LBS coverage (2020) | COVID-19 cardiovascular disease registry documents relationships between CVD and COVID-19

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Researchers for “AHA Goes Viral: COVID-19, Influenza Vaccines and Cardiovascular Disease,” Late-Breaking Sessions on Tuesday reported:

  • Nationwide COVID-19 cardiovascular disease registry details cardiovascular complications.
  • Black, Hispanic patients bear greater COVID-19 burden.
  • Young, obese patients with COVID-19 are at high risk for in-hospital complications including death.
  • Cardiovascular disease risk factors increase mortality risk in hospitalized COVID-19 patients.
  • High-dose flu vaccine is no more effective than regular-dose vaccines in high-risk CVD patients.

AHA registry describes cardiovascular complications from COVID-19 

The harm from COVID-19 comes primarily from its respiratory effects, ranging from pneumonia to acute respiratory distress syndrome. It also can be associated with cardiovascular complications, such as heart failure, cardiogenic shock, stroke and lethal arrhythmias. Research from the AHA COVID-19 Cardiovascular Disease Registry suggests that, although prior cardiovascular disease and CV risk factors increase the chance of a more severe illness, serious cardiovascular adverse events are less common than was feared based on early single center and regional reports.

The AHA registry grew out of early efforts at the University of Texas Southwestern to understand the pathophysiology and cardiovascular complications of COVID-19. Local researchers quickly recognized the need for broader perspective and proposed a national COVID-19 quality improvement registry to AHA leadership.

The AHA COVID-19 Cardiovascular Disease Registry went live and began collecting data within weeks of the initial proposal. The registry is taking innovative approaches to rapidly generate and disseminate new knowledge about COVID-19 by allowing multiple teams of investigators to perform studies at the same time. The registry uses the AHA’s cloud-based Precision Medicine Platform. Between 20 and 30 research projects are currently under way based on more than 20,000 patient records at more than 100 centers across the United States. 

Initial analysis of clean data from 14,889 patients at 99 sites show that cardiovascular disease and cardiovascular risk factors contribute to accentuated risk for hospital admission after COVID infection. Cardiovascular risk factors such as diabetes, obesity, hypertension and prior CV disease diagnoses are overrepresented in hospital admissions for COVID-19.

Atrial fibrillation, myocardial infarction and deep vein thromboembolism/pulmonary embolism are the most common in-hospital cardiovascular complications of COVID-19. But the absolute rates of cardiovascular complications, including heart attack, stroke, heart failure and myocarditis, are relatively low, about 9%.

“Most COVID-19 hospitalizations are not associated with concomitant cardiac complications,” said James de Lemos, MD, PhD, professor and Sweetheart Ball–Kern Wildenthal, MD, PhD, Distinguished Chair in Cardiology at the University of Texas Southwestern Medical Center. “At the same time, there is a subset of individuals that develop cardiovascular complications, which can be quite severe.”

Black, Hispanic patients bear greater burden of COVID-19 in-hospital mortality, morbidity

The American Heart Association COVID-19 Cardiovascular Disease Registry shows a strikingly uneven impact on different racial and ethnic groups during the first six months of the pandemic. Black and Hispanic patients had a greater risk of in-hospital death or morbidity because of their disproportionate representation among COVID-19 hospitalizations.

A retrospective analysis stratified the first 7,868 patients in the registry by race/ethnicity across 88 U.S. hospitals between Jan. 1 and July 22, 2020. The primary measures were in-hospital mortality, major adverse cardiovascular events (death, myocardial infarction, stroke, new onset heart failure or cardiogenic shock) and COVID-19 cardiorespiratory severity score.  

Overall, in-hospital mortality for the period studied was 18% with 53% of deaths occurring in Black and Hispanic patients.

Among patients in the registry, 33% were Hispanic, 25.5% non-Hispanic Black, 6.3% Asian and 35.2 non-Hispanic White. Black and Hispanic patients were significantly overrepresented in hospital admissions compared to the general population. Asian patients were roughly comparable and White patients significantly underrepresented.

Hispanic and Black patients in the registry were about 10 years younger than non-Hispanic White and Asian patients at admission for COVID-19 and more likely to be uninsured.

Black patients had the highest prevalence of obesity, hypertension and diabetes. Black patients also had the highest rates of mechanical ventilation (23.2%) and renal replacement therapy (6.6%), but the lowest rates of remdesivir use (6.1%).

There was no statistically significant difference for in-hospital mortality between non-Hispanic White, Black, Hispanic or Asian patients, said Fatima Rodriguez, MD, MPH, FAHA, assistant professor of cardiovascular medicine at Stanford University School of Medicine.  

“Although race and ethnicity were not independently associated with in-hospital mortality or MACE, Black and Hispanic patients are carrying a greater burden of morbidity and mortality given their overrepresentation in hospitalizations and much younger age when hospitalized,” Dr. Rodriguez said. “The real take-home is that we have to reduce transmission, do a better job of protecting these more vulnerable people in their communities and their places of work.”

Results were published simultaneously in Circulation. 

Obesity puts young patients at high risk from COVID-19

Obesity is an independent risk factor for death and poor outcomes for patients hospitalized with COVID-19. Researchers used the first release of data from the American Heart Association’s COVID-19 Cardiovascular Disease Registry to examine the association of body mass index (BMI) with in-hospital death, mechanical ventilation and adverse cardiovascular outcomes in those hospitalized with COVID-19. The study cohort included 7,606 patients across 88 U.S. institutions.

Characteristics of patients included in the first release of registry data indicates a higher BMI to be associated with younger age, female sex and a higher prevalence of Black race and diabetes. Evident from the registry data, patients admitted with COVID-19 were more likely to be obese when compared to the BMI distribution of the general population. Estimates of population BMI were based on data from the National Health and Nutrition Examination Survey. Stratified categories for BMI were based on World Health Organization obesity classes. Patients hospitalized with COVID-19 and class III obesity were 18 years younger than hospitalized patients with a normal BMI. 

Among those hospitalized with COVID-19, patients with class III obesity (BMI ≥40 kg/m2 ) had an odds ratio of 1.80 for in-hospital death or mechanical ventilation, and a hazard ratio for 1.26 for in-hospital death after adjustment for age, race, sex and baseline medical conditions as compared to normal weight patients. Furthermore, young (<50 years-old) and severely obese adults (BMI ≥40 kg/m2) hospitalized with COVID-19 had an odds ratio of 1.64 for either in-hospital death or mechanical ventilation compared to young, normal weight patients.)

Further adjusted analysis revealed class III obesity was associated with a greater than threefold higher risk for in-hospital initiation of renal replacement therapy (hazard ratio 3.86), and patients with class II obesity were nearly 2 times at increased risk for developing venous thromboembolism during hospitalization as compared to normal weight individuals.

“Many young patients weren’t worried about COVID-19, believing that youth was a warranty against severe infection or death from COVID,” said Nicholas Hendren, MD, chief cardiology fellow at the University of Texas Southwestern Medical Center. “What we found is that if you are young and obese, your risk from COVID-19 is not trivial. Obesity, regardless of age, should be considered a high-risk condition for COVID-19.”

Results were published simultaneously in Circulation.  

CVD and its risk factors boost risk for COVID-19 in-hospital mortality 

A retrospective analysis of nationwide electronic health record data of patients hospitalized for COVID-19 reveals that cardiovascular disease and its risk factors dramatically elevate the risk of in-hospital mortality. Other important risk factors for in-hospital death include older age, male sex and non-white race.

Researchers used de-identified EHR data for patients hospitalized with laboratory-confirmed or clinical diagnosis of COVID at 52 health centers participating in Cerner Real-World Data through July 1, 2020. Of 28,299 patients hospitalized for COVID-19 at these centers, 20.7% died in-hospital and 79.3% were discharged home.  

The median age of COVID-19 patients was 52. In-hospital mortality increased slowly with age until about 55, when mortality rose steeply with increasing years.  

By age 80, nearly 1 in 2 patients hospitalized with COVID-19 died.

Differences in mortality were seen by sex, with an odds ratio of 1.46 for males, but not by race. Mortality for White patients was 20.8.3%, compared to 24.1% for American Indian/Alaskan Native, 22.7% for Black, and 19.7% for Asian/Pacific Islander patients.  

Pre-existing CVD and its risk factors were all associated with increased mortality. In-hospital mortality ranged from 20.4% for persons with hypertension to 21.5% for those with diabetes, 28.8% for those with coronary artery disease and 34.2% for those with heart failure.

In-hospital cardiovascular events were uncommon, but deadly. Just 1.5% of patients had a stroke while hospitalized for COVID-19, but the mortality rate was 56.0%. Similarly, 5.0% of patients had an MI, of whom 55.5% died.

“These data reflect what doctors and nurses on the front line in hospitals across the U.S. are actually seeing, where more than 1 in 5 patients hospitalized with COVID-19 does not make it home,” said Ann Marie Navar, MD, PhD, associate professor of medicine at the University of Texas Southwestern Medical School.

“This is why many health care workers are such vocal proponents of social distancing and other public health measures to contain the virus,” Dr. Navar said. “I hope this work, by helping the public understand what we see every day, can help people do the right thing as it relates to containing transmission.”

High-dose flu vaccine not better than standard-dose in patients with high-risk CVD

High-dose influenza vaccine is no more effective than standard-dose vaccine in reducing severe cardiopulmonary events in patients recently hospitalized for cardiovascular disease. The Influenza Vaccine to Effectively Stop cardio Thoracic Events and Decompensated heart failure (INVESTED) trial compared all-cause mortality or hospitalization for cardiovascular or pulmonary causes in patients who received either high-dose influenza vaccine or a standard-dose vaccine.

A total of 5,260 patients were randomized to either high-dose trivalent or standard-dose quadrivalent influenza vaccine for up to three influenza seasons between 2016 and 89. The mean age of participants was 66 years and 72% were male.

All had been hospitalized within the prior year for myocardial infarction (37%) or within two years for heart failure (63%). They also had at least one additional risk factor such as diabetes, obesity, renal impairment, tobacco use, peripheral artery disease, age or an additional myocardial infarction or HF event.

The trial was terminated early for futility on the recommendation of the data safety monitoring group. 

Both groups had high rates of hospitalization for cardiovascular and pulmonary events or death during the trial, 44.5% for standard-dose vaccine versus 41.9% for high-dose, reported Orly Vardeny, PharmD, MS, associate professor of medicine at the University of Minnesota and the Minneapolis Veterans Administration Center for Care Delivery and Outcomes Research. The hazard ratio was 1.06, no significant difference in hospitalizations for cardiopulmonary events between the two vaccines.

“We did not show that one flu shot is better than the other for reducing death, or heart and lung hospitalizations in these high-risk patients,” Dr. Vardeny said. “The bottom line is that it is vitally important for people with heart disease to get their annual flu shots.”

The results of INVESTED will be published in the Journal of the American Medical Association