COVID-19 associated mortality and cardiovascular disease outcomes among US women veterans

Abstract

The burden of COVID-19 has been noted to be disproportionately greater in minority women, a population that is nevertheless still understudied in COVID-19 research. We conducted an observational study to examine COVID-19-associated mortality and cardiovascular disease outcomes after testing (henceforth index) among a racially diverse adult women veteran population. We assembled a retrospective cohort from a Veterans Affairs (VA) national COVID-19 shared data repository, collected between February and August 2020. A case was defined as a woman veteran who tested positive for SARS-COV-2, and a control as a woman veteran who tested negative. We used Kaplan-Meier curves and the Cox proportional hazards model to examine the distribution of time to death and the effects of baseline predictors on mortality risk. We used generalized linear models to examine 60-day cardiovascular disease outcomes. Covariates studied included age, body mass index (BMI), and active smoking status at index, and pre-existing conditions of diabetes, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and a history of treatment with antiplatelet or anti-thrombotic drug at any time in the 2 years prior to the index date. Women veterans who tested positive for SARS-CoV-2 had 4 times higher mortality risk than women veterans who tested negative (Hazard Ratio 3.8, 95% Confidence Interval CI 2.92 to 4.89) but had lower risk of cardiovascular events (Odds Ratio OR 0.78, 95% CI 0.66 to 0.92) and developing new heart disease conditions within 60 days (OR 0.67, 95% CI 0.58 to 0.77). Older age, obesity (BMI > 30), and prior CVD and COPD conditions were positively associated with increased mortality in 60 days. Despite a higher infection rate among minority women veterans, there was no significant race difference in mortality, cardiovascular events, or onset of heart disease. SARS-CoV-2 infection increased short-term mortality risk among women veterans similarly across race groups. However, there was no evidence of increased cardiovascular disease incidence in 60 days. A longer follow-up of women veterans who tested positive is warranted.

Figure 1

Time to death: Kaplan–Meier curves between SARS-CoV-2-positive and negative groups.

Figure 2

Estimated odds ratios of 60 day cardiovascular outcomes after SARS-CoV-2 exposure. CAHD: Coronary artery Atherosclerosis Disease; CKD: Chronic Kidney disease; CVD: cardiovascular disease; MI: Myocardial Ischemia; HTN: Hypertension; OR = Odds Ratios; CI: Confidence Intervals. a. Adjusted for age at index, race, diabetes, current smoking status, CVD, COPD, CKD, and anticoagulant medication. b. Adjusted for age at index, race, diabetes, current smoking status, COPD, CKD, and anticoagulant medication. c. CVD events included subcategories of events such as Ischemic or hemorrhagic stroke at 60 days, early MI at 7 days, and Heart failure at 60 days. All CVD events are withing 60 days from the index date except early MI which is within 7 days. d. New onset of heart disease included subcategories of heart disease such as Cardiomyopathy, CVD, HTN, CAHD, Cerebrovascular disease, and Other heart disease. e. A 95% CI excluding 1 indicates statistical significance at α: 0.05.

Figure 3

Odds ratios (OR) and 95% confidence interval estimates of risk factors for 60-day cardiovascular events among SARS-CoV-2-positive women veterans. BMI: Body Mass Index; CKD: Chronic Kidney Disease; COPD: Chronic Obstructive Pulmonary Disease; CVD: cardiovascular disease; DM: Diabetes; OR = Odds Ratios; CI: Confidence Intervals; LCL: Lower Confidence Limit; UCL: Upper Confidence Limit. a. 95% CI excluding 1 indicates statistical significance at α: 0.05.

Figure 4

Odds ratios and 95% confidence interval estimates of risk factors for 60-day new diagnosis of heart disease among SARS-CoV-2-positive women veterans. BMI: Body Mass Index; CKD: Chronic Kidney Disease; COPD: Chronic Obstructive Pulmonary Disease; CVD: cardiovascular disease; DM: Diabetes; OR: Odds Ratios; CI: Confidence Intervals; LCL: Lower Confidence Limit; UCL: Upper Confidence Limit. a. 95% CI excluding 1 indicates statistical significance at α = 0.05.

Figure 5

Procedure of inclusion and exclusion of the study data.