1 │ Introduction

On December 2019, coronavirus disease 2019 (COVID-19) emerged in Wuhan, China. The rapid spread of this disease in the world led to a global health crisis [1-14]. The mortality rate of COVID-19 patients was more than six million people in the world until March 20, 2022 [15]. However, previous evidence has reported different clinical features and epidemiological risk factors. Hence, contradictory findings were reported in relation to variables such as gender [16-18], high blood pressure [16, 17], smoking [19, 20], and diabetes [16, 17, 21] with the mortality rate of COVID-19 patients. Meanwhile, the presence of some comorbidities such as diabetes, blood pressure and heart diseases with COVID-19 was considered due to the possibility of negative clinical outcomes and higher mortality in these patients [22, 23]. During COVID-19, one of the comorbidities that can cause more severe negative clinical consequences than other patients is heart failure (HF) disease [22]. HF is a type of heart disease in which the functional capacity of the heart decreases. However, the association of HF with disease progression and mortality in COVID-19 patients has not yet been fully determined [24-26]. Based on previous evidence, cardiac injuries such as thrombosis and ventricular dysfunction can lead to increased cardiovascular risk. On the other hand, SARS-CoV-2 enters the cell via the angiotensin-converting enzyme-2 (ACE-2) receptor, which may play a role in the regulation of renin-angiotensin. In addition, inconsistent activation of the renin-angiotensin system is common in HF patients [22]. Hence, a study in the USA [22] showed that COVID-19 patients with HF are at greater risk of complications and mortality. In addition, they showed that male gender, morbid obesity, and older age were associated with higher odds of mortality in COVID-19 patients with HF.

Due to the importance of this issue, this research aimed to assess and compare characteristics of COVID-19 in dead or survived patients with HF.

2 │ Methods

2.1 │ Study design and subjects

Using a retrospective study, 78 HF patients with COVID-19 referred to a heart center in northern Iran were included. Data gathering was performed via census sampling from August 2020 to 2021. The medical records of Hf patients with COVID-19 were assessed. Patients with HF over the age of 18 years with a duration of HF> 3 months were included in this study. Also, patients with incomplete medical records were excluded.

2.2 │ Ethical consideration

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

2.3 │ Data collection

Data gathering was performed using a researcher-made checklist including age, sex, active smoking, a history of hospitalization due to heart problems, and body mass index (BMI), ejection fraction (EF), duration of HF, blood pressure, symptoms, comorbidities, and pharmacological treatment, and in-hospital mortality.

2.4 │ Statistical analysis

SPSS version 16.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis. Quantitative and qualitative variables were presented via mean (standard deviation) and number (percentage), respectively. The normal distribution of the data was assessed via the Kolmogorov-Smirnov test. Due to the abnormality of data distribution, Chi-square and t-tests were used to assess the relationship between study variables. Multiple logistic regression analysis was also applied to assess the relationships of clinical and demographic characteristics with in-hospital mortality. The significance level was considered P <0.05.

3 │ Results

3.1 │ Participants' characteristics

A total of 78 HF patients with COVID-19 were included in this study. Participants' mean age and BMI were 66.02 (SD=12.05) years and 26.17 (SD=3.32) kg/m2, respectively. Of the participants, 50% were male, 26.92% were active smokers, and 12.82% had a history of hospitalization due to heart problems during the COVID-19 pandemic (Table 1). As presented in Table 2, the mean EF, duration of HF, and blood pressure of the patients were 25.83 (SD=12.31), 3.79 (SD=2.10) years, and 126.65 (SD=24.67) mmHg, respectively. Also, 74.36% and 30.77% of patients had hypertension/hypotension and angioplasty, respectively. Finally, 55.13% of HF patients with COVID-19 died.

3.2 │ Comparison of the characteristics of COVID-19 in dead and survived patients with HF

The mean age of dead patients was higher compared to survived patients (66.72 vs. 65.17 years; P=0.233). Most of the dead (65.12%) were females but most of the survivors (68.57%) were males (P=0.003). The mean EF of dead patients was higher compared to survived patients (26.98 vs. 24.43; P=0.145). Mean blood pressure of dead patients was lower compared to survived patients (121.26 vs. 133.27 mmHg; P=0.032). The most common symptom of COVID-19 in the dead (44.19%) and survived (62.86%) was cough (P=0.368). The most common comorbidities in the dead (69.77%) and survived (80.00%) were hypertension/hypotension (P=0.303).

3.3 │ Relationships of clinical and demographic characteristics of HF patients with COVID-19 with in-hospital mortality

As presented in Table 3, multiple logistic regression analyses were conducted to assess the clinical and demographic characteristics with in-hospital mortality. Age and blood pressure were predictors of in-hospital mortality in HF patients with COVID-19. The odds of in-hospital mortality were higher in males compared with females (OR=35.717; 95% CI: 2.676 to 476.690; P=0.007). Also, the odds of in-hospital mortality increased with decreasing blood pressure (OR=0.945; 95% CI: 0.900 to 0.993; P=0.024).

Table 1. Demographic characteristics of HF patients with COVID-19 by in-hospital mortality (n=78).

HF: Heart Failure; SD: Standard Deviation; BMI: Body Mass Index.

Values are given as number (percentage) for categorical variables and as mean (standard deviation) for continuous variables.

*P-value was obtained with t-test.

**P-value was obtained with Chi-square test.

Table 2. Clinical features of HF patients with COVID-19 by in-hospital mortality (n=78).

HF: Heart Failure; SD: Standard Deviation; EF: Ejection fraction.

Values are given as number (percentage) for categorical variables and as mean (standard deviation) for continuous variables.

*P-value was obtained with t-test.

**P-value was obtained with Chi-square test.

Table 3. Relationships of clinical and demographic characteristics of HF patients with COVID-19 with in-hospital mortality.

SE: Standard Error; OR: Odds Ratio; CI: Confidence Interval; HF: Heart Failure; SD: Standard Deviation; EF: Ejection fraction.

P-value was obtained with Multiple Logistic Regression test.

Note. B: regression coefficient.

4 │ Discussion

The findings of the present study showed that 55.13% of HF patients with COVID-19 died. Most of the dead (65.12%) were females but most of the survivors (68.57%) were males. Mean blood pressure of dead patients was lower compared to survived patients. Age and blood pressure were predictors of in-hospital mortality in HF patients with COVID-19. The odds of in-hospital mortality were higher in males compared with females. Also, the odds of in-hospital mortality increased with decreasing blood pressure.

The findings of the present study showed that 55.13% of HF patients with COVID-19 died. Most of the dead (65.12%) were females but most of the survivors (68.57%) were males. The odds of in-hospital mortality were higher in males compared with females. Also, the odds of in-hospital mortality increased with decreasing blood pressure. Consistent with the findings of the present study, a study in the USA [27] showed that the mortality rate was higher in COVID-19 patients with HF compared to COVID-19 patients without HF (40% vs. 24.9%). Also, they showed that a history of HF was associated with more than threefold and almost twofold risk for mechanical ventilation connection and higher mortality in patients with COVID-19, respectively [27]. However, the findings of the present study were inconsistent with a study in the USA [22]. They showed that the mortality rate in COVID-19 patients with HF was 2.6%. Also, they showed that the mortality rate was higher in men than in women (66% vs. 34%) [22]. These differences can be due to differences in the type of studies, the studied samples, the research community and the study methodology [16, 18, 19, 26, 27]. The systemic effects of COVID-19 on the cardiovascular system are known [28, 29]. Hence, SARS-COV-2 has been found in epithelial cells, pericytes, and macrophages, leading to widespread inflammation and increased microvascular and macrovascular thrombosis that can be associated with myocardial damage [29, 30]. This damage is characterized by troponin concentration, which will ultimately lead to an increased risk of mortality in HF patients [31]. Therefore, it is recommended to design more valid and population-based studies in this field. Although HF has been identified as a risk factor for worse clinical outcomes in COVID-19, however, previous evidence regarding the clinical profile and prognosis of COVID-19 patients with HF is limited [22, 27].

Mean blood pressure of dead patients was lower compared to survived patients. Age and blood pressure were predictors of in-hospital mortality in HF patients with COVID-19. In fact, age and blood pressure were predictors of mortality in COVID-19 patients with HF. Previous evidence has shown that unstable diastolic and systolic blood pressure control in patients with COVID-19 is associated with adverse clinical outcomes including intensive care unit admission and mortality, especially when combined with other comorbidities such as HF [27, 32-34]. However, previous evidence in this area is limited. Therefore, it is suggested that researchers pay special attention to COVID-19 patients with HF in future studies.

4.1 │ Limitations

The current research had some limitations. The use of electronic health records to collect data could lead to bias in the validity of the findings. Hence, many COVID-19 patients with HF were not included due to deficiencies in medical records. On the other hand, readmission of COVID-19 patients with HF to other hospitals was not investigated.

5 │ Conclusions

Overall, this research showed that 55.13% of HF patients with COVID-19 died. Most of the dead (65.12%) were females but most of the survivors (68.57%) were males. Mean blood pressure of dead patients was lower compared to survived patients. Age and blood pressure were predictors of in-hospital mortality in HF patients with COVID-19. The odds of in-hospital mortality were higher in males compared with females. Also, the odds of in-hospital mortality increased with decreasing blood pressure. Therefore, health managers and policymakers should pay special attention to COVID-19 patients with HF.

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: PGV, AS, ZA, SK, NJP; Drafting the work or revising it critically for important intellectual content: PGV, AS, ZA, SK, NJP; Final approval of the version to be published: PGV, AS, ZA, SK, 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: PGV, AS, ZA, SK, 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.

Using artificial intelligent chatbots

None.