Acute Cardiac Events More Common in COVID-19 Patients With Heart Histories

About one in 10 patients hospitalized with COVID-19 experience acute cardiac events, which are linked to nearly double the risks of ICU admission and in-hospital death, a new analysis of 2021 data suggests.

The results, which stem from the COVID-19-Associated Hospitalization Surveillance Network (COVID-NET), are a reminder of the extrapulmonary complications that can occur with SARS-CoV-2 infection, researchers say.

Notably, “acute cardiac events were almost four times as frequent among patients with preexisting heart disease, but also occurred among patients with no underlying heart disease,” lead author Rebecca C. Woodruff, PhD, MPH (Centers for Disease Control and Prevention, Atlanta, GA), told TCTMD via email, saying that a strength of their study is its large and geographically diverse sample.

“An emerging body of research suggests that COVID-19 can cause cardiovascular complications up to a year postinfection. Although we cannot know for sure that the acute cardiac events documented in this study were caused by the patient’s COVID-19 illness, this study reinforces the need for more research regarding the cardiovascular complications of COVID-19,” Woodruff said.

She added that their findings, published earlier this week in the Journal of the American College of Cardiology, also indicate that when patients do experience an acute cardiac event while hospitalized for COVID-19, they “may benefit from more-intensive clinical evaluation and monitoring.”

George A. Mensah, MD (National Heart, Lung, and Blood Institute, Bethesda, MD), and colleagues, writing in an accompanying editorial, point out that the current study has its limitations. For example, the findings may not extend to ambulatory patients not ill enough to be hospitalized, they say, while “the ascertainment and lack of a contemporaneous control population (such as those hospitalized with acute influenza infection) make the exact cardiovascular risk estimates challenging to contextualize.”

Still, these results offer a useful “lens” by highlighting predictors of cardiac events in this specific setting, the editorialists agree. “We believe a strong case can be made for renewed emphasis on the full spectrum of primary and secondary prevention strategies to reduce the risk of acute cardiac events before, during, and after hospitalization for COVID-19. Effective treatment and control of hypertension and other cardiometabolic risk factors as well as guideline-directed management of underlying CVD and acute cardiac complications during COVID-19 hospitalization remain critical alongside primary management of COVID-19.”

COVID-NET

Woodruff et al analyzed data on 8,460 adults hospitalized with COVID-19 within 99 counties across 14 US states between January and November 2021. Based on this sample, an estimated 11.4% had at least one cardiac event during their hospital stay, most commonly ischemic heart disease (5.5%), such as type 2 MI and NSTEMI, and heart failure (5.4%), including acute-on-chronic diastolic and systolic heart failure. Just 0.3% had pericarditis or myocarditis, while 1% had a hypertensive crisis. At discharge, 1.8% had a diagnosis of acute MI and 3.4% a diagnosis of congestive heart failure.

Median age of those with an acute cardiac event was 69 years, and 56.5% were men. Around half (48.7%) were white, 33.6% Black, 7.4% Hispanic, and 7.1% Asian or Pacific Islander. Most (96.8%) had been admitted to the hospital for COVID-19. Nearly 13% were smokers, while most had hypertension (78.2%) and underlying cardiac disease (61.9%). Slightly less than half had obesity (48.9%) and diabetes mellitus (45.0%), while 30% had chronic kidney disease.

Patients in the cardiac-event group were more likely to have finished their primary COVID-19 vaccine series than those who didn’t have an event (25.8% vs 17.8%), and were more likely to have gotten an additional or booster dose (9.9% vs 6.6%). Woodruff explained this imbalance could be due to the vaccinated patients being older and having a greater number of comorbidities, factors that would put them at greater risk of acute cardiac events.

For acute ischemic heart disease in particular, predictors included older age and histories of chronic kidney disease, valve disease, or hypertension. Predictors of acute heart failure included male sex and histories of congestive heart failure, atrial fibrillation, or hypertension, while history of CAD actually was linked to a lower risk.

Almost one in four patients with a history of underlying cardiac disease based on ICD-10 codes experienced an acute event (23.4%). Within this group, older age, male sex, and history of valve disease predicted ischemic heart disease, while acute heart failure was predicted by history of congestive heart failure or atrial fibrillation, and again lower with a history of CAD.

Without preexisting disease, 6.2% of the adults hospitalized with COVID-19 had an acute cardiac event. Importantly, hypertension predicted acute cardiac events even when there was no underlying cardiac disease.

The findings also illustrate the burden acute cardiac events put on the healthcare system, according to the researchers. “For example, almost 40% of patients who experienced an acute cardiac event required intensive care unit admission and 21% died during hospitalization,” amounting to adjusted risk ratios of 1.9 (95% CI 1.2-2.1) and 1.7 (95% CI 1.3-2.1), respectively, compared with no cardiac event.

Their data set doesn’t allow continued follow-up after discharge, said Woodruff, “but we do plan to look at select types of acute cardiac events in greater depth. For example, we are currently examining the frequency and severity of acute myocarditis among patients hospitalized with COVID-19 in closer detail.”