HRs]) and burdens (excess cases per 1,000 persons) of incident cardiovascular outcomes. Diseases of interest included cerebrovascular disorders, dysrhythmias, heart failure (HF), ischemic heart disease, inflammatory heart disease, and thrombotic disorders. COVID-19 patients were stratified by acute care setting: nonhospitalized, hospitalized, and intensive care. To eliminate potential contributions of vaccine exposure to myocarditis and pericarditis, patients were censored at the time of vaccination, and the authors adjusted for vaccination as a time-varying covariate.

Results:

Risk and burdens of all cardiovascular disorders studied were increased following COVID-19 diagnosis, as compared with the contemporary and historical cohorts. Of all cardiovascular diagnoses studied, the burdens of atrial fibrillation (AF) and HF were greatest (compared with contemporary controls, HR for AF 1.71, burden per 1,000 persons 10.74; HR for HF 1.72, burden 11.61). COVID patients were at higher risk of ischemic heart disease diagnoses (HR for composite outcome 1.66, burden 7.28). Although myocarditis risk was increased in patients who had had COVID, the population burden was low (HR 1.85, burden 0.98). HR for any cardiovascular outcome was 1.63, with burden 45.29. Risks of all cardiovascular disorders increased with severity of the acute COVID illness, with patients who required intensive care having particularly high risk of subsequent AF (HR 7.69 vs. 1.32 for nonhospitalized patients, burden 97.34 vs. 4.88) and HF (HR 6.05 vs. 1.37 for nonhospitalized patients, burden 79.19 vs. 6.05). Subgroup analyses based on race, sex, and common comorbidities (including hypertension, diabetes, and chronic kidney disease) showed that risks of incident cardiovascular disease were increased in all groups.

Conclusions:

COVID-19 is associated with increased risk and population burden of incident cardiovascular disease in the ensuing 12 months, with new AF and HF being most common. Increased severity of the acute infection confers higher risk of subsequent cardiovascular conditions.

Perspective:

The findings of this study likely reflect direct and indirect sequelae of COVID-19 illness. It is biologically plausible that hypercoagulability, endothelial dysfunction, and residual inflammation may lead to adverse cardiovascular events among patients recovering from COVID-19. Deconditioning and lingering symptoms such as dyspnea often cause patients to seek follow-up cardiovascular care and testing, and ascertainment bias may contribute to increased diagnosis of cardiovascular disorders among patients who have severe lower respiratory disease. Moreover, previously asymptomatic patients with undiagnosed structural heart disease may manifest symptomatic HF and AF in the setting of multiple medical stressors. A limitation of this study is that the population was largely male and White. Further research will be needed to determine what strategies might mitigate cardiovascular risk following COVID-19 infection, especially among patients recovering from critical illness.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Pericardial Disease, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Hypertension

Keywords: Acute Coronary Syndrome, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiovascular Diseases, Cerebrovascular Disorders, COVID-19, COVID-19 Testing, Critical Illness, Diabetes Mellitus, Dyspnea, Heart Failure, Hypertension, Inflammation, Myocardial Ischemia, Myocarditis, Pericarditis, Renal Insufficiency, Chronic, Risk Factors, Secondary Prevention, Thrombophilia, Thrombosis, Vaccination, Vaccines, Vascular Diseases, Veterans


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