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

  1. Kevin O’Gallagher
  2. Anthony Shek
  3. Daniel M. Bean
  4. Rebecca Bendayan
  5. Alexandros Papachristidis
  6. James T. H. Teo
  7. Richard J. B. Dobson
  8. Ajay M. Shah
  9. Rosita Zakeri

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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.

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  1. Version published to 10.1186/s12872-021-02137-9
  2. ScreenIT

    SciScore for 10.1101/2020.12.02.20242933: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: Approvals: This study was conducted under London South East Research Ethics Committee approval (reference 12/LO/2048) granted to the King’s Electronic Records Research Interface (KERRI); specific work on COVID-19 was reviewed with expert patient input on a virtual committee with Caldicott Guardian oversight.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Analyses were performed using STATA/IC (
    STATA/IC
    suggested: None
    (v16.1; StataCorp LLC, TX).
    StataCorp
    suggested: (Stata, RRID:SCR_012763)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Limitations: Our analysis was limited to individuals who required hospital admission and are therefore only generalisable to this population. A small minority of patients were still in hospital and were censored at the study end-date (2.1%). However, a sensitivity analysis in patients who were either discharged or died revealed similar findings (Supplemental Figure 3). The availability and feasibility of cardiac magnetic resonance imaging, as part of the revised Lake Louise 2018 Criteria35 for the diagnosis of myocarditis, was reduced during the pandemic peak, which may have underestimated the incidence of myocarditis. Finally, our multivariable analyses adjusted for the presence or absence of several comorbidities, however measures of control (e.g. blood pressure control for hypertension or HbA1c for diabetes) were not assessed and may impact the risk of death.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a protocol registration statement.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  3. Version published to 10.1101/2020.12.02.20242933v1 on medRxiv