Outcome of COVID-19 in Hospitalized Patients With CVD

Quick Takes

  • This study is an analysis of two multinational European registries examining the association between pre-existing CVD and in-hospital mortality of 16,511 adult patients with COVID-19.
  • A history of CVD was not independently associated with mortality. Among heart disease subtypes, only advanced heart failure was associated with high in-hospital mortality.
  • Cardiovascular complications during hospitalization were rare, occurring in <1% of patients.

Study Questions:

How do subtypes of heart disease impact in-hospital mortality of patients with coronavirus disease 2019 (COVID-19)?

Methods:

The authors combined data from two multinational European registries (CAPACITY-COVID and LEOSS), from which they analyzed a subcohort of hospitalized adult (aged ≥18 years) patients with confirmed severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection and available data on history of cardiac disease and outcomes. Extent and scope of patient inclusion varied by site of enrollment. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. The following heart disease subtypes were analyzed: arrhythmias/conduction disorders, coronary artery disease, myocardial infarction, heart failure, and valvular heart disease. All analyses were adjusted for the following covariates: age, sex, body mass index, diabetes, hypertension, chronic kidney disease, chronic obstructive pulmonary disease, and geographic region of inclusion.

Results:

A total of 16,511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male (64%), and had a higher burden of comorbidities. There were no major differences in symptoms at presentation between patients with and without prior heart disease. Mortality was higher in patients with cardiac disease compared to those without (29.7% vs. 15.9%, respectively). The association, however, was no longer significant in multivariable analysis (adjusted risk ratio [aRR], 1.08; 95% confidence interval [CI], 1.02-1.15; p = 0.12 corrected for multiple testing). Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for New York Heart Association (NYHA) class III/IV heart failure (aRR, 1.41; 95% CI, 1.20-1.64; p < 0.018). None of the other heart disease subtypes, including ischemic heart disease, remained significant after multivariable adjustment. Subgroup analyses did not reveal any interactions. Serious cardiac complications including myocarditis, myocardial infarction, and new-onset heart failure were diagnosed in 0.2% (n = 37), 0.6% (n = 95), and 1.2% (n = 197) of patients, respectively. Malignant ventricular arrhythmias, endocarditis, and pericarditis also occurred in <1% of patients. Among thromboembolic complications, pulmonary embolism was most prevalent, being diagnosed in 3.5% (n = 569) of patients.

Conclusions:

Among heart disease subtypes, patients with NYHA class III/VI heart failure are at higher risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Perspective:

Cardiovascular disease (CVD) was long perceived as a major risk factor for COVID-19 and a common complication in hospitalized patients. This large observational multinational registry, owing to its large sample size, provides important data that clarifies the impact of various heart disease subtypes on COVID-19 outcomes. While patients with pre-existing CVD are at higher risk of mortality related to COVID-19, this association appears to be largely driven by age and other shared risk factors such as hypertension, diabetes mellitus, and kidney disease. It is only the subset of patients with NYHA class III/IV heart failure that appear to have a significantly higher risk of in-hospital mortality. Most importantly and contrary to common perception, cardiovascular complications are rare in hospitalized patients with COVID-19, occurring in <1% of patients. These data are essential for establishing guidelines surrounding the specific management of patients with CVD in relation to COVID-19 and provides clarity to patients regarding their risk. Patients with CVD should nevertheless be construed as a high-risk patient group given they commonly share risk with COVID-19 such as advanced age, hypertension, diabetes mellitus, obesity, and others.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Pericardial Disease, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Hypertension

Keywords: Arrhythmias, Cardiac, Cardiovascular Diseases, Comorbidity, Coronary Artery Disease, COVID-19, Diabetes Mellitus, Endocarditis, Heart Disease Risk Factors, Heart Failure, Hospital Mortality, Hypertension, Kidney Diseases, Myocardial Infarction, Myocarditis, Pericarditis, Primary Prevention, Pulmonary Embolism, Risk Factors, SARS-CoV-2


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