In survivors of acute COVID-19, CV risk, burden ‘substantial’
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Compared with controls, survivors of acute COVID-19 have elevated CV risks and burdens at 1 year, even if they were not hospitalized for COVID-19, researchers reported in Nature Medicine.
“Our results provide evidence that the risk and 1-year burden of cardiovascular disease in survivors of acute COVID-19 are substantial,” Yan Xie, MPH, biostatistician in the Clinical Epidemiology Center at the VA St. Louis Health Care System, and colleagues wrote.
Xie and colleagues used Veterans Affairs databases to create three cohorts: 153,760 veterans who survived the first 30 days of COVID-19, a contemporary control group of 5,637,647 veterans who had no evidence of COVID-19 and a historical control group of 5,859,411 veterans from 2017 who did not have COVID-19.
Participants were followed for approximately 1 year, corresponding to 12,095,836 person-years of follow-up, for incidence of various CV outcomes. The COVID-19 cohort was stratified into three groups representing disease severity: not hospitalized, hospitalized and admitted to the ICU.
Elevated risks and burdens
Xie and colleagues found that compared with contemporary controls, the COVID-19 cohort had elevated risk for and burden of the following CV outcomes at 1 year:
- cerebrovascular outcomes (HR = 1.53; 95% CI, 1.45-1.61; burden per 10,000 persons = 5.48; 95% CI, 4.65-6.35);
- arrhythmia outcomes (HR = 1.69; 95% CI, 1.64-1.75; burden per 10,000 persons = 19.86; 95% CI, 18.31-21.46);
- ischemic heart disease outcomes (HR = 1.66; 95% CI, 1.52-1.8; burden per 10,000 persons = 7.28; 95% CI, 5.8-8.88);
- other CV disorders such as HF, nonischemic cardiomyopathy, cardiac arrest and cardiogenic shock (HR = 1.72; 95% CI, 1.65-1.79; burden per 10,000 persons = 12.72; 95% CI, 11.54-13.96);
- thromboembolic disorders (HR = 2.39; 95% CI, 2.27-2.51; burden per 10,000 persons = 9.88; 95% CI, 9.05-10.74);
- major adverse CV events, defined as MI, stroke or all-cause death (HR = 1.55; 95% CI, 1.5-1.6; burden per 10,000 persons = 23.48; 95% CI, 21.54-25.48); and
- any CV outcome (HR = 1.63; 95% CI, 1.59-1.68; burden per 10,000 persons = 45.29; 95% CI, 42.22-48.45).
The results were similar when the COVID-19 group was compared with the historical controls, Xie and colleagues wrote.
The results did not vary by age, race, sex, obesity, smoking, diabetes, chronic kidney disease, hyperlipidemia and CVD. An analysis of only participants who had no CVD at baseline was consistent with the main results, the researchers wrote.
Severity of infection
Compared with the contemporary control group, in the COVID-19 group, the risks and 1-year burdens of the CV outcomes increased with increasing severity of infection, but even those who had COVID-19 and were not hospitalized for it had elevated risk for most CV outcomes compared with controls, according to the researchers, who noted there were similar findings for the COVID-19 group compared with the historical controls.
In addition, Xie and colleagues wrote, COVID-19 was associated with elevated risk for myocarditis and pericarditis when participants were censored at the time of first COVID-19 vaccine dose and after adjustment for vaccination as a time-varying covariate.
“Care strategies of people who survived the acute episode of COVID-19 should include attention to cardiovascular health and disease,” Xie and colleagues wrote. “Our study shows that the risk of incident cardiovascular disease extends well beyond the acute phase of COVID-19.”
Perspective
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Jeffey J. Hsu, MD, PhD, FACC
The study by Dr. Xie and colleagues provides interesting data on the potential long-term CV consequences of COVID-19. Importantly, the researchers studied a specific population — older veterans with a mean age of 61 years who were predominantly male (89%), white (71%), and current/former smokers (55%). But in this patient population, they found that testing positive for COVID-19 appeared to increase the risk for adverse cardiac events within the next year, even in patients who were not hospitalized for COVID-19. The key take-home messages I interpreted from this study were:
- In this population, patients who survive acute COVID-19 illness have an increased risk for having an adverse CV event within the next year after the initial infection, even if they were not hospitalized for COVID-19. This risk was even higher in patients who were hospitalized for COVID-19 and even higher in those who required ICU-level care.
- The range of adverse events include not only ischemic heart disease and stroke, but also HF and arrhythmias.
- The increased risk was apparent even in patients without a prior history of comorbidities, such as CVD, obesity or hypertension.
- With the known concerns of acute COVID-19 illness, and with this study adding to the continued emergence of data demonstrating the longer-term risks of infection, every effort should be made to prevent infection in the first place, which can be most effectively done with vaccination.
This study highlights the need for clinicians to incorporate a patient's COVID-19 history in their evaluation, with proactive assessment for any signs or symptoms concerning for CVD. There should be particularly heightened awareness in patients who were hospitalized for their acute COVID-19 illness, given the even higher risk seen in this group of patients.
It still remains unclear whether the CV sequelae of COVID-19, both in the acute and postacute phases, are unique to the SARS-CoV-2 virus. For instance, it is highly plausible that the findings of this study could also be seen if the authors evaluated patients diagnosed with influenza infection, and it is well known that vaccination against influenza significantly reduces CV events. I would speculate that the inflammatory burden of COVID-19 may be the primary culprit of the subsequent CV risk, but I think further research is needed to identify whether there indeed is any specific tropism of the SARS-CoV-2 virus for the CV system. Additionally, this study evaluated an older, predominantly white and male demographic. I would like to see whether these findings are also present in a younger and more diverse population.
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