Acute cardiac events are common during COVID-19-associated hospitalizations, particularly among patients with underlying cardiac disease, and are associated with severe COVID-19 outcomes, according to a new study. Rebecca C. Woodruff, PhD, MPH, of the COVID-19 Response Team at the U.S. Centers for Disease Control and Prevention (CDC), and colleagues reported these findings in a manuscript published Monday online and in the Feb. 14 issue of the Journal of the American College of Cardiology. This study received grant support from the CDC. Woodruff and colleagues' aims were to estimate the prevalence, risk factors, and outcomes associated with acute cardiac events during COVID-19-associated hospitalizations among adults. Although acute COVID-19 requiring hospitalization typically manifests as acute respiratory illness, extrapulmonary complications can include myocardial injury, arrhythmias, heart failure, cardiogenic shock, myocarditis, and ischemia. Increased risk for cardiac complications can persist up to 1 year after patients have recovered from acute COVID-19. A comprehensive assessment of acute cardiac events among a large and geographically diverse sample of patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and their associated risk factors and severe disease outcomes can inform clinical and public health practice, the authors wrote. From January to November 2021, medical chart abstraction was conducted on a probability sample of adults hospitalized with laboratory-confirmed SARS-CoV-2 infection identified from 99 U.S. counties in 14 U.S. states in the COVID-19-Associated Hospitalization Surveillance Network. Among 8,460 adults, 11.4% (95% confidence interval [CI]: 10.1%-12.9%) experienced an acute cardiac event during a COVID-19-associated hospitalization. Prevalence was higher among adults who had underlying cardiac disease (23.4%; 95% CI: 20.7%-26.3%) compared with those who did not (6.2%; 95% CI: 5.1%-7.6%). Acute ischemic heart disease (5.5%; 95% CI: 4.5%-6.5%) and acute heart failure (5.4%; 95% CI: 4.4%-6.6%) were the most prevalent events; 0.3% (95% CI: 0.1%-0.5%) experienced acute myocarditis or pericarditis. Risk factors varied by underlying cardiac disease status. Patients with at least one acute cardiac event had greater risk of intensive care unit admission (adjusted risk ratio [aRR]: 1.9; 95% CI: 1.8-2.1) and in-hospital death (aRR: 1.7; 95% CI: 1.3-2.1) compared with those who did not. The authors suggested that these findings have implications for clinical and public health practice. Clinicians should be aware that acute cardiac events are common extrapulmonary complications of COVID-19 illness, including among patients without documented underlying cardiac disease. Clinicians should consider conducting a thorough history and physical evaluation among adults hospitalized with laboratory-confirmed SARS-CoV-2 infection and monitoring them for evidence of cardiac complications, including cardiac arrhythmias and cardiogenic shock, throughout their hospitalization, Woodruff and colleagues wrote. Additionally, all patients and especially those with underlying cardiac disease, should the receive recommended outpatient and inpatient COVID-19 treatments expected to have the highest net clinical benefit based on a thorough assessment with their clinicians of the potential benefits, risks, and side effects of any intervention. These strategies, in combination with other evidence-based approaches to prevent or mitigate COVID-19, could reduce morbidity and mortality from associated cardiac complications, the authors wrote For example, clinicians can emphasize that patients with underlying cardiac disease seek testing and care early if they become ill with symptoms consistent with COVID-19, as these patients might be eligible for treatments to prevent mild or moderate illness from progressing to severe illness if detected early. Adults can engage in evidence-based strategies to prevent SARS-CoV-2 infection or reduce their risk of severe COVID-19, including receiving COVID-19 vaccination and booster doses as recommended, adhering to current recommendations for community mitigation measures, and treating underlying cardiac disease or other medical conditions associated with increased risk of severe COVID-19, Woodruff and colleagues said. An editorial comment published on this study by George A. Mensah, MD, from the National Heart, Lung, and Blood Institute, and colleagues concluded that the study findings are consistent with the published literature on the importance of underlying cardiovascular disease and risk factors. The editorialists wrote that mechanistically, emerging evidence suggests that myocardial injury coupled with cardiac and vascular thromboses predisposes to adverse outcomes in acute cardiac complications of COVID-19 and that a 2021 consensus paper from several European cardiovascular societies shows this concept of microvascular injury, endothelial dysfunction, and thrombosis from a hypercoagulable state resulting from viral infection, possibly secondary to intense systemic inflammatory cascade and immune responses that may contribute to acute cardiovascular events. Mensah and colleagues added that unfortunately, emerging evidence suggests a potentially longer-lasting cardiovascular legacy of previous SARS-CoV-2 infection. Sources: Woodruff RC, Garg S, George MG, et al. Acute Cardiac Events During COVID-19-Associated Hospitalizations. J Am Coll Cardiol 2023;81:557–569. Mensah GA, Vaduganathan M, Roth GA. Acute Cardiovascular Complications of COVID-19: The High Risk of Underlying Heart Disease. J Am Coll Cardiol 2023;81:570–573. Image Credit: rost9 – stock.adobe.com