Cohort study of risk factors of acute and chronic cardiovascular events in COVID-19 patients

Date of ISAC Approval: 
Lay Summary: 
This research aims to inform patient management during the present COVID-19 coronavirus pandemic. Early findings suggest that patients with COVID-19 commonly experience conditions affecting the heart and blood vessels (cardiovascular conditions) such as heart failure. Acute heart failure often leads to very severe outcomes including death. We are also interested in understanding the risk factors for longer-term cardiovascular outcomes in COVID-19 patients such as chronic heart failure. Those with cardiovascular risk factors, such as high blood pressure, and who have experienced cardiovascular conditions in the past, seem to be at increased risk of poor COVID-19 outcomes. However, studies have reported several cases of cardiovascular events following a COVID-19 diagnosis in patients without a history of cardiovascular disease. It appears that the SARS-CoV-2 virus that causes COVID-19, might be capable of directly causing damage to the heart and more research is required to understand which patients are likely to benefit from dedicated, specialist cardiac care and monitoring. This study will use Clinical Practice Research Datalink (CPRD) data to collate cardiovascular risk factors in COVID-19 patients to assess their association with cardiovascular events including acute heart failure, chronic heart failure and death. We will analyse data from patients who have diagnoses of heart failure or other cardiovascular conditions, comparing risk factors and disease progression among those with a preceding COVID-19 diagnosis to those without.
Technical Summary: 
Cardiovascular risk factors and heart conditions have been associated with increased risk of poor COVID-19 outcomes. Several hospitalised COVID-19 patients have developed cardiovascular outcomes including acute heart failure, chronic heart failure, pulmonary edema and myocardial infarction. Pre-existing cardiovascular disease seems to be an important driver of COVID-19 severity, however other studies have noted serious cardiovascular outcomes in COVID-19 patients without a history of cardiovascular disease. SARS-CoV-2 could directly induce myocardial damage, potentially via the proinflammatory cytokine storm. We seek to improve evidence in this area for earlier identification of COVID-19 patients at high risk of cardiovascular outcomes who could benefit from dedicated cardiac monitoring and early referral to specialist teams. We will use the Clinical Practice Research Datalink (CPRD) Aurum and GOLD datasets to conduct a population cohort study, evaluating outcomes among patients experiencing cardiovascular events following COVID-19 diagnosis. Outcomes will be hospital readmission and mortality within 60 days following cardiovascular diagnoses. Cox proportional hazards regression models will use hazard ratios to compare outcomes to a matched cohort of patients who have similar cardiovascular diagnoses but no COVID-19 diagnosis, adjusting for covariates including gender and deprivation and comparing risk profiles between groups. Cardiovascular disease risk factors will be compiled including smoking status, blood pressure, cholesterol, diabetes and body mass index. Hospital admissions and cardiovascular events will be identified using the Hospital Episode Statistics Admitted Patient Care registry. We will use the Office for National Statistics (ONS) Death Registration Data for mortality data if possible, but note that the latest release (set 20) only covers up to June 2020. Should there be no further release prior to initiating our analysis, we will use the CPRD Aurum and GOLD death dates instead. A secondary analysis will evaluate longer-term cardiovascular effects of COVID-19 using CPRD data on relevant prescriptions including diuretics and anticoagulants.
Health Outcomes to be Measured: 
Primary analysis Within 60 days of cardiovascular diagnosis (index date): - Hospital admission. - Mortality. Secondary analysis Chronic cardiovascular conditions following index dates among those surviving, measured according to prescriptions for: - diuretics - anticoagulants - aspirin - antihypertensive drugs - antiplatelet drugs - lipid lowering drugs (mainly statins).

Martin Gulliford - Chief Investigator - King’s College London
Emma Rezel-Potts - Corresponding Applicant - King’s College London

HES Admitted;ONS;Practice IMD;Patient IMD