Heart Failure May Hit COVID Patients, Even Without CVD History

Batya Swift Yasgur MA, LSW

April 28, 2021

Patients hospitalized with COVID-19 could be at risk of developing heart failure (HF), even in the absence of a history of cardiovascular disease (CVD) or cardiovascular risk factors (CVRF), new research suggests.

Investigators retrospectively analyzed the electronic medical records of close to 1600 hospitalized patients with confirmed COVID-19, 37 of whom developed HF. Of these, eight patients had no history of CVD or CVRF.

"New diagnoses of acute heart failure were relatively infrequent amongst patients hospitalized with COVID-19," Anuradha Lala, MD, Icahn School of Medicine at Mount Sinai, New York City, told theheart.org | Medscape Cardiology.

Nevertheless, because "symptoms of heart failure — particularly shortness of breath — can mimic symptoms associated with COVID-19, being alerted to the findings of this study might prompt clinicians to monitor for signs of congestion more consistent with heart failure than COVID-19 alone," she said in a press release.

The letter was published online April 26 in the Journal of the American College of Cardiology.

"Elusive" Mechanisms

Although there have been reports of precipitation of HF in the setting of COVID-19, population-based studies "are needed to provide a context within which the frequency of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV2)-related HF can be appreciated," the authors write.

To further examine the issue, the researchers analyzed medical records of 6439 patients with COVID-19 (mean age, 64 years; 45% female), who had been admitted to Mount Sinai hospitals between February 27 and June 26, 2020. Patients were then followed until October 7, 2020.

Of the patients, 6.6% had a history of HF and 0.6% developed new HF during their hospitalization: 13 presented with shock (four cardiogenic, six septic, and three mixed), and five presented with acute coronary syndrome (ACS).

"Remarkably, 8 patients (22%) had neither CVRF nor CVD, while 14 (38%) had a history of CVD, and 15 (40%) had at least 1 CVRF," the authors report.

They note that patients with neither CVRF nor CVD were younger than those with these conditions (mean age, 43 vs 73 years, respectively). They were also mostly male, had lower body mass, and had fewer comorbidities (such as respiratory or renal disease), compared with other new HF patients.

Risk for admission to the intensive care unit was higher in patients with new HF than in those without HF (32% vs 17%), as was risk for intubation (24% vs 12%). However, risk for mortality was similar in the two groups (27% vs 25%).

And patients with new HF had higher concentrations of troponin and B-type higher natriuretic peptide (BNP) plasma levels than patients without CVRF and CVD.

Cardiac Biomarkers With and Without a History of CVD or Risk Factors
Patients With HF Troponin, ng/mL BNP, pg/mL
History of CVRF 0.03 163
History of CVD 0.18 356
No history of CVRF or CVD 221.45 588

Despite the higher frequency of cardiogenic shock and ACS in the eight new HF patients without CVRF or CVD, length of hospital stay was similar to that of the other patients with new HF.

"The mechanisms by which one may develop new HF in the setting of COVID-19 remain elusive, but may include indirect effects of acute illness or direct viral injury," Lala commented.

"Interesting imaging studies of patients post-COVID-19 have demonstrated fibrosis of the heart on cardiac MRI, so following patients longitudinally will be important for understanding mechanisms and time course," she said.

Close Follow-up

Commenting in the study for theheart.org | Medscape Cardiology, Biykem Bozkurt, MD, PhD, Mary and Gordon Cain Chair and Professor of Medicine, Baylor College of Medicine, Houston, said the findings are "in line with former reports that COVID-19 infection can affect the heart and result in myocardial injury, myocardial dysfunction, and heart failure."

It is "important to recognize cardiac involvement in patients with COVID-19 infection and it is critical to triage patients appropriately," said Bozkurt, who is the immediate past president of the Heart Failure Society of America and senior associate editor of Circulation.

Patients with mild to moderate symptoms of COVID-19 with evidence of cardiac involvement from biomarkers or imaging "need to be followed-up closely to determine resolution of symptoms, signs, and cardiac involvement," emphasized Bozkurt, who was not involved with the study.

Lala encouraged clinicians to "be alert to look for signs and symptoms of heart failure beyond shortness of breath, which may be present in acute COVID-19 illness."

Lala recommended looking at markers of congestion, measuring biomarkers, and obtaining an echocardiogram in select cases where symptoms of heart failure appear more apparent, "particularly in those patients with risk factors for or overt cardiovascular disease which may predispose risk for heart failure."

The authors conclude that "understanding specific mechanisms underlying the manifestation of COVID-19 as new HF warrants further study."

No source of study funding listed. Lala has received personal fees from Zoll outside of the submitted work. The other authors' disclosures are listed on the original paper. Bozkurt declares no relevant financial relationships.

J Am Coll Cardiol. Published online April 26, 2020. Letter


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