The association between macrovascular complications and intensive care admission, invasive mechanical ventilation, and mortality in people with diabetes hospitalized for coronavirus disease-2019 (COVID-19)

Abstract

Background: It is not clear whether pre-existing macrovascular complications (ischemic heart disease, stroke or peripheral artery disease) are associated with health outcomes in people with diabetes mellitus hospitalized for COVID-19.

Methods: We conducted cohort studies of adults with pre-existing diabetes hospitalized for COVID-19 infection in the UK, France, and Spain during the early phase of the pandemic (between March 2020-October 2020). Logistic regression models adjusted for demographic factors and other comorbidities were used to determine associations between previous macrovascular disease and relevant clinical outcomes: mortality, intensive care unit (ICU) admission and use of invasive mechanical ventilation (IMV) during the hospitalization. Output from individual logistic regression models for each cohort was combined in a meta-analysis.

Results: Complete data were available for 4,106 (60.4%) individuals. Of these, 1,652 (40.2%) had any prior macrovascular disease of whom 28.5% of patients died. Mortality was higher for people with compared to those without previous macrovascular disease (37.7% vs 22.4%). The combined crude odds ratio (OR) for previous macrovascular disease and mortality for all four cohorts was 2.12 (95% CI 1.83-2.45 with an I² of 60%, reduced after adjustments for age, sex, type of diabetes, hypertension, microvascular disease, ethnicity, and BMI to adjusted OR 1.53 [95% CI 1.29-1.81]) for the three cohorts. Further analysis revealed that ischemic heart disease and cerebrovascular disease were the main contributors of adverse outcomes. However, proportions of people admitted to ICU (adjOR 0.48 [95% CI 0.31-0.75], I² 60%) and the use of IMV during hospitalization (adjOR 0.52 [95% CI 0.40-0.68], I² 37%) were significantly lower for people with previous macrovascular disease.

Conclusions: This large multinational study of people with diabetes mellitus hospitalized for COVID-19 demonstrates that previous macrovascular disease is associated with higher mortality and lower proportions admitted to ICU and treated with IMV during hospitalization suggesting selective admission criteria. Our findings highlight the importance correctly assess the prognosis and intensive monitoring in this high-risk group of patients and emphasize the need to design specific public health programs aimed to prevent SARS-CoV-2 infection in this subgroup.

Keywords: COVID-19; Diabetes; Macrovascular disease; Mortality.

Fig. 1

Inclusion and exclusion criteria

Fig. 2

Odds ratio for the association between mortality and the presence of previous macrovascular disease in each of the four cohorts and overall (A). I² indicates heterogeneity in the estimates. Odds ratio estimates adjusted for: model 1: age and sex (B); model 2: model 1 + type of diabetes, arterial hypertension, and the presence of microvascular disease (C); model 3: model 2 + ethnicity and BMI (D). HM cohort is excluded from model 3 due to lack of ethnicity data

Fig. 3

Odds ratio for the association between intensive care unit admission and the presence of previous macrovascular disease in each of the four cohorts and overall (A). I² indicates heterogeneity in the estimates. Odds ratio estimates adjusted for: model 1: age and sex (B); model 2: model 1 + type of diabetes, arterial hypertension, and the presence of microvascular disease (C); model 3: model 2 + ethnicity and BMI (D). HM cohort is excluded from model 3 due to lack of ethnicity data

Fig. 4

Odds ratio for the association between use of invasive mechanical ventilation during the hospitalization and the presence previous of macrovascular disease in each of the two cohorts and overall (A). I² indicates heterogeneity in the estimates. Odds ratio estimates adjusted for: model 1: age and sex (B); model 2: model 1 + type of diabetes, arterial hypertension, and the presence of microvascular disease (C)