Heart Failure Doubles Risk of Dying From COVID-19

Patients with a history of heart failure (HF) who are hospitalized for COVID-19 are nearly twice as likely to die as those without a HF history, according to new data on patients treated as the pandemic rocked New York City.

“When I started this study, I thought yes, they'll be at higher risk for adverse outcomes, but I did not expect for it to be to this degree,” senior author Anuradha Lala, MD (Icahn School of Medicine at Mount Sinai, New York, NY), told TCTMD.

The study, published October 28, 2020, in the Journal of the American College of Cardiology, also showed that COVID-19 patients with HF had hospital stays averaging about 2 days longer than those without HF, and that they were twice as likely to require mechanical ventilation (22.8% vs 11.9%; P < 0.001). In-hospital mortality was 40% for the HF group compared with 24.9% for those without HF, remaining higher even after adjustment for comorbidities (adjusted OR 1.88; 95% CI 1.27-2.78).

To TCTMD, Lala said while the data are disconcerting, they should motivate clinicians who are not already doing so to give their HF patients reminders at every visit about minimizing their risk of contracting the virus through the mask wearing, hand washing, and social distancing.

“I'm taking time out of my visits to really emphasize this, because I recognize the repercussions if they do indeed get infected,” she said. Lala added that encouraging open dialog and making it clear that physicians also are in a learning process, is more important than ever.

“The more we know about how our patients are doing, the better we can advise them in terms of their care and their precautions,” she said.

You do have to wonder how much of an impact the innovations and improvements in management that have occurred since that time would have, if we were to see these same heart failure patients in hospitals today. Andrew Sauer

Commenting for TCTMD, Andrew J. Sauer, MD (University of Kansas Medical Center, Kansas City), cautioned that the study represents an important though somewhat outdated snapshot of outcomes for patients treated in what is now considered the first wave of COVID-19, at a time when New York City was the overwhelmed epicenter of the virus.

“By [the authors’] own admission, utilization of some of the novel therapies that have been approved for use in COVID-19 since then, such as remdesivir and also IV steroids like solumedrol, don't really apply to this era. You do have to wonder how much of an impact the innovations and improvements in management that have occurred since that time would have, if we were to see these same heart failure patients in hospitals today,” he said.

Similar Outcomes for Preserved vs Reduced EF

The study, led by Jesus Alvarez-Garcia, MD, PhD (Icahn School of Medicine), looked at outcomes for 6,439 COVID-19 patients hospitalized across five different Mount Sinai Health System hospitals in New York City between late February and late June 2020. Of those, 422 (6.6%) had a history of HF. Overall, HF patients were older, had more comorbidities, and were taking more medications for cardiovascular disease than those without HF. The HF cohort also had higher systolic blood pressure, lower oxygen saturation, lower lymphocyte, hemoglobin, and platelet count, as well as lower sodium and alanine aminotransferase. In-hospital management for HF patients was more likely to include supplemental oxygen and anticoagulation compared with those without a history of HF, but there were no major differences in use of antiviral or steroid therapies.

When the researchers looked at outcomes within the HF group by left ventricular ejection fraction, they found no significant differences between those with preserved (HFpEF), reduced (HFrEF), or mid-range (HFmrEF) ejection fraction in terms of length of stay, need for ICU care, intubation/mechanical ventilation, AKI, shock, thromboembolic events, arrhythmias, or 30-day readmission.

However, in-hospital survival was higher in the HFmrEF group than in either the HFrEF or HFpEF groups (log-rank P = 0.147). While the numbers are small, Lala said, the finding “supports the general notion that this is indeed a distinct group, with potentially distinct outcomes [in comparison to] patients with preserved function or patients with reduced function.”

Although there was concern in the early months of the pandemic about potential harm with renin-angiotensin-aldosterone system inhibitors, the study found no association between their use and worse prognosis, adding to accumulating supportive observational and RCT data.

What the Future Holds

Knowing that a patient with COVID-19 also has a history of HF ultimately “may help guide triage upon hospital presentation and potentially dictate aggressive therapies,” Lala and colleagues say.

Sauer said that moving forward, it definitely will be important to get answers to questions about the potential advantage of early, aggressive treatment with things like remdesivir (Gilead Sciences) and corticosteroids in HF patients, even if those patients don’t meet the current criteria for use of the drugs.

Beyond that, there is the issue of how best to manage those who recover from the virus, something Lala said is the “the billion-dollar question” and likely means incorporating imaging modalities and timing follow-up visits to stay on top of any residual symptoms.

There is a large population [of our patients] that are, quite frankly, sick of it, and they think that it’s past us. It isn’t and they need to be reminded of that. Anuradha Lala

“We’re doing research on this at the moment, but the short answer, which is not sexy or satisfying, is that we just don’t know,” she said. “I think a lot has to be learned in terms of their follow-up, and the more we keep that open dialog with physicians and patients and their caretakers, the better it is and the more we will learn.”

Both Lala and Sauer agreed that making sure HF patients continue to have consistent contact with their physicians and not have gaps in seeking care is an important takeaway, as is reminding them to remain proactive about continuing to protect themselves from contracting the virus.

“It’s not over, so don’t take it casually,” Lala said. “At the same time, it’s not something to stop living your life for or to be completely paralyzed with fear. But, there is a large population [of our patients] that are, quite frankly, sick of it, and they think that it’s past us. It isn’t and they need to be reminded of that.”