COVID-19 CVD registry highlights racial/ethnic disparities, risk in obesity
Click Here to Manage Email Alerts
CVD complications in patients with COVID-19 are less common than were believed, but COVID-19 complications disproportionately affect patients with obesity and Black and Hispanic individuals, according to new registry data.
Researchers presented the initial data from the American Heart Association’s COVID-19 CVD registry at the AHA’s virtual scientific sessions.
As of Sept. 30, the registry included 14,889 patients from 99 sites, James A. de Lemos, MD, professor of medicine and Sweetheart Ball – Kern Wildenthal, MD, PhD, Distinguished Chair in Cardiology at UTSouthwestern Medical Center, said during a presentation.
“The objectives of the registry are to accelerate the pace of COVID-19 quality improvement and research,” de Lemos said. “We aimed for granular data collection and are collecting over 200 unique data elements for each individual, with extensive serial laboratory data.”
Most patients had CV risk factors, including 58% with hypertension, 35% with diabetes, 45% with obesity (BMI > 30 kg/m2) and 34% with hyperlipidemia, de Lemos said.
Also, he said, among prior CV conditions, 5% had MI, 4% had PCI, 3% had CABG, 10% had stroke, 11% had HF and 9% had atrial fibrillation, noting that 13% had chronic kidney disease.
The CVD composite outcome of CV death, stroke, MI, HF or shock occurred in 8.8% of patients, 3% had MI, 1.3% had stroke, 1.8% had new-onset HF, 1.7% had cardiogenic or mixed shock, 0.3% had myocarditis, 7.9% had new-onset AF and 3.6% had deep vein thrombosis or pulmonary embolism, he said.
“The in-hospital cardiac complications occurred less frequently than we feared when we initially set up the registry and were evaluating early single-center experiences,” de Lemos said.
The rate of in-hospital mortality was 16.7% and 2.8% of patients required hospice care, he said. Most deaths were from respiratory causes (72%), with 10% of patients dying of cardiac causes and 18% dying of other causes, often sepsis, according to the researchers.
Among the cohort, 30% required a stay in the ICU, 20% required mechanical ventilation and 4.2% required new dialysis or renal replacement therapy.
“Unfortunately, the pandemic through the end of September has a depressingly high major mortality and morbidity rate,” de Lemos said during the presentation. “The cardiovascular complications are important in a subset of individuals but are less common than initially feared. We emphasize that given the scale of the pandemic, the aggregate number of these cardiac complications remains substantial.”
Race, ethnicity data
Black and Hispanic patients accounted for more than 50% of the COVID-19 hospitalizations among 7,868 patients included in the AHA registry as of July 22 for whom race/ethnicity information was available, Fatima Rodriguez, MD, MPH, assistant professor of cardiovascular medicine at Stanford University School of Medicine, said during a presentation.
Compared with local census data, white individuals were underrepresented in the registry (35.2% vs. 59.3%), but Black (25.5% vs. 10.6%) and Hispanic (33% vs. 9%) individuals were overrepresented, she said.
Compared with those of other races and ethnicities, Black patients had the highest rates of obesity (49.3%), diabetes (45.2%) and hypertension (69.9%), she said.
Of note, she said, Black patients were less likely to receive remdesivir (Veklury, Gilead Sciences), an FDA-approved therapy, compared with those of other groups (6.1% vs. 8% for white patients, 9.5% for Hispanic patients and 9.2% for Asian/Pacific Islander patients).
Compared with non-Hispanic white patients, risk for mortality or major adverse CV events was not significantly higher for patients of other races or ethnicities, but Asian/Pacific Islander patients had significantly higher risk for COVID-19 disease severity (adjusted OR = 1.48; 95% CI, 1.16-1.9).
Black patients accounted for 24% of in-hospital deaths, white patients for 40%, Hispanic patients for 29% and Asian/Pacific Islander patients for 7%, according to the researchers.
Black patients also had higher rates of mechanical ventilation and renal replacement therapy than other patients, Rodriguez said, noting one-third of them required an ICU stay.
“The implications of our work are that although race and ethnicity was not significantly associated with clinical outcomes, Black and Hispanic patients bore a greater burden of morbidity and mortality due to their disproportionate representation,” Rodriguez said during her presentation. “Our work emphasizes that interventions to reduce disparities should move upstream from hospitalizations.”
BMI data
Among the 7,606 patients in the registry as of July 22 for whom BMI data were available, the cohort was more likely to be obese compared with the National Health and Nutrition Examination Survey U.S. national registry, especially among patients aged 50 years or younger, Nicholas S. Hendren, MD, chief cardiology fellow at UTSouthwestern Medical Center, said during a presentation.
Black patients had higher rates of class III obesity (40 kg/m2 or more) compared with patients of other races and ethnicities.
Compared with those with normal weight, those with obesity had elevated risk for death or mechanical ventilation, with the risk rising with increasing obesity class (OR for class I obesity vs. normal weight = 1.28; 95% CI, 1.09-1.51; OR for class II obesity vs. normal weight = 1.57; 95% CI, 1.29-1.91; OR for class II obesity vs. normal weight = 1.8; 95% CI, 1.47-2.2). He noted the endpoint was driven by mechanical ventilation, which was significantly higher in patients with overweight or any class of obesity compared with patients with normal weight (OR for overweight vs. normal weight = 1.28; 95% CI, 1.09-1.51; OR for class I obesity vs normal weight = 1.54; 95% CI, 1.29-1.84; OR for class II obesity vs. normal weight = 1.88; 95% CI, 1.52-2.32; OR for class III obesity vs. normal weight = 2.08; 95% CI, 1.68-2.58).
He noted class III obesity was associated with elevated risk for in-hospital mortality only in patients aged 50 years or younger (HR = 1.36; 95% CI, 1.01-1.84).
The hazards of poor outcomes related to obesity were most pronounced in patients aged 50 years or younger (P for interaction < .05 for all primary endpoints), he said.
“We believe that clear public health messaging is needed for younger obese individuals who may underestimate their risk if they get COVID-19, and that severely obese individuals should be considered high risk for severe COVID-19 infection and may warrant prioritization for a COVID-19 vaccine," Hendren said during the presentation.
The race/ethnicity and BMI analyses were simultaneously published in Circulation.
References:
- Hendren N, et al.
- Rodriguez F, et al. LBS.08: AHA goes viral: COVID-19, influenza and cardiovascular disease. Both presented at: American Heart Association Scientific Sessions; Nov. 13-17, 2020 (virtual meeting).
- Hendren N, et al. Circulation. 2020;doi:10.1161/CIRCULATIONAHA.120.051936.
- Rodriguez F, et al. Circulation. 2020;doi:10.1161/CIRCULATIONAHA.120.052278.
Perspective
Back to Top
These authors suggest poor outcomes in nonwhite vs. white patients are likely attributed to higher incidence of CV risk factors/disease in nonwhite patients, but the sex-related COVID-19 disparities are also important to note. Global health data among > 41 million confirmed cases and > 1.1 million deaths indicate that there are similar numbers of cases for women and men. However, for every 10 cases in women, there are 12 hospitalizations, 19 ICU admissions and 14 deaths among men (globalhealth5050.org/the-sex-gender-and-covid-19-project. Accessed Dec. 29, 2020).
Men have higher 30-day mortality (8.8% vs. 4.3% in women) and benefit for women persists after propensity matching for comorbidities (Alkhouli M, et al. Mayo Clin Proc. 2020;doi:10.1016/j.mayocp.2020.05.014). This implies that differences are not simply explained by higher CV risk factor incidence, as suggested for the racial/ethnic disparities. It is possible that the magnitude of each, or several risk factors in concert, plus key social factors contribute to the observed sex-related COVID-19 severity differences. These factors could also contribute to the racial/ethnic diversities.
Perspective
Back to Top
Thomas M. Maddox, MD, MSc
There were four take-home messages from these analyses. No. 1, it is impressive how fast the researchers were able to stand the registry up and how many patients are now in the registry. It is good that this can be demonstrated in something that moves as rapidly as this pandemic.
No. 2, it is important to realize this is a somewhat selected population. These patients were in the hospital, and as we know, the majority of patients with COVID-19 do not need to be hospitalized. When looking at the prevalence rates of hypertension, diabetes and obesity and the mortality rates, if one did not appreciate the selected nature of the group, one might think this disease is so much more deadly than we thought. But as we know, that is a little confounded.
However, it was very important to understand the characteristics and outcomes of the hospitalized group. It was important to realize the overall cardiac complications were around 8% to 9%, driven largely by AF and clotting. For inpatient cardiologists, it is important to know what we should keep an eye out for. Early on, we were concerned about HF. With more experience, we have realized that, while it is worrisome when it happens, and it is not unheard of, the more common concerns are AF and vein thromboses. While those are serious, the management of them is well understood.
No. 3, it is good to know there is not a statistical difference between the racial and ethnic groups in mortality and major adverse CV events, although we know that in the community, there are differences, which the investigators mentioned. It was interesting that the Asian population had greater severity of COVID-19. I had not seen that before. That opens up some new areas of questions and investigations.
No. 4, patients with obesity, particularly those aged 50 years or younger, seem to do worse, especially in terms of needing mechanical ventilation. In other conditions, obesity complicates respiratory mechanics, so this is not unheard of. This suggests we need to have our radars up when it comes to these patients, particularly now, as ICU capacities are starting to fill up.
As we move into the era of therapeutics, we have seen efficacy with remdesivir and steroids, and we know there are people with clinical characteristics that the trials suggest benefit from these medications. We need to consistently deliver that. Are we ensuring that, regardless of how you come to us, we are giving you the opportunity to get what we know to be the best treatments?
The most prevalent medication used in the race/ethnicity data set was hydroxychloroquine. By July, we did not have the data telling us what we now know, that it is just not that effective. I would like to see a breakdown of medications used between July and today. We also want to ensure that patients are not getting treatments that do not help. These registries give us almost real-time feedback about practice patterns and whether they concur with the science.
Collapse
de Lemos JA, et al. LBS.08: AHA goes viral: COVID-19, influenza and cardiovascular disease. Presented at: American Heart Association Scientific Sessions; Nov. 13-17, 2020 (virtual meeting).
Read more about
Click Here to Manage Email Alerts