Providers need to focus on detecting and treating cardiovascular complications in at-risk patients, and not get lost in the fact they have COVID-19, said Manan Pareek, MD, PhD, FAHA, FESC, an internal medicine hospital resident at the Yale University School of Medicine.
Providers need to focus on detecting and treating cardiovascular complications in at-risk patients, and not get lost in the fact they have coronavirus disease 2019 (COVID-19), said Manan Pareek, MD, PhD, FAHA, FESC, an internal medicine hospital resident at the Yale University School of Medicine.
The American Journal of Managed Care® (AJMC®): What information did the Cardiac Complications Registry consist of and what findings did the data yield?
Pareek: So the way that we built this registry was that we received information from some of the registry resources that we have at our hospital, that were able to provide us lists of patients who had been admitted with the diagnosis of COVID-19. Most of them confirmed by the RT PCR [reverse transcription polymerase chain reaction] way of detecting the virus. With those lists, we were also able to automatically obtain laboratory studies on these patients, particularly those at admission. From there on, we were actually a group of mostly residents who built this database.
We actually came up with, I think around 200 variables that we then manually collected on these patients. Now given the cardiovascular focus most of these variables had to do with cardiovascular diseases. Data that were collected were of course, demographics, things like age and sex, etc. We focused heavily on prevalent conditions, mostly cardiovascular conditions, any type of cardiovascular disease, any type of cardiovascular risk factors, things like hypertension, diabetes, hyperlipidemia, and other important conditions, [chronic obstructive pulmonary disease], asthma, chronic kidney disease, that might, one way or the other, effect their prognosis. Medications because as you know, there's been a lot of focus on certain drugs in the context of COVID-19. So those were the demographic data.
Then we also collected information on their clinical presentation. That included all the symptoms that we could think of related to COVID-19 including things like loss of taste and loss of smell, and the more prevalent fever, cough, fatigue, etc. Their vitals, whether they were on oxygen supplementation at admission and then their laboratory data. We actually had a protocol IDL (interface description language) that was rendered by a multidisciplinary group of experts from different specialties. In that protocol, there was a recommendation to draw various laboratory studies particularly related to inflammation but also things like troponin and B-type natriuretic peptide. So all those things were automatically drawn, we just needed to make sure they were in our database. Then finally, we were and are still collecting and adjudicating data on their events, including death, but most of all cardiovascular complications, MI, myocardial injury, heart failure, decompensated heart failure, etc.
Main findings from the study were that there was a very high prevalence of cardiovascular diseases among these individuals. So what we can say from that is that these were really high-risk patients from a cardiovascular standpoint. I think things like hypertension, diabetes, hyperlipidemia, all of those were prevalent in more than a third of our study population. Almost half of the study population had a history of some sort of cardiovascular disease. And again, 40% or more were on antihypertensive drugs or statins, or aspirin, all these various cardiovascular drugs. Because these were sick patients admitted to a tertiary care hospital we found a high mortality, almost 20%, and our composite cardiovascular endpoint incidence was almost 40%. So there is a very high risk of cardiovascular complications in this population. Obviously, it depends on how you define your endpoints. But it's important to look out for. And then the last thing that we also looked at, was predictors of mortality, predictors of cardiovascular events in this population. Our findings generally confirmed those that have been seen in other studies of this type, older age, male sex, history of various cardiovascular conditions, oxygen supplementation at admission, high troponin, high inflammatory markers, low albumin, all of these things were associated with adverse outcomes.
As for how to use these findings going forward, this is a very descriptive study. So, there are a lot of issues regarding causality that we can't determine also, we have no randomization or anything. But I think main take home points include the fact that these are actually very high-risk patients, patients admitted to tertiary care centers in the US have a very high risk of cardiovascular complications and I think we need to focus on detecting them and treating them appropriately and being careful not just getting lost in the fact that they have COVID-19, because some of the symptoms that you can have it COVID-19 may resemble concomitant cardiovascular complications.
AJMC®: As the pandemic continues to unfold across the country, what can cardiologists do to address complications among those at risk of being exposed to COVID-19?
Dr. Pareek: That's actually a very difficult question, but it's a good question. The thing is, a lot of institutions, particularly in the United States, have very elaborate protocols on how to monitor and treat these patients. And that sometimes makes things a little bit difficult when you're conducting a study, because a lot of institutions have their own esoteric treatment protocols that might actually affect cardiovascular outcomes. If we think about the sickest patients, for instance, that are mechanically ventilated and proned, we are not able to get a cardiovascular history in any of these patients. Furthermore, one of the findings in our study was actually that chest pain was negatively associated with developing a myocardial infarction in this population. So we have a disease that may mask a lot of the classic cardiovascular complications that you can experience during hospitalization but may also actually be a risk factor in and of itself for cardiovascular disease. I think the best thing I can say for now is that clinicians just need to be vigilant about this. I think we actually need to be more aggressive with monitoring these patients from a cardiovascular perspective, actually having a lower threshold for conducting, say, echocardiograms or other types of imaging. But that's also difficult because it's a balance between exposure and yield. It's a question that's particularly hard in this population.
AJMC®: Is there a concern that the quest to bring a COVID-19 vaccine to market quickly may come at the expense producing robust data on individuals with cardiac risk factors, thus jeopardizing the safety of the vaccine in this population?
Dr. Pareek: My personal thought is that I actually think it's the other way around, at least when you try to extrapolate from prior studies on respiratory infections and vaccines. There are some observational data to suggest, for instance, that the pneumovax vaccine may reduce the risk of future cardiovascular events. We have a lot of good data from Denmark, for instance, on the influenza vaccine, that this vaccine may reduce the risk of mortality in heart failure and cardiovascular mortality among patients with diabetes. So my thought is that vaccines may actually be able to prevent some of these complications rather than putting patients at risk.
AJMC®: Do you have any final thoughts you'd like to share?
Dr. Pareek: I think that a lot of these these data that are generated on COVID-19 patients need to be interpreted in the particular context from where the data are derived. We have to do with the tertiary care center, these are some of the sickest COVID-19 patients so obviously, mortality is going to be very high and I don't think that should discourage us. It's just a matter of reading papers and knowing where the data actually came from and also knowing that these are not data on causality. These are not data that tell us directly how to treat the patients but are mostly descriptive and there's the need for more rigorous studies in this setting.