COVID-19 among heart failure patients: A retrospective study of 294 patients at a referral cardiac center in northern Iran

Article Type : Original/Research Papers

Authors

1 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran

2 Burn and Regenerative Medicine Research Center, Guilan University of Medical Sciences, Rasht, Iran

3 Department of Cardiology, Cardiovascular Diseases Research Center, Heshmat Hospital, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran

4 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran

5 Department of Nursing, Cardiovascular Diseases Research Center, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran

6 Social Determinants of Health Research Center (SDHRC), Guilan University of Medical Sciences, Rasht, Iran

Abstract

Cardiovascular disease, especially heart failure (HF), is the most important comorbidity that increases the risk of death in COVID-19 patients. This study aimed to assess and compare demographic characteristics, clinical features, and clinical outcomes in HF patients with and without COVID-19. Using a retrospective research, 294 patients with HF referred to a cardiac center in Guilan province, northern Iran were enrolled. Data were collected using census sampling from August 2020 to 2021. In this study, the medical records of all patients with HF were assessed. In this research, 294 HF patients were enrolled. Also, 26.53% of HF patients had COVID-19. Mean EF, blood pressure, and HF duration in HF patients with COVID-19 were 25.83 (SD=12.31), 126.65 (SD=24.67) mmHg, and 3.79 (SD=2.10) years, respectively. The most common symptoms in HF patients with COVID-19 were cough (52.56%), headache (44.87%), and gastrointestinal problems (43.59%), respectively. Finally, 55.13% of HF patients with COVID-19 died. The mean age of HF patients with COVID-19 was higher than in HF patients without COVID-19 (66.02 vs. 62.79 years; P=0.031). Hyperlipidemia was higher in HF patients with COVID-19 than in HF patients without COVID-19 (25.64% vs. 13.89%; P=0.018). Also, in-hospital mortality was higher in HF patients with COVID-19 than in HF patients without COVID-19 (55.13% vs. 16.20%; P<0.001). Overall, HF patients with COVID-19 are at particular risk for severe complications and high mortality. Therefore, it is recommended to pay special attention to HF patients with COVID-19.

Keywords

1 Introduction

Since December 2019, COVID-19 led to a health problem in the world. Although the full spectrum of this infection in humans has not been fully identified, it is progressing rapidly [1-7]. Based on the World Health Organization, a total of 470,839,745 confirmed cases of COVID-19 had been identified around the world by March 22, 2022, out of which 6,092,933 died. In Iran, a total of 7,142,289 confirmed cases of COVID-19 had been identified around the world by March 22, 2022, out of which 139,662 died [8]. Comorbidity has been introduced as a basic predictor of death among COVID-19 patients [1-7]. Previous evidence has shown that cardiovascular disease, especially heart failure (HF), is the most important comorbidity that increases the risk of death among COVID-19 patients [1, 9]. A study [9] found that 16% of patients who died from COVID-19 had cardiac symptoms. Also, an observational study [10] on 8,910 COVID-19 patients found that in-hospital death risk was higher in COVID-19 patients with HF compared with COVID-19 patients without HF (15.3% vs. 5.6%). Therefore, HF is known as an independent predictor of death in patients with COVID-19 [10]. Overall, HF patients are at particular risk for severe complications and high mortality due to weakened immune systems and decreased hemodynamic ability to fight infections. Production of more TNF-α monocytes and less IL-10 than in healthy individuals, which in combination with the extensive inflammatory response associated with COVID-19 infection, increases the need for cardiac function. However, HF patients usually do not have adequate cardiac output [1, 11].

Although the COVID-19 pandemic is almost over and a lot of information is known about this disease, narrow gaps in our understanding of the disease among HF patients, and thus, aid decision-making by health care providers and administrators, more evidence is needed on the prevention, control, and treatment of COVID-19 among HF patients. Due to the importance of this issue, this research aimed to assess and compare demographic characteristics, clinical features, and clinical outcomes in HF patients with and without COVID-19.

 

2 Methods

2.1 Study design and subjects

Using a retrospective study, 294 HF patients referred to a cardiac center in Guilan province, northern Iran were enrolled. Data were collected using census sampling from August 2020 to 2021. In this study, the medical records of all HF patients were assessed. HF patients over the age of 18 years with a duration of HF over three months were included in the research. Also, patients with incomplete medical records were excluded from the present study. The Research Ethics Committee of Guilan University of Medical Sciences confirmed this research (IR.GUMS.REC.1399.023).

 

2.2 Data collection

Data collection was conducted via a researcher-made checklist including demographic characteristics (age, sex, active smoking, a history of hospitalization due to heart problems, and body mass index [BMI]), clinical features (infection with COVID-19, ejection fraction [EF], duration of HF, blood pressure, symptoms [fever, tremor, cough, body pain, gastrointestinal problems, sore throat, loss of olfactory sense, loss of the sense of taste, and headache], comorbidities [diabetes mellitus, myocardial infarction, angioplasty, valve diseases, hyperlipidemia, and hypertension/hypotension], and pharmacological treatment [anti-platelets, nitrates, beta blockers, multivitamin, anti-lipids, angiotensin-converting-enzyme inhibitors, angiotensin receptor blockers, antidiabetics, diuretics, antipsychotics, proton-pump inhibitors, and calcium channel blockers]), and clinical outcome (in-hospital mortality).

 

2.3 Statistical analysis

Data analysis were conducted via SPSS.V.16.0. Study variables were showed using mean (standard deviation) and number (percentage), respectively. The relationship between study variables was assessed via Chi-square and t-tests. P<0.05 was considered as a significant level.

 

3 Results

3.1 Participants

In this research, 294 HF patients were enrolled. Of the participants, 55.78% were male, 23.13% were active smokers, 12.59% had a history of hospitalization due to heart problems during the COVID-19 pandemic, 50.34% had a BMI of 25 to 30 kg/m2, and 66. 67% had hypertension/hypotension. Mean age, EF, blood pressure, and duration of HF in patients with HF were 63.65 (SD=12.86) years, 24.67 (SD=11.85), 126.90 (SD=25.42) mmHg, and 3.86 (SD=2.28) years, respectively. Also, 26.53% of HF patients had COVID-19 (Tables 1 & 2).

 

3.2 Demographic characteristics, clinical features, and clinical outcomes in HF patients with COVID-19

Of the HF patients with COVID-19, 50.00% were male, 26.92% were active smokers, 12.82% had a history of hospitalization due to heart problems during the COVID-19 pandemic, 56.41% had a BMI of 25 to 30 kg/m2, and 74.36% had hypertension/hypotension. Mean age, EF, blood pressure, and HF duration in HF patients with COVID-19 were 66.02 (SD=12.05) years, 25.83 (SD=12.31), 126.65 (SD=24.67) mmHg, and 3.79 (SD=2.10) years, respectively. The most common symptoms in HF patients with COVID-19 were cough (52.56%), headache (44.87%), and gastrointestinal problems (43.59%), respectively. Finally, 55.13% of HF patients with COVID-19 died (Tables 1 & 2).

 

3.3 Comparison of demographic characteristics, clinical features, and clinical outcomes in HF patients with and without COVID-19

The mean age of HF patients with COVID-19 was higher than in HF patients without COVID-19 (66.02 vs. 62.79 years; P=0.031) (Table 1). Hyperlipidemia was higher in HF patients with COVID-19 than in HF patients without COVID-19 (25.64% vs. 13.89%; P=0.018). Also, in-hospital mortality was higher in HF patients with COVID-19 than in HF patients without COVID-19 (55.13% vs. 16.20%; P<0.001) (Table 2).

 

Table 1. Demographic characteristics of HF patients with or without COVID-19.

 

Total (n=294)

HF patients

P-value

COVID-19 (n=78)

Non-COVID-19 (n=216)

Age (years)

63.65 (SD=12.86)

66.02 (SD=12.05)

62.79 (SD=13.05)

0.031

Sex

 

 

 

0.230

   Male

164 (55.78)

39 (50.00)

125 (57.87)

   Female

130 (44.22)

39 (50.00)

91 (42.13)

Active smoking

 

 

 

0.354

   Yes

68 (23.13)

21 (26.92)

47 (21.76)

   No

226 (76.87)

57 (73.08)

169 (78.24)

History of hospitalization due to heart problems

 

 

 

0.541

   Yes

37 (12.59)

10 (12.82)

27 (12.50)

   No

257 (87.41)

68 (87.18)

189 (87.50)

BMI (kg/m2)

 

 

 

0.457

   18.5-24.9

116 (39.46)

27 (34.62)

89 (41.20)

   25-30

148 (50.34)

44 (56.41)

104 (48.15)

   >30

30 (10.20)

7 (8.97)

23 (10.65)

 

Table 2. Clinical features and outcomes of HF patients with or without COVID-19.

 

Total (n=294)

HF patients

P-value

COVID-19 (n=78)

Non-COVID-19 (n=216)

Clinical features

EF

24.67 (SD=11.85)

25.83 (SD=12.31)

24.24 (SD=11.67)

0.364

Duration of HF (years)

3.86 (SD=2.28)

3.79 (SD=2.10)

3.87 (SD=2.35)

0.771

Blood pressure (mmHg)

126.90 (SD=25.42)

126.65 (SD=24.67)

126.99 (SD=25.73)

0.748

Symptoms

 

 

 

<0.001

   Fever

32 (10.88)

26 (33.33)

6 (2.78)

   Tremor

37 (12.58)

33 (42.31)

4 (1.85)

   Cough

46 (15.65)

41 (52.56)

5 (2.31)

   Body pain

35 (11.90)

29 (37.18)

6 (2.78)

   Gastrointestinal problems

39 (13.27)

34 (43.59)

5 (2.31)

   Sore throat

31 (10.54)

27 (34.62)

4 (1.85)

   Loss of olfactory sense

36 (12.24)

31 (39.74)

5 (2.31)

   Loss of the sense of taste

31 (10.54)

26 (33.33)

5 (2.31)

   Headache

42 (14.29)

35 (44.87)

7 (3.24)

Comorbidities

 

 

 

 

   Diabetes mellitus

 

 

 

0.073

      Yes

132 (44.90)

41 (52.56)

91 (42.13)

      No

162 (55.10)

37 (47.44)

125 (57.87)

   Myocardial infarction

 

 

 

0.759

      Yes

29 (9.86)

7 (8.97)

22 (10.19)

      No

265 (90.14)

71 (91.03)

194 (89.81)

   Angioplasty

 

 

 

0.616

      Yes

84 (28.57)

24 (30.77)

60 (27.78)

      No

210 (71.43)

54 (69.23)

156 (72.22)

   Valve diseases

 

 

 

0.715

      Yes

53 (18.03)

13 (16.67)

40 (18.52)

      No

241 (81.97)

65 (83.33)

176 (81.48)

   Hyperlipidemia

 

 

 

0.018

      Yes

50 (17.01)

20 (25.64)

30 (13.89)

      No

244 (82.99)

58 (74.36)

186 (86.11)

   Hypertension/Hypotension

 

 

 

0.060

      Yes

196 (66.67)

58 (74.36)

138 (63.89)

      No

98 (33.33)

20 (25.64)

78 (36.11)

Pharmacological treatment

 

 

 

0.206

   Anti-platelets

291 (98.98)

77 (98.72)

214 (99.07)

   Nitrates

283 (96.26)

75 (96.15)

208 (96.30)

   Beta blockers

244 (82.99)

66 (84.61)

178 (82.41)

   Multivitamin

260 (88.43)

67 (85.90)

193 (89.35)

   Anti-lipids

279 (94.90)

73 (93.59)

206 (95.37)

   Angiotensin-converting-enzyme inhibitors

257 (87.41)

65 (83.33)

192 (88.89)

   Angiotensin receptor blockers

274 (93.20)

74 (94.87)

200 (92.59)

   Antidiabetics

168 (57.14)

49 (62.82)

119 (55.09)

   Diuretics

279 (94.90)

72 (92.31)

207 (95.83)

   Antipsychotics

22 (7.48)

8 (10.26)

14 (6.48)

   Proton-pump inhibitors

258 (87.75)

68 (87.18)

190 (87.96)

   Calcium channel blockers

13 (4.42)

5 (6.41)

8 (3.70)

Clinical outcomes

 

 

 

 

In-hospital Mortality

 

 

 

<0.001

   Yes

78 (26.53)

43 (55.13)

35 (16.20)

   No

216 (73.47)

35 (44.87)

181 (83.80)

 

4 Discussion

Demographic findings vary based on variables such as the type of population studied, different characteristics of the studied samples, the number of comorbidities, and the conditions of different patients in different studies [12-15]. A study in the USA [15] found that 6.3% of HF patients had COVID-19. Hyperlipidemia in HF patients with COVID-19 may be due to the nature of cardiac disease and its side effects. Hypertension and hyperlipidemia are common in these patients, which can be the cause of negative outcomes in these patients [10, 16].

In the research, the most common symptoms in HF patients with COVID-19 were cough (52.56%), headache (44.87%), and gastrointestinal problems (43.59%), respectively. Consistent with this finding, a study in Spain [17] found that cough is the most common symptom in HF patients with COVID-19. A notable point in the present study was the presence of headache and gastrointestinal symptoms in HF patients with COVID-19. Although headache and gastrointestinal symptoms were present in COVID-19 patients [5, 18-22], it is unclear whether these symptoms are present in HF patients with COVID-19. Thus, more evidence is required to confirm the present finding. Headache and gastrointestinal complications in HF patients with COVID-19 can be due to the side effects of some drugs used in these patients [23-25]. However, patients' atypical symptoms such as headache and gastrointestinal symptoms can not be ignored.

This research found that 55.13% of HF patients with COVID-19 died. Also, in-hospital mortality was higher in HF patients with COVID-19 than in HF patients without COVID-19. A systematic review and meta-analysis [26] showed that HF was associated with higher hospitalization, morbidity, and mortality in COVID-19 patients. Consistent with the present study, a study in the USA [15] showed that the mortality rate was higher in HF patients with COVID-19 than in COVID-19 patients without HF (24.2% vs. 14.2%). Therefore, HF patients with COVID-19 are at particular risk for severe complications and high mortality. Hence, it is suggested that future researchers assess HF as an important predictor of mortality for COVID-19.

 

4.1 Limitations

Some COVID-19 patients were not included in the present research due to incomplete and non-electronic records. Also, in the present study, the length of stay in the hospital was not collected as an important indicator to evaluate the clinical consequences of the participants.

 

5 Conclusions

Overall, HF patients with COVID-19 are at particular risk for severe complications and high mortality. Therefore, it is recommended to pay special attention to HF patients with COVID-19.

 

Acknowledgements

Not applicable.

 

Authors’ contributions

Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: SK, AS, ZA, MJG, NJP; Drafting the work or revising it critically for important intellectual content: SK, AS, ZA, MJG, NJP; Final approval of the version to be published: SK, AS, ZA, MJG, NJP; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: SK, AS, ZA, MJG, NJP.

 

Funding

Self-funded.

 

Ethics approval and consent to participate

The Research Ethics Committee of Guilan University of Medical Sciences confirmed this research (IR.GUMS.REC.1399.023). After obtaining permission from the hospital administration, the researchers visited the hospital. Verbal informed consent was obtained from participants.

 

Competing interests

We do not have potential conflicts of interest with respect to the research, authorship, and publication of this article.

 

Availability of data and materials

The datasets used during the current study are available from the corresponding author on request.

 

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (CC BY-NC 4.0).

© 2024 The Author(s).

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Volume 2, Issue 2
April 2024
Pages 59-64
  • Receive Date: 03 September 2023
  • Revise Date: 16 September 2023
  • Accept Date: 18 September 2023
  • First Publish Date: 01 December 2023
  • Publish Date: 01 April 2024