Pre-existing cardiovascular disease rather than cardiovascular risk factors drives mortality in COVID-19

Abstract

Background: The relative association between cardiovascular (CV) risk factors, such as diabetes and hypertension, established CV disease (CVD), and susceptibility to CV complications or mortality in COVID-19 remains unclear.

Methods: We conducted a cohort study of consecutive adults hospitalised for severe COVID-19 between 1st March and 30th June 2020. Pre-existing CVD, CV risk factors and associations with mortality and CV complications were ascertained.

Results: Among 1721 patients (median age 71 years, 57% male), 349 (20.3%) had pre-existing CVD (CVD), 888 (51.6%) had CV risk factors without CVD (RF-CVD), 484 (28.1%) had neither. Patients with CVD were older with a higher burden of non-CV comorbidities. During follow-up, 438 (25.5%) patients died: 37% with CVD, 25.7% with RF-CVD and 16.5% with neither. CVD was independently associated with in-hospital mortality among patients < 70 years of age (adjusted HR 2.43 [95% CI 1.16-5.07]), but not in those ≥ 70 years (aHR 1.14 [95% CI 0.77-1.69]). RF-CVD were not independently associated with mortality in either age group (< 70 y aHR 1.21 [95% CI 0.72-2.01], ≥ 70 y aHR 1.07 [95% CI 0.76-1.52]). Most CV complications occurred in patients with CVD (66%) versus RF-CVD (17%) or neither (11%; p < 0.001). 213 [12.4%] patients developed venous thromboembolism (VTE). CVD was not an independent predictor of VTE.

Conclusions: In patients hospitalised with COVID-19, pre-existing established CVD appears to be a more important contributor to mortality than CV risk factors in the absence of CVD. CVD-related hazard may be mediated, in part, by new CV complications. Optimal care and vigilance for destabilised CVD are essential in this patient group. Trial registration n/a.

Keywords: COVID-19; Cardiovascular disease; Cardiovascular risk factors; Diabetes; Hypertension.

Fig. 1

Cumulative incidence plots displaying the probability of in-hospital death and discharge over time. The light blue region represents the probability of being alive and still in hospital at the time of study close. CV denotes cardiovascular; CVD, cardiovascular disease

Fig. 2

Risk of in-hospital mortality stratified by age and cardiovascular risk group. A Age < 70 years (n = 828). B. Age 70 years and over (n = 893). aHR denotes adjusted hazard ratio; CVD, cardiovascular disease; RF, cardiovascular risk factors; RF-CVD, cardiovascular risk factors without established CVD. Model 1 adjusted for age, sex and ethnicity. Model 2 adjusted for age, sex, ethnicity, non-cardiac comorbidities (asthma, COPD, chronic renal failure, pulmonary embolism, DVT) and medications (ACEI or ARB, aldosterone receptor antagonists, beta-blockers, calcium channel blockers, loop diuretics, statins, anticoagulants, antiplatelet agents, metformin, sulphonylureas, SGLT2 inhibitors, DPP4 inhibitors, thiazolidinediones, GLP1 receptor agonists, insulin)

Fig. 3

Risk of COVID-19 related complications by cardiovascular risk group. A Any cardiovascular complications. B Non-arrhythmia related cardiovascular complications. C Venous thromboembolism. aOR, adjusted odds ratio; CV, cardiovascular; CVD, cardiovascular disease; DVT, deep vein thrombosis; PE, pulmonary embolism; MI, myocardial infarction; VTE, venous thromboembolism. Each model is adjusted for the variables listed, as well as age, sex, ethnicity, non-cardiac comorbidities (asthma, COPD, chronic renal failure, pulmonary embolism, DVT) and medications (ACEI or ARB, aldosterone receptor antagonists, beta-blockers, calcium channel blockers, loop diuretics, statins, anticoagulants, antiplatelet agents, metformin, sulphonylureas, SGLT2 inhibitors, DPP4 inhibitors, thiazolidinediones, GLP1 receptor agonists, insulin)