Retracted: Underlying cardiovascular disease associated with increased mortality in COVID-19 patients

This article has since been retracted by NEJM on 6/11/2020.

This 2MM article summary is left unchanged for historical context.


1. Underlying cardiovascular disease was shown to be associated with increased risk of in-hospital death among coronavirus disease 2019 (Covid-19) hospitalized patients.

2. Angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) were not shown to be associated with in-hospital mortality among COVID-19 hospitalized patients.

Evidence Rating Level: 2 (Good)

Study Rundown: Recently, there is a growing recognition of patients with underlying cardiovascular risk may be disproportionately affected by COVID-19. Previous case series studies note cardiac arrhythmias, cardiomyopathy, and cardiac arrest as the terminal events in patients with COVID-19. Furthermore, concerns are mounting of cardiovascular disease medical therapies contributing to the severity of illness in the patient population. As such, this study investigated the relationship between underlying cardiovascular disease and COVID-19 outcomes along with evaluating the association between cardiovascular therapeutics and illness mortality. The study collected patient data from the Surgical Outcomes Collaborative (Surgisphere) capturing COVID-19 infection status, underlying cardiovascular disease, and current cardiovascular medications. The study found underlying cardiovascular disease was independently associated with an increased risk of in-hospital death. The results did not show an increased risk of in-hospital mortality with ACE inhibitor or ARB use. This retrospective study was limited by the geographic patient selection for the study. Majority of the patients for the study came from Europe; however, in the timeframe used for the study, Asia was equally negatively affected by COVID-19 as seen in China and South Korea. Therefore, a better distribution of the geographic location during patient selection would have provided stronger study conclusions. Nonetheless, this study was strengthened by providing statistically analyzed data to confirm previous observations between underlying cardiovascular disease and in-hospital deaths. For physicians, these findings highlight the additional care COVID-19 patients with underlying cardiovascular conditions require to overcome the illness.

Click to read the study in NEJM

Relevant Reading: Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China

In-Depth [retrospective cohort]: This observational study retrospectively collected data from 8,910 patients at 169 hospitals in 11 countries from Asia, Europe, and North America. Data were collected from inpatient and outpatient electronic health records, financial records, supply-chain databases, and point-of-care data entry for procedures. Cardiovascular coexisting conditions were collected based on codes from the International Classification of Diseases, 10th Revision, Clinical Modification, and COVID-19 positivity was defined as a laboratory finding confirming SARS-CoV2 infection from high-throughput sequencing or real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) of nasal or pharyngeal swab specimens. Inclusion criteria included: patients with a confirmed positive Covid-19 test, hospitalization between December 20, 2019, to March 15, 2020, and a recorded hospital death (nonsurvivors) or hospital discharge (survivors) as of March 28, 2020. Exclusion criteria included: patients admitted during the time window but still hospitalized on March 15, 2020 and patients who did not have their status of death or discharge recorded by the hospital as of March 28, 2020. The primary outcome was the evaluation between the relationship of preexisting cardiovascular disease and drug therapy with the end point of in-hospital death. Confounding variables including demographic characteristics and coexisting conditions were controlled for during the data analyses. Overall, nonsurvivors were older and more likely to be white and male with a history of current smoking. In regard to preexisting cardiovascular conditions, survivors had a lower prevalence of coronary artery disease (-9.2, 95% confidence interval [CI], -12.8 to -5.7), heart failure (-3.7, 95% CI, -5.8 to -1.8), and cardiac arrhythmias (-3.6, 95% CI, -5.8 to -1.4) compared to nonsurvivors. In regard to medications, survivors more commonly used ACE inhibitors (5.9, 95% CI, 4.3 to 7.5) and statins (2.8, 95% CI, 0.5 to 5.1) compared to nonsurvivors, whereas there was no association between survival and the use of ARBs (-1.2, 95% CI, -3.5 to 1.1). Finally, a multivariable logistic-regression model for independent predictors of in-hospital death was performed. The odds ratios for an in-hospital death with the risk factor of coronary artery disease was 2.70 (95% CI, 2.08 to 3.51), receiving an ACE inhibitor was 0.33 (95% CI, 0.20 to 0.54), and receiving an ARB was 1.23 (95% CI, 0.87 to 1.74). Taken together, the study concluded that underlying cardiovascular disease had an increased risk association with in-hospital death; however, the use of ACE inhibitors or ARBs did not show an increased risk association with in-hospital mortality.

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