Cardiovascular Complications Likely Component of Long COVID

The proportion of patients who developed cardiovascular complications in post-acute, "Long", COVID-19 in a 1-year population study was larger than investigators expected,prompting their call for increased monitoring and preparedness.

Ziyad Al-Aly, MD, director, Clinical Epidemiology Center, Veterans Affairs St. Louis Health Care System, MO, and colleagues sought to expand on the information available from the few studies that have examined post-acute COVID-19 cardiovascular outcomes, most of which were short-term and limited to hospitalized individuals.

The investigators constituted the retrospective study of the 1 year course following COVID-19 diagnosis from medical records of 153,760 veterans who contracted and survived COVID-19 for at least 30 days, 5,637,647 participants for a contemporary cohort, and 5,859,411 in a historical cohort who were treated prior to the COVID-19 pandemic.

In a one year period, persons contracting COVID-19, regardless of whether hospitalized, exhibited increased risk of stroke (hazard ratio [HR]=1.52, 95% CI 1.43-1.62); transient ischemic attacks (TIA) (HR=1.7, CI 1.37-1.62); and atrial fibrillation (HR=1.71, CI 1.64-1.79. In addition, risk was increased for other dysrhythmias; inflammatory disease of the heart or pericardium; ischemic heart disease; as well as other cardiovascular disorders including heart failure, non-ischemic cardiomyopathy, cardiac arrest, cardiogenic shock, and thromboembolic disorders.

The investigators considered several mechanisms that could underlie the association between COVID-19 and post-acute phase development of cardiovascular diseases, including lingering damage from viral invasion of cardiomyocytes with subsequent cell death; endothelial cell infection and endotheliitis, transcriptional alteration of multiple cell types in heart tissue; and a number of other putative mechanisms.

"A deeper understanding of the biologic mechanisms will be needed to inform development of prevention and treatment strategies of the cardiovascular manifestations among people with COVID-19," the investigators indicated.

Although their analysis showed that risks increased with increased severity of the acute COVID-19 presentation—from non-hospitalized to hospitalized to requiring intensive care—the investigators emphasize, "that the risks and associated burdens were evident among those who were not hospitalized during the acute phase of the disease; this group represents the majority of people with COVID-19."

Al-Aly and colleagues characterize the increased risk for cardiovascular complication during Long-COVID as "substantial," and recommend appropriate, extended follow-up with attention to cardiovascular health and diseases.

In email correspondence to editors at JAMA, shared in a column by Associate Managing News Editor Jennifer Abbasi, Al-Aly described the breadth of increased cardiovascular disease as "eye opening." Although he and colleagues had anticipated that these outcomes would more likely occur in patients with the much associated pre-existing conditions like diabetes, Al-Aly related that COVID-19 appeared to be "an equal opportunity offender."

"The risks were evident in young people and old people, in Black people and White people, in males and females, in people who smoke and people who did not smoke, in people who have diabetes, and people without diabetes, etc.It really did not spare any subgroup," he indicated.

Al-Aly concluded his correspondence by pointing that while the risks reported in his study may appear small against the large number of people with COVID-19, that the proportion will still likely translate into millions who develop heart disease in the US and many more around the world.

"We need to realize this now and make sure we are prepared and ready to address the needs of these patients," Al-Aly declared.