5 Studies Address Cardiac, Heart Failure Outcomes Affected by COVID-19

In a session on day 1 of ESC Congress 2021, co-chaired by Mikhail N. Kosiborod, MD, cardiologist, vice president of Research at Saint Luke's Health System, Kansas City, Missouri, and Michele Senni, MD, chief of the Cardiovascular Department at Papa Giovanni XXIII Hospital in Bergamo, Italy, 5 clinicians from around the world presented their findings on how the COVID-19 pandemic has and hasn’t affected cardiac care, in particular for patients with heart failure.

Their mixed findings indicate that there is still much to be learned on the complex interaction among COVID-19 infection, cardiovascular care, and heart failure.

Unplanned Admissions¹

Nur Adawiyah Yusoff, RN, from Changi General Hospital in Singapore, addressed unplanned admissions for heart failure. She emphasized that although globally there is a high burden on health care systems from the COVID-19 pandemic, admissions for acute heart failure have actually dropped and that this decrease may be the result of lockdowns, “potentially leading to adverse outcomes, such as increased morbidity and mortality.”

With few data available on the effect of the pandemic on heart failure–related care in multiethnic Southeast Asian countries, her single-center study examined admissions for acute heart failure, hypothesizing that totals were influenced by both the pandemic and its related lockdown restrictions and comparing outcomes from before (January 23-July 31, 2019; the control period; n = 164) and during the pandemic (January 23-July 31, 2020; the study period; n = 183).

Among the patients in both groups, all were 67 years and older and most were male and of Chinese ethnicity. Their average hospital stay was 4 days. However, during the pandemic vs before, a subgroup analysis of the period April 7-June 1 for 2019 and 2020 showed, patients were sicker upon admission, with mean (SD) Charlson Comorbidity Index scores of 2.88 (2.1) vs 1.97 (1.8) (P < .05). Despite this, overall admissions were shown to be down in the beginning of the pandemic (daily average dropped from 2.44 to 1.39) compared with the same period in 2019 (January 23-April 6). They didn’t rise again (to 2.28 daily average) until after reopening, at which point they were shown to be higher compared with the same period in 2019 (June 2-July 31).

Noting the importance of seeking medical attention, Yusoff did note that “the lockdown measures implemented may have influenced a patient’s decision to step out of the house for medical treatment, leading to serious adverse effects from acute heart failure.” Patient education is essential, she emphasized, and telehealth can be used to advance care, but further studies need to examine patient behavior as it affects medication adherence, diet/fluid restriction, and other lifestyle modifications brought on by the pandemic.

Heart Transplant Recipients²

Daniel Miklin, MD, from the University of Southern California, discussed outcomes among heart transplant recipients, who face an even greater risk from COVID-19 because of immunosuppression, “which provides a significant risk for morbidity and mortality” among this patient population. In addition, due to limited data on this patient population, he said, data are few and far between on their initial management. Data do show, however, a 20% to 30% mortality among those infected with COVID-19, he stated.

His retrospective review of 235 patients—with a median (interquartile range) age of 56.0 (41.0-63.5) years, of whom 71% were male, 55% had nonischemic/dilated cardiomyopathy, and the most common comorbidity was hyperlipidemia (58%)—showed they were an average 7 years post heart transplant and on an immunosuppression regimen of tacrolimus (97%). Upon hospital admission, most presented with upper respiratory infection or acute hypoxic respiratory failure (29% each) or dyspnea (26%).

Most received supportive care (55%), but for those requiring care, they received steroids (19%), remdesevir (19%), or antibiotics (23%), with the most common change to immunosuppression regimens being to decrease mycophenolate (29%).

“Interestingly, our outcomes demonstrated only 7% mortality, with a 93% survival rate,” Miklin stated. Most patients (55%) received outpatient care, and of the 45% requiring hospitalization who did not succumb to their illness, all were discharged successfully.

The findings are in great contrast to those of other studies, he added, which show mortality ranging from 20% in Israel to 37% in Italy. This may be because the patients in his study were younger, not as far out from their transplant, and those on triplet immunosuppression therapy may be reaping protective benefits in the form of limited cytokine storm.

He, too, emphasized the need for additional research, especially into long-term outcomes and therapy optimization for this unique patient group.

Cardiac Complications³

Gianluca Rigatelli, MD, PhD, of the Division of Cardiology at General Hospital of Rovigo, in Italy, summarized findings on acute heart failure related to COVID-19 infection. His systematic review and meta-analysis aimed to gauge “the pooled incidence of acute heart failure as a cardiac complication of COVID-19 disease and to estimate the related mortality risk in these patients.”

Using a cutoff of December 26, 2020, and following searches of MEDLINE, Scopus, and Web of Science, he and his team’s analysis focused on a 1064-patient cohort, representing 6 studies, among whom 6.9% to 63.4% of patients hospitalized for COVID-19 had complications brought on by acute heart failure. Pooled incidence analysis showed that 20.2% (95% CI, 11.1%-33.9%; P < .0001) of patients with COVID-19 had complications from acute heart failure and they had a significantly increased mortality risk (odds ratio, 9.36; 95% CI, 4.76-18.4; P < .0001).

“Acute heart failure represents a frequent complication of COVID-19 infection,” Rigatelli noted, “and it is associated with a higher risk of mortality in the short-term period.” However, meta-regression analysis did not find a statistically significant relationship between age and incidence of acute heart failure from COVID-19 infection (P = .062) or overall mortality risk (P = .053).

Prognostic Biomarkers⁴

Patients with COVID-19–related pneumonia and no history of heart failure were the focus of an abstract from Tufan Cinar, MD, of Sultan Abdulhamid Han Training and Research Hospital in Istanbul, Turkey; in particular, the potential of N-terminal pro-brain type natriuretic peptide (NT-proBNP), a nonactive prohormone, as a prognostic indicator of mortality from possible heart failure. NT-proBNP levels are known to be above average in patients with heart failure vs those without heart failure.⁵

Among the 137 patients included in his analysis, for which the primary outcome was in-hospital death, overall mortality was 18.9%. The most common comorbidities among those who died were hypertension, chronic kidney disease, coronary artery disease, stroke, and dementia. Elevated levels of white blood cells (WBC), glucose, creatinine, troponin I, and NT-proBNP were also seen, but only NT-proBNP, WBC, and troponin I levels, in addition to age, were linked to increased in-hospital mortality following multivariable analysis.

Further ROC analysis showed an ideal NT-proBNP predictive level of 260 ng/L, at a sensitivity of 82% and specificity of 93% (AUC, 0.86; 95% CI, 0.76-0.97), for in-hospital mortality, “which clearly shows that the NT-proBNP levels are independently linked with in-hospital mortality rates in subjects with COVID-19 pneumonia and without heart failure.”

This indicates, he added, that the biomarker holds value as a prognostic parameter in these cases.

Device Therapy⁶

For their study on the effects of the COVID-19 pandemic on device therapy for patients with heart failure, presenter Rimma Hall of the Department of Cardiology, Cambridge University Hospital NHS Foundation Trust, and her fellow investigators examined the effects of the COVID-19 pandemic on device therapy for patients with heart failure. They compared the practice of defibrillator implantation and cardiac resynchronization for patients with arrhythmias and heart failure against National Institute for Health and Care Excellence guidelines.

“The study period coincided with the COVID-19 pandemic,” Hall said, “this allowed us to assess its impact on device therapy.”

In particular, for infection-control purposes, her team found that care for patients admitted to the hospital, there was a redistribution to ward-based care and away from specialty care, so they wanted to examine the impact of this change on patients who required specialty care but were not receiving it. Outcomes from March to August 2020 were compared with the same period in 2019, and there were 18 patients eligible for device therapy in both groups.

Among the patients, although they saw consistent prescribing of device therapy among both periods, in particular those with serious ventricular arrhythmia, familial cardiac condition with high risk of sudden cardiac death, and history of surgical repair of congenital heart disease. However, they did see a reduction in the proportion of patients with heart failure who were eligible for device therapy from 94% in 2019 to 79% in 2020 (P = .03).

Additional findings show an 8% reduction in admissions for heart failure patients during the pandemic and a trend toward a greater chance of patients who were considered too frail for device therapy. In 2020, 26 of 31 patients not receiving cardiology-directed care were deemed too frail for device therapy.

Possible reasons for their findings, Hall noted, included being pressured to quickly discharge patients, greater perception of potential patient frailty, and nonspecialty physicians having a lack of knowledge of indications for device therapy.

“Cardiac services should actively look for heart failure patients who may have missed out on life-saving therapies during the pandemic,” she concluded.

References

1. Yusoff NA. The effect of the COVID-19 pandemic on heart failure unplanned admission: a single center study. Presented at: ESC Congress 2021; August 27-31, 2021. Virtual.

2. Miklin D.Outcomes of COVID-19 infection in heart transplant recipients. Presented at: ESC Congress 2021; August 27-31, 2021. Virtual.

3. Rigatelli G. Heart failure as a complication of covid-19 infection: systematic review and meta-analysis. Presented at: ESC Congress 2021; August 27-31, 2021. Virtual.

4. Cinar T. Prognostic significance of N-terminal pro-BNP in patients with COVID-19 pneumonia without previous history of heart failure. Presented at: ESC Congress 2021; August 27-31, 2021. Virtual.

5. NT-proB-type natriuretic peptide (BNP). Cleveland Clinic. Accessed August 27, 2021. https://my.clevelandclinic.org/health/diagnostics/16814-nt-prob-type-natriuretic-peptide-bnp

6. Hall R. Impact of the covid-19 pandemic on the device therapy for patients with the heart failure. Presented at: ESC Congress 2021; August 27-31, 2021. Virtual.