COVID-19 Mortality in HF Patients: Nearly 1 in 4

Debra L. Beck

December 29, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Patients with heart failure who are infected with SARS-CoV-2 are at high risk for complications, with nearly 1 in 4 dying during hospitalization, according to a large database analysis that included more than 8000 patients who had heart failure and COVID-19.

In-hospital mortality was 24.2% for patients who had a history of heart failure and were hospitalized with COVID-19, as compared to 14.2% for individuals without heart failure who were hospitalized with COVID-19.

For perspective, the researchers compared the patients with heart failure and COVID-19 to patients who had a history of heart failure and were hospitalized for an acute worsening episode: the risk for death was about 10-fold higher with COVID-19.

"These patients really face remarkably high risk, and when we compare that to the risk of in-hospital death with something we are a lot more familiar with — acute heart failure — we see that the risk was about 10-fold greater," said first author Ankeet S. Bhatt, MD, MBA, from Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

In an article published online in JACC Heart Failure on December 28, a group led by Bhatt and senior author Scott D Solomon, MD, report an analysis of administrative data on a total of 2,041,855 incident hospitalizations logged in the Premier Healthcare Database between April 1, 2020, and September 30, 2020.

The Premier Healthcare Database comprises data from more than 1 billion patient encounters, which equates to approximately 1 in every 5 of all inpatient discharges in the United States.

Of 132,312 hospitalizations of patients with a history of heart failure, 23,843 (18.0%) were hospitalized with acute heart failure, 8383 patients (6.4%) were hospitalized with COVID-19, and 100,068 (75.6%) were hospitalized for other reasons.

Outcomes and resource utilization were compared to 141,895 COVID-19 hospitalizations of patients who did not have heart failure.

Patients were deemed to have a history of heart failure if they were hospitalized at least once for heart failure from January 1, 2019, to March 21, 2020, or had at least two heart failure outpatient visits during that period.

In comments to theheart.org | Medscape Cardiology, Solomon noted some of the pros and cons of the data used in this study.

"Premier is a huge database, encompassing about one quarter of all the healthcare facilities in the United States and one fifth of all inpatient visits, so for that reason we're able to look at things that are very difficult to look at in smaller hospital systems, but the data are also limited in that you don't have as much granular detail as you might in smaller datasets," said Solomon.

"One thing to recognize is that our data start at the point of hospital admission, so were looking only at individuals who have crossed the threshold in terms of their illness and been admitted," he added.

Use of in-hospital resources was significantly greater for patients with heart failure hospitalized for COVID-19, compared to patients hospitalized for acute heart failure or for other reasons. This included "multifold" higher rates of ICU care (29% vs 15%), mechanical ventilation (17% vs 6%), and central venous catheter insertion (19% vs 7%; P < .001 for all).

The proportion of patients who required mechanical ventilation and care in the ICU in the group with COVID-19 but who did not have no heart failure was similar to those who had both conditions.

The greater odds of in-hospital mortality among patients with both heart failure and COVID-19 compared to individuals with heart failure hospitalized for other reasons was strongest in April, with an adjusted odds ratio (OR) of 14.48, compared to subsequent months (adjusted OR for May – September, 10.11; P for interaction < .001).

"We're obviously not able to say with certainty what was happening in April, but I think that maybe the patients who were most vulnerable to COVID-19 may be more represented in that population, so the patients with comorbidities or who are immunosuppressed or otherwise," said Bhatt in an interview.

"The other thing we think is that there may be a learning curve in terms of how to care for patients with acute severe respiratory illness. That includes increased institutional knowledge — like the use of prone ventilation — but also therapies that were subsequently shown to have benefit in randomized clinical trials, such as dexamethasone," he added.

"These results should remind us to be innovative and thoughtful in our management of patients with heart failure while trying to maintain equity and good health for all," write Nasrien E. Ibrahim, MD, from Massachusetts General Hospital, Boston, Ersilia DeFillipis, MD, Columbia University, New York City, and Mitchel Psotka, MD, PhD, Innova Heart and Vascular Institute, Falls Church, Virginia, in an editorial accompanying the study.

The data emphasize the importance of ensuring equal access to services such as telemedicine, virtual visits, home nursing visits, and remote monitoring, they note.

"As the COVID-19 pandemic rages on and disproportionately ravages socioeconomically disadvantaged communities, we should focus our efforts on strategies that minimize these inequities," the editorialists write.

Solomon noted they although Black and Hispanic patients were overrepresented in the population of heart failure patients hospitalized with COVID-19, once in the hospital, race was not a predictor of in-hospital mortality or the need for mechanical ventilation.

Bhatt has received speaker fees from Sanofi Pasteur and is supported by a National Institutes of Health/National Heart, Lung, and Blood Institute postdoctoral training grant. Solomon has received grant support and/or speaking fees from a number of companies and from the National Institutes of Health/National Heart, Lung, and Blood Institute. The editorialists have disclosed no relevant financial relationships.

J Am Coll Cardiol Heart Fail. Published online December 28, 2020. Full text, Editorial

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