Prognosis Poor for Patients With Heart Failure, COVID-19

Patients with heart failure should be classified as high risk in light of the coronavirus disease 2019 (COVID-19) pandemic, because they are thought to be more susceptible to the virus, according to study results published in ESC Heart Failure.

“There are limited data on outcomes in those with preexisting HF developing COVID-19, and in the UK, patients with HF are not currently included on lists to be shielded,” said the authors. “This study sought to quantify the additional risk posed by COVID-19 infection in hospitalized patients with chronic HF by assessing in-hospital mortality.”

The primary outcome was in-hospital mortality, and the secondary outcomes were acute kidney injury (AKI), myocardial injury, respiratory compromise requiring noninvasive ventilation or continuous positive airway pressure, and lengths of stay in hospital.

The retrospective analysis encompassed all patients (N = 134) with preexisting chronic heart failure admitted to a large London tertiary center from March 1 through May 6, 2020, including those with heart failure with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF). COVID-19 diagnosis was determined with nasopharyngeal swab polymerase chain reaction assay.

Among the patients with diagnosed COVID-19 (n = 40; 29.8%), the mean (SD) age was 79.37 (12) years compared with 77.1 (13.6) in the COVID-19–negative group (n = 94). Most (54.3%) patients in both cohorts were White (40.0% and 54.3%, in the positive and negative patient groups, respectively). However, significantly more patients of Asian/British Asian descent tested positive vs negative: 35.0% vs 19.1%.

The top comorbidities in the both patient groups were hypertension, diabetes, and atrial fibrillation, at 77.0%, 55.0%, and 50.0%, respectively, of COVID-19–positive patients and 67.0%, 51.1%, and 42.6% of COVID-19–negative patients.

Of the remaining comorbidities evaluated (ischemic heart disease, chronic obstructive pulmonary disease, asthma, chronic kidney disease [CKD]), the largest difference was seen for patients with chronic heart failure who tested positive for COVID-19: 37.5% had CKD compared with 19.1% in the negative group (P = .02). More patients in the COVID-19–positive group also had HFpEF (52.5% vs 47.8%), while more in the COVID-19–negative group had HFrEF (52.2% vs 42.2%).

And among the patients admitted to the hospital testing positive, mortality was almost 5 times greater, at 50.0% vs 10.6% (relative risk [RR], 4.70; 95% CI, 2.42-9.12; P < .001). The cause of death for 40% of these patients was COVID-19 pneumonia and decompensated heart failure. More of this group also had evidence of myocardial injury (57.5% vs 31.9%; RR, 1.81; 95% CI, 1.21-2.68; P < .01) and required supplemental oxygen on admission and treatment for a superadded bacterial infection (55.0% vs 32.5%; RR, 1.67; 95% CI, 1.12-2.49; P = .01).

“The risk of mortality in hospitalized HF patients with COVID-19 is higher than for previously quoted overall inpatient mortality: 50% in our study vs 23% overall,” the authors concluded. “This may be due to the high prevalence of comorbidities and frailty in patients with HF, which have a well-established link with poorer outcomes from COVID-19.”

They also note that the risk of myocardial injury and AKI is similar to conclusions from previous studies and that this risk is likely a result of excess activation of inflammatory and immunological pathways, ultimately causing cardiac dysfunction and renal hypoperfusion.

Further studies are warranted, according to the investigators, as is early recognition of COVID-19, especially for individuals who present with advanced illness due to waiting too long in their communities. In addition, access to COVID-19 testing needs to improve, as does patient education on when to seek medical attention, to improve mortality.

Reference

Chatrath N, Kaza N, Pabari PA, et al. The effect of concomitant COVID-19 infection on outcomes in patients hospitalized with heart failure. ESC Heart Fail. Published online October 11, 2020. doi:10.1002/ehf2.13059