Cardiovascular Risk Factors and Clinical Outcomes among Patients Hospitalized with COVID-19: Findings from the World Heart Federation COVID-19 Study

Dorairaj Prabhakaran 1, Kavita Singh 2 3, Dimple Kondal 4, Lana Raspail 5, Bishav Mohan 6, Toru Kato 7 8, Nizal Sarrafzadegan 9, Shamim Hayder Talukder 10, Shahin Akter 11, Mohammad Robed Amin 12, Fastone Goma 13, Juan Gomez-Mesa 14, Ntobeko Ntusi 15, Francisca Inofomoh 16, Surender Deora 17, Evgenii Philippov 18, Alla Svarovskaya 19, Alexandra Konradi 20, Aurelio Puentes 21, Okechukwu S Ogah 22, Bojan Stanetic 23, Aurora Issa 24, Friedrich Thienemann 25, Dafsah Juzar 26 27, Ezequiel Zaidel 28, Sana Sheikh 29, Dike Ojji 30, Carolyn S P Lam 31 32, Junbo Ge 33, Amitava Banerjee 34, L Kristin Newby 35, Antonio Luiz P Ribeiro 36, Samuel Gidding 5, Fausto Pinto 37, Pablo Perel 38, Karen Sliwa 39; WHF COVID-19 Study Collaborators

Affiliations

doi: 10.5334/gh.1128

Abstract

Background and aims: Limited data exist on the cardiovascular manifestations and risk factors in people hospitalized with COVID-19 from low- and middle-income countries. This study aims to describe cardiovascular risk factors, clinical manifestations, and outcomes among patients hospitalized with COVID-19 in low, lower-middle, upper-middle- and high-income countries (LIC, LMIC, UMIC, HIC).

Methods: Through a prospective cohort study, data on demographics and pre-existing conditions at hospital admission, clinical outcomes at hospital discharge (death, major adverse cardiovascular events (MACE), renal failure, neurological events, and pulmonary outcomes), 30-day vital status, and re-hospitalization were collected. Descriptive analyses and multivariable log-binomial regression models, adjusted for age, sex, ethnicity/income groups, and clinical characteristics, were performed.

Results: Forty hospitals from 23 countries recruited 5,313 patients with COVID-19 (LIC = 7.1%, LMIC = 47.5%, UMIC = 19.6%, HIC = 25.7%). Mean age was 57.0 (±16.1) years, male 59.4%, pre-existing conditions included: hypertension 47.3%, diabetes 32.0%, coronary heart disease 10.9%, and heart failure 5.5%. The most frequently reported cardiovascular discharge diagnoses were cardiac arrest (5.5%), acute heart failure (3.8%), and myocardial infarction (1.6%). The rate of in-hospital deaths was 12.9% (N = 683), and post-discharge 30 days deaths was 2.6% (N = 118) (overall death rate 15.1%). The most common causes of death were respiratory failure (39.3%) and sudden cardiac death (20.0%). The predictors of overall mortality included older age (≥60 years), male sex, pre-existing coronary heart disease, renal disease, diabetes, ICU admission, oxygen therapy, and higher respiratory rates (p < 0.001 for each). Compared to Caucasians, Asians, Blacks, and Hispanics had almost 2-4 times higher risk of death. Further, patients from LIC, LMIC, UMIC versus. HIC had 2-3 times increased risk of death.

Conclusions: The LIC, LMIC, and UMIC's have sparse data on COVID-19. We provide robust evidence on COVID-19 outcomes in these countries. This study can help guide future health care planning for the pandemic globally.

Keywords: COVID-19; cardiovascular disease; mortality.

Conflict of interest statement

The authors have no competing interests to declare.

Figures

Figure 1 Participating countries and patient recruitment in the WHF COVID-19 study. N = number of patients recruited in the study by participating country.

Figure 1 Participating countries and patient recruitment in the WHF COVID-19 study. N = number of patients recruited in the study by participating country.

Figure 2a Comparison of in-hospital deaths and post-discharge 30-day deaths among COVID-19 patients by ethnic groups. * p < 0.001 for in-hospital deaths between Caucasians vs. Hispanics, Blacks, and Asians. * P < 0.001 for post-discharge 30-day deaths between Caucasians vs. Middle Eastern and Asians. show full caption

Figure 2a Comparison of in-hospital deaths and post-discharge 30-day deaths among COVID-19 patients by ethnic groups. * p < 0.001 for in-hospital deaths between Caucasians vs. Hispanics, Blacks, and Asians. * P < 0.001 for post-discharge 30-day deaths between Caucasians vs. Middle Eastern and Asians. show full caption

Figure 2b Comparison of in-hospital deaths and post-discharge 30-day deaths in COVID-19 patients by World Bank income groups. * p < 0.001 for both in-hospital deaths and post-discharge 30-day deaths between HIC vs. LIC, LMIC, and UMIC. HIC = high income countries; UMIC = upper middle-income countries; LMIC = lower middle-income countries; LIC = low-income countries. show full caption

Figure 2b Comparison of in-hospital deaths and post-discharge 30-day deaths in COVID-19 patients by World Bank income groups. * p < 0.001 for both in-hospital deaths and post-discharge 30-day deaths between HIC vs. LIC, LMIC, and UMIC. HIC = high income countries; UMIC = upper middle-income countries; LMIC = lower middle-income countries; LIC = low-income countries. show full caption

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References

  1.  
    1. Thienemann F, Pinto F, Grobbee DE, et al. World Heart Federation Briefing on Prevention: Coronavirus Disease 2019 (COVID-19) in Low-Income Countries. Glob Heart. 2020; 15(1): 31. [published Online first: 4 June 2020]. DOI: 10.5334/gh.778 - DOI - PMC - PubMed
  2.  
    1. Hopman J, Allegranzi B, Mehtar S. Managing COVID-19 in Low- and Middle-Income Countries. JAMA. 2020; 323(16): 1549–50. [published Online first: 17 March 2020]. DOI: 10.1001/jama.2020.4169 - DOI - PubMed
  3.  
    1. Angrup A, Kanaujia R, Ray P, et al. Healthcare facilities in low- and middle-income countries affected by COVID-19: Time to upgrade basic infection control and prevention practices. Indian J Med Microbiol. 2020; 38(2): 139–43. [published Online first: 05 September 2020]. DOI: 10.4103/ijmm.IJMM_20_125 - DOI - PMC - PubMed
  4.  
    1. Grasselli G, Greco M, Zanella A, et al. Risk Factors Associated With Mortality Among Patients With COVID-19 in Intensive Care Units in Lombardy, Italy. JAMA Intern Med. 2020; 180(10): 1345–55. [published Online first: 16 July 2020]. DOI: 10.1001/jamainternmed.2020.3539 - DOI - PMC - PubMed
  5.  
    1. Wiersinga WJ, Rhodes A, Cheng AC, et al. Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review. JAMA. 2020; 324(8): 782–93. [published Online first: 11 July 2020]. DOI: 10.1001/jama.2020.12839 - DOI - PubMed
  6.  
    1. O’Driscoll M, Ribeiro Dos Santos G, Wang L, et al. Age-specific mortality and immunity patterns of SARS-CoV-2. Nature. 2021; 590(7844): 140–45. [published Online first: 3 November 2020]. DOI: 10.1038/s41586-020-2918-0 - DOI - PubMed
  7.  
    1. Verity R, Okell LC, Dorigatti I, et al. Estimates of the severity of coronavirus disease 2019: A model-based analysis. The Lancet Infectious Diseases. 2020; 20(6): 669–77. DOI: 10.1016/S1473-3099(20)30243-7 - DOI - PMC - PubMed
  8.  
    1. Parasher A. COVID-19: Current understanding of its Pathophysiology, Clinical presentation and Treatment. Postgrad Med J. 2021; 97(1147): 312–20. [published Online first: 27 September 2020]. DOI: 10.1136/postgradmedj-2020-138577 - DOI - PMC - PubMed
  9.  
    1. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study. The Lancet Respiratory Medicine. 2020; 8(5): 475–81. DOI: 10.1016/S2213-2600(20)30079-5 - DOI - PMC - PubMed
  10.  
    1. Xiong T-Y, Redwood S, Prendergast B, et al. Coronaviruses and the cardiovascular system: Acute and long-term implications. Eur Heart J. 2020; 41(19): 1798–800. DOI: 10.1093/eurheartj/ehaa231 - DOI - PMC - PubMed
  11.  
    1. Alharthy A, Aletreby W, Faqihi F, et al. Clinical Characteristics and Predictors of 28-Day Mortality in 352 Critically Ill Patients with COVID-19: A Retrospective Study. J Epidemiol Glob Health. 2021; 11(1): 98–104. [published Online first: 24 October 2020]. DOI: 10.2991/jegh.k.200928.001 - DOI - PMC - PubMed
  12.  
    1. Adu-Amankwaah J, Mprah R, Adekunle AO, et al.The cardiovascular aspect of COVID-19. Ann Med. 2021; 53(1): 227–36. [published Online first: 22 December 2020]. DOI: 10.1080/07853890.2020.1861644 - DOI - PMC - PubMed
  13.  
    1. Sliwa K, Singh K, Raspail L, et al. The World Heart Federation Global Study on COVID-19 and Cardiovascular Disease. Glob Heart. 2021; 16(1): 22. [published Online first: 28 May 2021]. DOI: 10.5334/gh.950 - DOI - PMC - PubMed
  14.  
    1. Bank W. Poverty and Shared Prosperity 2020: Reversals of Fortune. 2020.
  15.  
    1. Bukhman G, Mocumbi AO, Atun R, et al. The Lancet NCDI Poverty Commission: Bridging a gap in universal health coverage for the poorest billion. The Lancet. 2020; 396(10256): 991–1044. DOI: 10.1016/S0140-6736(20)31907-3 - DOI - PMC - PubMed
  16.  
    1. World Bank county classification by income. (Accessed 04 January 2022). https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-b....
  17.  
    1. Alkmim MB, Silva CBG, Figueira RM, et al. Brazilian National Service of Telediagnosis in Electrocardiography. Stud Health Technol Inform. 2019; 264: 1635–36. [published Online first: 24 August 2019]. DOI: 10.3233/shti190571 - DOI - PubMed
  18.  
    1. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009; 42(2): 377–81. [published Online first: 22 October 2008]. DOI: 10.1016/j.jbi.2008.08.010 - DOI - PMC - PubMed
  19.  
    1. Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019; 95: 103208. [published Online first: 13 May 2019]. DOI: 10.1016/j.jbi.2019.103208 - DOI - PMC - PubMed
  20.  
    1. Karp I. Re: ‘Estimating the relative risk in cohort studies and clinical trials of common outcomes’. Am J Epidemiol. 2014; 179(8): 1034–5. [published Online first: 21 February 2014]. DOI: 10.1093/aje/kwt435 - DOI - PubMed
  21.  
    1. McNutt LA, Wu C, Xue X, et al. Estimating the relative risk in cohort studies and clinical trials of common outcomes. Am J Epidemiol. 2003; 157(10): 940–3. [published Online first: 15 May 2003]. DOI: 10.1093/aje/kwg074 - DOI - PubMed
  22.  
    1. Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004; 159(7): 702–6. [published Online first: 23 March2004]. DOI: 10.1093/aje/kwh090 - DOI - PubMed
  23.  
    1. Dai CL, Kornilov SA, Roper RT, et al. Characteristics and Factors Associated with COVID-19 Infection, Hospitalization, and Mortality Across Race and Ethnicity. Clin Infect Dis; 2021. [published Online first: 21 February 2021]. DOI: 10.1093/cid/ciab154 - DOI - PMC - PubMed
  24.  
    1. Acosta AM, Garg S, Pham H, et al. Racial and Ethnic Disparities in Rates of COVID-19-Associated Hospitalization, Intensive Care Unit Admission, and In-Hospital Death in the United States From March 2020 to February 2021. JAMA Netw Open. 2021; 4(10): e2130479. [published Online first: 22 October 2021]. DOI: 10.1001/jamanetworkopen.2021.30479 - DOI - PMC - PubMed
  25.  
    1. Qureshi AI, Baskett WI, Huang W, et al. Effect of Race and Ethnicity on In-Hospital Mortality in Patients with COVID-19. Ethn Dis. 2021; 31(3): 389–98. [published Online first: 24 July 2021]. DOI: 10.18865/ed.31.3.389 - DOI - PMC - PubMed
  26.  
    1. Xiong TY, Redwood S, Prendergast B, et al. Coronaviruses and the cardiovascular system: Acute and long-term implications. Eur Heart J. 2020; 41(19): 1798–800. [published Online first: 19 March 2020]. DOI: 10.1093/eurheartj/ehaa231 - DOI - PMC - PubMed
  27.  
    1. Behrouzi B, Araujo Campoverde MV, Liang K, et al. Influenza Vaccination to Reduce Cardiovascular Morbidity and Mortality in Patients With COVID-19: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020; 76(15): 1777–94. [published Online first: 10 October 2020]. DOI: 10.1016/j.jacc.2020.08.028 - DOI - PMC - PubMed
  28.  
    1. Yedlapati SH, Khan SU, Talluri S, et al. Effects of Influenza Vaccine on Mortality and Cardiovascular Outcomes in Patients With Cardiovascular Disease: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2021; 10(6): e019636. [published Online first: 16 March 2021]. DOI: 10.1161/JAHA.120.019636 - DOI - PMC - PubMed
  29.  
    1. Udell JA, Zawi R, Bhatt DL, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: A meta-analysis. JAMA. 2013; 310(16): 1711–20. [published Online first: 24 October 2013]. DOI: 10.1001/jama.2013.279206 - DOI - PubMed
  30.  
    1. Verma S, Saksena S, Sadri-Ardekani H. ACE2 receptor expression in testes: Implications in coronavirus disease 2019 pathogenesisdagger. Biol Reprod. 2020; 103(3): 449–51. [published Online first: 20 May 2020]. DOI: 10.1093/biolre/ioaa080 - DOI - PMC - PubMed
  31.  
    1. Al-Benna S. Angiotensin-converting enzyme 2 gene expression in human male urological tissues: implications for pathogenesis and virus transmission pathways. Afr J Urol. 2021; 27(1): 89. [published Online first: 8 July 2021]. DOI: 10.1186/s12301-021-00192-4 - DOI - PMC - PubMed
  32.  
    1. Prabhakaran D, Chandrasekaran AM, Singh K, et al. Yoga-Based Cardiac Rehabilitation After Acute Myocardial Infarction: A Randomized Trial. J Am Coll Cardiol. 2020; 75(13): 1551–61. [published Online first: 4 April 2020]. DOI: 10.1016/j.jacc.2020.01.050 - DOI - PMC - PubMed
  33.  
    1. Dhakal BP, Sweitzer NK, Indik JH, et al. SARS-CoV-2 Infection and Cardiovascular Disease: COVID-19 Heart. Heart Lung Circ. 2020; 29(7): 973–87. [published Online first: 1 July 2020]. DOI: 10.1016/j.hlc.2020.05.101 - DOI - PMC - PubMed
  34.  
    1. Nishiga M, Wang DW, Han Y, et al. COVID-19 and cardiovascular disease: From basic mechanisms to clinical perspectives. Nat Rev Cardiol. 2020; 17(9): 543–58. [published Online first: 22 July 2020]. DOI: 10.1038/s41569-020-0413-9 - DOI - PMC - PubMed
  35.  
    1. Ma L, Song K, Huang Y. Coronavirus Disease-2019 (COVID-19) and Cardiovascular Complications. J Cardiothorac Vasc Anesth. 2021; 35(6): 1860–65. [published Online first: 27 May 2020]. DOI: 10.1053/j.jvca.2020.04.041 - DOI - PMC - PubMed
  36.  
    1. Chang WT, Toh HS, Liao CT, et al. Cardiac Involvement of COVID-19: A Comprehensive Review. Am J Med Sci. 2021; 361(1): 14–22. [published Online first: 15 November 2020]. DOI: 10.1016/j.amjms.2020.10.002 - DOI - PMC - PubMed
  37.  
    1. Shi S, Qin M, Shen B, et al. Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. JAMA Cardiology. 2020; 5(7): 802–10. DOI: 10.1001/jamacardio.2020.0950 - DOI - PMC - PubMed
  38.  
    1. Pareek M, Singh A, Vadlamani L, et al. Relation of Cardiovascular Risk Factors to Mortality and Cardiovascular Events in Hospitalized Patients With Coronavirus Disease 2019 (from the Yale COVID-19 Cardiovascular Registry). Am J Cardiol. 2021; 146: 99–106. [published Online first: 5 February 2021]. DOI: 10.1016/j.amjcard.2021.01.029 - DOI - PMC - PubMed
  39.  
    1. Mehraeen E, Karimi A, Barzegary A, et al. Predictors of mortality in patients with COVID-19-a systematic review. Eur J Integr Med. 2020; 40: 101226. [published Online first: 27 October 2020]. DOI: 10.1016/j.eujim.2020.101226 - DOI - PMC - PubMed
  40.  
    1. Wynants L, Van Calster B, Collins GS, et al. Prediction models for diagnosis and prognosis of covid-19: systematic review and critical appraisal. BMJ. 2020; 369: m1328. [published Online first: 9 April2020]. DOI: 10.1136/bmj.m1328 - DOI - PMC - PubMed
  41.  
    1. Zhang JJY, Lee KS, Ang LW, et al. Risk Factors for Severe Disease and Efficacy of Treatment in Patients Infected With COVID-19: A Systematic Review, Meta-Analysis, and Meta-Regression Analysis. Clin Infect Dis. 2020; 71(16): 2199–206. [published Online first: 15 May 2020]. DOI: 10.1093/cid/ciaa576 - DOI - PMC - PubMed
  42.  
    1. Mesas AE, Cavero-Redondo I, Alvarez-Bueno C, et al. Predictors of in-hospital COVID-19 mortality: A comprehensive systematic review and meta-analysis exploring differences by age, sex and health conditions. PLoS One. 2020; 15(11): e0241742. [published Online first: 4 November 2020]. DOI: 10.1371/journal.pone.0241742 - DOI - PMC - PubMed
  43.  
    1. Lippi G, Wong J, Henry BM. Hypertension in patients with coronavirus disease 2019 (COVID-19): a pooled analysis. Pol Arch Intern Med. 2020; 130(4): 304–09. [published Online first: 2 April 2020]. DOI: 10.20452/pamw.15272 - DOI - PubMed
  44.  
    1. Mubarik S, Liu X, Eshak ES, et al. The Association of Hypertension With the Severity of and Mortality From the COVID-19 in the Early Stage of the Epidemic in Wuhan, China: A Multicenter Retrospective Cohort Study. Front Med (Lausanne). 2021; 8: 623608. [published Online first: 1 June 2021]. DOI: 10.3389/fmed.2021.623608 - DOI - PMC - PubMed
  45.  
    1. Bian J, Li Z. Angiotensin-converting enzyme 2 (ACE2): SARS-CoV-2 receptor and RAS modulator. Acta Pharm Sin B. 2021; 11(1): 1–12. [published Online first: 20 October 2020]. DOI: 10.1016/j.apsb.2020.10.006 - DOI - PMC - PubMed
  46.  
    1. Wu J, Deng W, Li S, et al. Advances in research on ACE2 as a receptor for 2019-nCoV. Cell Mol Life Sci. 2021; 78(2): 531–44. [published Online first: 12 August 2020]. DOI: 10.1007/s00018-020-03611-x - DOI - PMC - PubMed

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