Risk of Acute MI and Ischemic Stroke After COVID-19

Quick Takes

  • COVID-19 is an independent risk factor for acute myocardial infarction (AMI) and ischemic stroke, even after adjusting for the effect of important confounders.
  • Acute cardiovascular events might represent a key clinical manifestation of COVID-19 and the long-term effects might be a challenge for the future.
  • These findings have important implications for clinical practice and suggest a need to focus on preventive and therapeutic strategies, and vaccination, which may reduce the burden of morbidity and mortality in COVID-19.

Study Questions:

What is the risk of acute myocardial infarction (AMI) and ischemic stroke associated with coronavirus disease 2019 (COVID-19) among all COVID-19 cases in Sweden?

Methods:

The investigators conducted a self-controlled case series (SCCS) and matched cohort study in Sweden. The personal identification numbers of all patients with COVID-19 in Sweden from February 1–Sept 14, 2020 were identified and cross-linked with national inpatient, outpatient, cancer, and cause of death registers. The controls were matched on age, sex, and county of residence in Sweden. International Classification of Diseases codes for AMI or ischemic stroke were identified in causes of hospital admission for all patients with COVID-19 in the SCCS and all patients with COVID-19 and the matched control individuals in the matched cohort study. The SCCS method was used to calculate the incidence rate ratio (IRR) for first AMI or ischemic stroke following COVID-19 compared with a control period. The matched cohort study was used to determine the increased risk that COVID-19 confers compared with the background population of increased AMI or ischemic stroke in the first 2 weeks following COVID-19. The authors used a conditional Poisson regression method, to calculate the incidence rate ratio (IRR) of AMI and ischemic stroke in temporal risk periods following COVID-19 onset, using only individuals who were diagnosed with COVID-19 and had an AMI or ischemic stroke.

Results:

A total of 86,742 patients with COVID-19 were included in the SCCS study, and 348,481 matched control individuals were also included in the matched cohort study. When day of exposure was excluded from the risk period in the SCCS, the IRR for AMI was 2.89 (95% confidence interval, 1.51–5.55) for the first week, 2.53 (1.29–4.94) for the second week, and 1.60 (0.84–3.04) in weeks 3 and 4 following COVID-19. When day of exposure was included in the risk period, IRR was 8.44 (5.45–13.08) for the first week, 2.56 (1.31–5.01) for the second week, and 1.62 (0.85–3.09) for weeks 3 and 4 following COVID-19. The corresponding IRRs for ischemic stroke when day of exposure was excluded from the risk period were 2.97 (1.71–5.15) in the first week, 2.80 (1.60–4.88) in the second week, and 2.10 (1.33–3.32) in weeks 3 and 4 following COVID-19; when day of exposure was included in the risk period, the IRRs were 6.18 (4.06–9.42) for the first week, 2.85 (1.64–4.97) for the second week, and 2.14 (1.36–3.38) for weeks 3 and 4 following COVID-19. In the matched cohort analysis excluding day 0, the odds ratio (OR) for AMI was 3.41 (1.58–7.36) and for stroke was 3.63 (1.69–7.80) in the 2 weeks following COVID-19. When day 0 was included in the matched cohort study, the OR for AMI was 6.61 (3.56–12.20) and for ischemic stroke was 6.74 (3.71–12.20) in the 2 weeks following COVID-19.

Conclusions:

The authors concluded that COVID-19 is a risk factor for AMI and ischemic stroke.

Perspective:

This SCCS method and the matched cohort study (control individuals adjusted for important cardiovascular risk factors) reports that laboratory-diagnosed COVID-19 is an independent risk factor for AMI and ischemic stroke, even after adjusting for the effect of important confounders. These data suggest that acute cardiovascular events might represent a key clinical manifestation of COVID-19 and the long-term effects might be a challenge for the future. These findings have important implications for clinical practice and suggest a need to focus on preventive and therapeutic strategies, and vaccination, which may reduce the burden of morbidity and mortality with COVID-19.

Clinical Topics: Acute Coronary Syndromes, Prevention

Keywords: Acute Coronary Syndrome, Brain Ischemia, Cardiovascular Diseases, Coronavirus, COVID-19, Inpatients, Myocardial Infarction, Myocardial Ischemia, Neoplasms, Outpatients, Primary Prevention, Risk Factors, Stroke, Vaccination, Vascular Diseases


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