Relationship Between Preexisting Cardiovascular Disease and Death and Cardiovascular Outcomes in Critically Ill Patients With COVID-19

Abstract

Background: Preexisting cardiovascular disease (CVD) is perceived as a risk factor for poor outcomes in patients with COVID-19. We sought to determine whether CVD is associated with in-hospital death and cardiovascular events in critically ill patients with COVID-19. Methods: This study used data from a multicenter cohort of adults with laboratory-confirmed COVID-19 admitted to intensive care units at 68 centers across the United States from March 1 to July 1, 2020. The primary exposure was CVD, defined as preexisting coronary artery disease, congestive heart failure, or atrial fibrillation/flutter. Myocardial injury on intensive care unit admission defined as a troponin I or T level above the 99th percentile upper reference limit of normal was a secondary exposure. The primary outcome was 28-day in-hospital mortality. Secondary outcomes included cardiovascular events (cardiac arrest, new-onset arrhythmias, new-onset heart failure, myocarditis, pericarditis, or stroke) within 14 days. Results: Among 5133 patients (3231 male [62.9%]; mean age 61 years [SD, 15]), 1174 (22.9%) had preexisting CVD. A total of 1178 (34.6%) died, and 920 (17.9%) had a cardiovascular event. After adjusting for age, sex, race, body mass index, history of smoking, and comorbidities, preexisting CVD was associated with a 1.15 (95% CI, 0.98–1.34) higher odds of death. No independent association was observed between preexisting CVD and cardiovascular events. Myocardial injury on intensive care unit admission was associated with higher odds of death (adjusted odds ratio, 1.93 [95% CI, 1.61–2.31]) and cardiovascular events (adjusted odds ratio, 1.82 [95% CI, 1.47–2.24]), regardless of the presence of CVD. Conclusions: CVD risk factors, rather than CVD itself, were the major contributors to outcomes in critically ill patients with COVID-19. The occurrence of myocardial injury, regardless of CVD, and its association with outcomes suggests it is likely due to multiorgan injury related to acute inflammation rather than exacerbation of preexisting CVD. Registration: NCT04343898; https://clinicaltrials.gov/ct2/show/NCT04343898 .

Severe COVID-19 outcomes by cardiovascular risk profile in England in 2020: a population-based cohort study

“…Nevertheless, complete case analysis gives unbiased results when the chance of being a complete case is independent of outcome after taking covariates into account, even when data are missing not at random. 26 Our findings extend those from previous smaller studies of individual cardiovascular risk factors and COVID-19 outcomes, 27,28 supporting a strong association between raised cardiovascular risk profile and severe COVID-19 outcomes. While a previous Mendelian randomisation study, which by design avoids reverse causation and most confounding, failed to show an association between some genetically-predicted cardiovascular risk factors (blood pressure, BMI, type 2 diabetes and coronary artery disease) and COVID-19 hospitalisation, 29 estimates had wide confidence intervals and did not capture full profiles of either cardiovascular risk or severe COVID-19 outcomes.…”

Association between cardiovascular risk and coronavirus disease 2019: findings from 2021 National Health Interview Survey

“…Our studies further identified a dose-response relationship between increased cardiovascular risk factors and the risk of COVID-19. This dose-response effect may represent a cumulative effect of multiple risk factors on the occurrence and severity of COVID-19 [27] . Further prospective cohort studies are needed to determine potential causal associations.…”

“…The mechanisms by which pre-existing CVD disorders impact the risk of COVID-19 are not fully understood. Inflammation, multiorgan dysfunction, vascular injury, and metabolic and endothelial disarray may play a role in the risk of COVID-19 [3] , [27] . For example, studies have shown that excess adiposity and cardiometabolic disorders may increase the risk of COVID-19 and the severity of the disease outcomes by increased risks of inflammation, immune dysfunction, hypercoagulation, and mechanical obstruction [3] , [4] , [28] , [29] , [30] .…”

Impact of COVID-19 pandemic on cardiovascular diseases hospitalisation, management and mortality in Switzerland

“…Third, pre-existing CVD is strongly associated with a poor outcome of COVID-19 infection, and the mortality of the COVID-19 positive patients with underling CVD comorbidities is substantially high. [37][38][39][40] Therefore, it is possible that the increase in patients with CVD who died from COVID-19 in 2020 (and who were not considered as dying of CVD) could partly explain the decrease of CVD in-hospital deaths in 2020. Finally, a direct effect of COVID-19 infection on CVD cannot be discarded, as it was estimated that a 10% COVID-19 prevalence could lead to up to 62 410 excess deaths in England.…”