COVID-19 Warnings: Individuals With Heart Failure At Higher Mortality Risk Upon Contracting SARS-CoV-2, Extra Precautions Warranted

COVID-19 Warnings: According to a new study by researchers from the University of Bristol-UK and the University Hospitals Bristol and Weston NHS Foundation Trust, patients with acute heart failure nearly double their risk of dying if they get COVID-19.


 
In this single‐centre observational study, the study team examined referrals to the acute heart failure team over a period of 16 weeks (7 January to 27 April 2020) spanning the ongoing COVID‐19 pandemic; 283 patients referred to the acute heart failure services over the study period were included on the basis of typical symptoms, raised BNP, and echocardiogram. There was a substantial but statistically non‐significant drop in referrals with 164 referred in the 8 weeks before the first UK death due to COVID‐19 on 2 March 2020 (BC), compared with 119 referred after (AC) in the subsequent 8 weeks, representing a 27% reduction overall (P = 0.06). The 30 day case fatality rate was increased from 11% in the BC group compared with 21% in the AC group (risk ratio = 1.9, 95% confidence interval 1.09–3.3). Age, gender, length of stay, left ventricular ejection fraction, and N‐terminal pro‐brain natriuretic peptide were similar between the groups. Admission creatinine, age, and AC cohort status were found to be univariable predictors of mortality. On multivariate Cox regression analysis, only age (hazard ratio 1.04, P = 0.03) and AC cohort status (hazard ratio 2.1, P = 0.017) remained significant predictors of mortality. On sensitivity analysis, this increased mortality was driven by COVID‐19 positive status.
 
There was a reduction in referral of patients with acute heart failure with significant increase in mortality in the 8 weeks following the first reported UK death due to COVID‐19. The observation of increased mortality does not appear related to a change in population in terms of demographics, left ventricular ejection fraction, or N‐terminal pro‐brain natriuretic peptide. The observed increased mortality appears to be related to the coexistence of COVID-19 infection with acute heart failure.
 
The study highlights the need for widespread preventative and shielding measures particularly in this group of patients especially in the light of the second wave. Longer follow‐up with inclusion of data from other centres and community heart failure services will be needed.
 
The study findings were published in the peer reviewed journal: ESC Heart Failure, a journal of the European Society of Cardiology (ESC).https://onlinelibrary.wiley.com/doi/full/10.1002/ehf2.13158
 
Significantly the small, single-center study highlights the need for patients with heart failure to take extra precautions to avoid catching COVID-19.
 
Study lead investigator Dr Amardeep Dastidar, a consultant interventional cardiologist at North Bristol NHS Trust and Bristol Heart Institute, UK told Thailand Medical News, "Our results support prioritizing heart failure patients for COVID-19 vaccination once it is available."
 
He further added, "In the meantime, heart failure patients of all ages should be considered a high-risk group and be advised to maintain social distance and wear a face mask to prevent infection."
 
Typically heart failure refers to progressive weakening of the heart's pump function with symptoms of breathlessness, ankle swelling, and fatigue. Sudden and severe worsening of symptoms is called acute heart failure - this is a medical emergency and requires admission to the hospital for intravenous medication and intensive monitoring.
 
The new research examined referral rates for acute heart failure during the pandemic and 30-day mortality. The analysis included 283 patients with acute heart failure admitted to the cardiology department of North Bristol NHS Trust. Two-thirds of the patients had chronic heart failure and presented with acute deterioration.
 
Importantly the date of the first UK coronavirus death, 2 March 2020, was the cut-off to define two groups: before-COVID (7 January to 2 March; eight weeks) and after-COVID (3 March to 27 April; eight weeks; i.e. during the pandemic).
 
Interestingly there was a substantial, but statistically non-significant, drop in admissions for acute heart failure during the pandemic. A total of 164 patients were admitted in the eight weeks before-COVID compared to 119 patients after-COVID - a 27% reduction (p=0.06).
 
Dr Dastidar added, “This study finding may reflect public concerns about social distancing at the start of the national lockdown, delayed reporting of symptoms, and anxiety regarding hospital attendance. In support of these explanations, our data demonstrate an increase in referrals during the later weeks of lockdown in line with UK media reports encouraging patients to seek medical attention if needed."
 
It was noted that the 30-day mortality rate of patients with acute heart failure nearly doubled during the pandemic. Some 11% of patients in the before-COVID group died within 30 days compared to 21% of the after-COVID group - a relative risk of 1.9 (95% confidence interval 1.09-3.3).
 
The study team examined what factors may have been responsible for the higher death rate during the pandemic. Older age and admission during the pandemic were linked with death after adjusting for other factors that could influence the relationship, with hazard ratios of 1.04 and 2.1, respectively.
 
It was also observed that when patients with a positive COVID test were removed from the analysis, there was no difference in mortality between the before- and after-COVID groups - indicating that patients with both acute heart failure and COVID-19 had a poorer prognosis.
 
Dr Dastidar said, "This may suggest a direct interaction or susceptibility to worse outcomes for acute heart failure patients with superimposed COVID infection. It is noteworthy that our region had very low rates of COVID infection during the study and yet a connection with higher mortality was still apparent."
 
He pointed out that routine testing for COVID-19 infection was not in place at the time of the study.
 
Dr Dastidar commented, "It would be informative to review more recent admissions when COVID testing was more widely implemented to further support our findings. As this was a single-center study, it would be valuable to confirm the findings in a countrywide analysis. Additionally, we are keen to review longer-term data to look for patterns of prognosis at later stages in this patient population."
 
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