key: cord-0819031-mg4kk4id
authors: Xu, Qian; Samanapally, Harideep; Nathala, Pavani; Salunkhe, Vidyulata; Furmanek, Stephen; Cahill, Meredith N.; McGuffin, Trevor; Mohammad, Tahboub; Marsili, Bradford; Petrey, Jessica; Carrico, Ruth; Ramirez, Julio; Akca, Ozan; Clifford, Sean P.; Pahwa, Siddharth; Roser, Lynn; Kong, Maiying; Huang, Jiapeng
title: Outcomes and Risk Factors for Cardiovascular Events in Hospitalized COVID-19 Patients
date: 2021-03-27
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2021.03.035
sha: f5c95dae30337715b255f27d6f0ae8ec84a89e3b
doc_id: 819031
cord_uid: mg4kk4id

OBJECTIVE: To analyze outcomes and risk factors of cardiovascular events in a metropolitan COVID-19 database, and to perform a subgroup analysis in African American populations to determine whether outcomes and risk factors are influenced by race. DESIGN: Retrospective cohort analysis from March 9, 2020 to June 20, 2020. SETTING: Population-based study in Louisville, KY, USA PARTICIPANTS: 700 adult inpatients hospitalized with COVID-19. INTERVENTIONS: N/A MEASUREMENTS AND MAIN: Results: Our cohort consisted of 126 patients (18%) with cardiovascular events and 574 patients without cardiovascular events. Patients with cardiovascular events had a much higher mortality rate than those without cardiovascular events (45.2% vs. 8.7%, p<0.001). There was no difference between African Americans and Whites regarding mortality (43.9% vs 46.3%, p=1) and length of stay for survivors (11 days vs. 9.5 days, p=0.301). Multiple logistics regression analysis suggested that male, race, lower SaO2/FiO2, higher serum potassium, lower serum albumin, and number of cardiovascular co-morbidities were highly associated with the occurrence of cardiovascular events in COVID-19 patients. Lower serum albumin and neoplastic/immune compromised diseases were highly associated with cardiovascular events for African American COVID-19 patients. SaO2/FiO2 ratio and cardiovascular comorbidity count were significantly associated with cardiovascular events in white patients. CONCLUSIONS: : Cardiovascular events were prevalent and associated with worse outcomes in hospitalized patients with COVID-19. Outcomes of cardiovascular events in African American and white COVID-19 patients were similar after propensity score matching analysis. There were common and unique risk factors for cardiovascular events in African American COVID-19 patients when compared with white patients.

The first case of Severe Acute Respiratory Syndrome-related Coronavirus-2 (SARS-CoV-2) was reported in Wuhan, China in December 2019, and coronavirus disease 2019 (COVID-19) was declared a global pandemic by the World Health Organization on March 12, 2020 1 . This disease has resulted in substantial morbidity and mortality across the world 2 . Currently, there are numerous aspects relating to the pathogenesis and clinical course of COIVD-19 infection that remain unclear, as patients may be asymptomatic or have severe clinical manifestations of the disease. While SARS-CoV-2 primarily affects the lungs, it is also known to have significant effects on other organ systems, including the cardiovascular system, however, knowledge of the cardiovascular pathophysiology remains limited 3, 4 . Many recent studies reported a higher prevalence of preexisting cardiovascular diseases is associated with worse outcomes and increased risk of death among COVID-19 patients 5, 6, 7 . Currently, there is not enough data on detailed risk factor analysis in COVID-19 patients who suffered a new clinically diagnosed cardiovascular event 5,8-12 . In addition, minority ethnic groups are reported to experience a higher burden of severe COVID-19 than white individuals, but there is uncertainty about the underlying factors and where risk lies during the disease trajectory. African American individuals have higher circulating biomarkers of systemic inflammation and myocyte injury, and subclinical cardiovascular disease occurs at a young age. Thus, African American individuals may be particularly vulnerable to the untoward effects of COVID-19 14 . Previous studies adjusted for clinical and demographic factors but involved aggregate analyses over large geographical regions and did not control for the wide local variations in ethnic composition and socio-demographic factors within such regions. A recent study found a strong association between African American or mixed ethnicity and an increased risk of admission for COVID-19. Neither African American nor mixed ethnicity was independently associated with increased in-hospital mortality risk, but a higher in-hospital mortality risk was estimated for Asian patients 15 . We have established a large COVID-19 database in a US metropolitan city in a midwestern state which took into account the local population and individual level co-morbidities 16 . In this study, our primary objectives are to analyze outcomes and risk factors of cardiovascular (CV) events in a metropolitan COVID-19 database. Our secondary objectives are to perform a subgroup analysis in African American populations to determine whether outcomes and risk factors are influenced by race.

This retrospective cohort study was undertaken by the COVID-19 CardioVascular Research Group (COVID-CVRG), at the University of Louisville Center of Excellence for Research in Infectious Diseases (CERID), to examine clinical, demographic, and laboratory predictors of cardiovascular events and clinical outcomes among hospitalized COVID-19 patients in Louisville, KY hospitals. This study used data from electronic medical records (EMRs) of patients diagnosed with COVID-19 as identified by the CERID team 17 .

The University of Louisville Institutional Review Board (IRB) approved the CERID COVID-19

Cardiovascular Study, conducted at participating hospitals (IRB# 20-0257). In addition, the respective IRBs of the individual hospitals approved conduction of these studies at their institutions. All studies were exempt from ascertaining informed consent. Information from the patient's EMR was entered into a secure, health insurance portability and accountability act (HIPAA) compliant REDCAP database. Standard data security procedures were utilized and approved by the respective IRBs to safeguard patients' private healthcare information.

Patients in the CERID COVID-19 Cardiovascular Study were hospitalized at nine different hospitals within the Louisville metropolitan area including: one academic medical/trauma center; one large tertiary care/transplant hospital; three large (>400 beds) tertiary care community hospitals; three moderately sized (<400 beds) tertiary care community hospitals; and one community women's hospital with delivery services.

Data used in this study consisted of 700 adult inpatients hospitalized with COVID-19 from March 9, 2020 to June 20, 2020. Inclusion criteria for this study included all adult hospitalized inpatients (equal or older than 18 years old) with a diagnosis of COVID-19 as defined by evidence of a positive Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) on the first or the repeat test and/or ground glass opacities on a chest computerized tomography (CT). This study excluded any COVID-19 patient who was not admitted as a hospital inpatient.

Standard testing was performed in the clinical laboratory of each participating facility. Certified laboratory at each facility performed the RT-PCR testing. Confirmation of positive or suspected positive COVID-19 patients was determined by daily EMR screenings or reports delivered by the participating facilities. Before July, 2020, either positive RT-PCR tests or bilateral ground glass opacities on CT scan were considered positive for COVID-19. Out of the 700 hospitalized COVID-19 patients in our database, 17 had CT-only inclusion criteria. Clinical diagnoses of COVID-19 were made by individual physicians at each site independently. Due to the limited availability of COVID-19 RT-PCR testing in Louisville, KY during the early 2020, the 17 cases of CT diagnosis for COVID-19 were included with realized limitations. After July 2020, all cases were confirmed by positive RT-PCR results. Data collected consisted of COVID-19 test results, past medical and social history, current medications, signs and symptoms of illness, physical examination, laboratory, radiologic and microbiologic findings, management and therapies, inhospital complications, the clinical course and outcomes of each patient. A comprehensive data abstraction instrument was developed by epidemiologists, physicians, nurses, biostatisticians, and students who were members of the CERID work group. Specially trained data abstractors utilized the data abstraction instrument to extrapolate data from the EMR of each patient. Each data point and variable were investigated in depth by the data abstractors to ensure consistency.

Demographic Variables. Demographic data collected included patient's age, gender, height, weight and race. Race and ethnicity were combined into the following categories: Hispanic; Non-Hispanic white; Non-Hispanic black; Non-Hispanic others (Table 1A) .

Comorbidity Variables. Data on pre-existing comorbidities was collected from the EMR and included diabetes, renal disease, liver disease, pulmonary disease, neoplastic or immune compromising diseases, and preexisting cardiovascular disease. Data on comorbidities was utilized to evaluate the influence of these disease states on clinical outcomes of patients with COVID-19 (Table 1A) .

Clinical and Laboratory Variables. Clinical and laboratory data were collected within 48 hours of admission or during intensive care unit (ICU) admission and included body mass index (BMI), oxygen saturation/fraction of inspired oxygen (SpO2/FiO2) ratio, partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio, arterial blood gases (ABGs) when available, hemoglobin, hematocrit, platelets, white blood count, neutrophil count, complete metabolic profile (CMP), bicarbonate level, serum potassium, serum blood urea nitrogen, serum creatinine, serum albumin, serum bilirubin, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels, activated prothrombin time (aPT), activated partial thromboplastin time (aPTT), international normalized ratio (INR) measurement, troponin, ferritin, procalcitonin, domain-dimer (D-dimer) level, B-type natriuretic peptide (BNP) and N-terminal pro b-type natriuretic peptide (NTproBNP), interleukin-6 (IL-6), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) ( Table 1B) . Please note many patients didn't have arterial blood gas samples during admission and PaO2 was not available. However, almost all patients had SpO2 and was used to calculate S/F ratio.

In this study, the primary outcome variable of interest was cardiovascular events. We defined cardiovascular events as those events that occurred after admission to the hospital and included individual and composite cardiovascular events. The endpoints used in the analysis were diagnosed heart failure, cardiogenic shock, acute myocardial infarction, cardiomyopathy, myocarditis, cardiac arrhythmias (including tachycardia, bradycardia, supraventricular tachycardia, atrial tachycardia, bundle branch blocks), cerebrovascular events (CVA), pulmonary embolism (PE), pulmonary edema, deep-vein thrombosis (DVT), and cardiac arrest.

Clinical diagnoses of cardiovascular events were made by individual physicians at each site independently. Research staff only retrieved these diagnosis through chart reviews and documentation, but did not make any new diagnosis. We realized the limitations of potentially different diagnostic criteria used among providers, yet presented real world situations and future attempts will be made to use a more uniformed diagnostic criteria by the research team. The secondary endpoints include mortality, length of stay (LOS) for survivors, and days to mortality for non-survivors. LOS for survivors were defined the time between the date of admission and the date of discharge from hospital in days. Days to mortality for non-survivors were defined as the time between the date of admission and the time of death in days. We also examined intensive care unit (ICU) admission, invasive mechanical ventilation (defined as requiring endotracheal intubation), septic shock, disseminated intravascular coagulation (DIC) and adult respiratory distress syndrome (ARDS) to assess clinical severities among COVID-19 patients.

Continuous measurements were summarized by mean and standard deviation (SD), and categorical variables were summarized by counts and percentages. Comparison between the groups (e.g., patients without cardiovascular events versus patients with cardiovascular events) was performed using Mann-Whitney U test for continuous variables and Chi-square test.

Subgroup analyses for African American and white patients were performed to examine the risk factors of cardiovascular events for each sub-population using Mann-Whitney U test and Chisquare test as appropriate (see the columns under "African American Patients" and "White Patients"). In addition, we compared the variables between African American and white patients who did not have cardiovascular events (see the column "p-values without CV"), as well as those who had cardiovascular events (see the column "p-values with CV"). Furthermore, we compared mortality, LOS for survivors, and days to mortality for non-survivors between African American and white patients who had cardiovascular events using the propensity score matching techniques with control of the patients' demographic information and comorbidities, and the results were reported.

Pearson's correlation coefficients were used to evaluate the correlation between different variables. Multiple logistics regression analyses were conducted to examine which variables (i.e., laboratory data, demographic data, and co-morbidities) predict cardiovascular event for the entire cohort, African American only patients, and white only patients, respectively. Multiple logistics regression analyses included the variables which were predictive for cardiovascular events in bivariate analyses and were not highly correlated. Kaplan-Meier estimator was conducted to compare the survivals between patients with and without cardiovascular events for the entire cohort, African American only patients, and white only patients, respectively. A pvalue < 0.05 was considered statistically significant. The statistical analyses were carried out using the statistics software R version 4.0.2 (https://www.r-project.org/). patients had more than 2 CV events. The incidence of cardiovascular events in our COVID-19 database was 18%. Patients with cardiovascular events had a much higher mortality rate than those without cardiovascular events (45.2% vs. 8.7%). Kaplan-Meier curves and the log-rank test revealed the survival curves between the two groups were significantly different, and patients with cardiovascular events had a significantly decreased probability of surviving ( Figure   1A ). A median survival period for patients with cardiovascular events was 18 days, and a median survival period for patients without cardiovascular events was 100 days. For the entire cohort, the median length of stay was significantly increased for patients who suffered cardiovascular events when compared to patients without cardiovascular events (9 days vs. 5 days). However, there was no difference for days to mortality for non-survivors between the two groups. We then performed disease severity comparisons between patients with and without CV events. The percentage for patients with CV events needing treatment in the ICU was significantly higher than that for patients without CV events (68.3% vs. 30%, p<0.001), and the percentage for patients with CV events needing invasive mechanical ventilation was also significantly higher than that for patients without CV events (55.6% vs. 15.5%, p<0.001). 46 Figure 1B ). White COVID-19 patients' mortality rates were 46.3% and 9.0% for those with and without cardiovascular events respectively, and patients with cardiovascular events had only a 20% chance to survival beyond 24 days while patients without cardiovascular events had an 80% chance to survival beyond 100 days ( Figure 1C ). However, there was no significant mortality difference between African American and white COVID-19 patients with or without cardiovascular events based on the log-rank test as well as the weighted Kaplan-Meier statistics. Median length of stay was significantly longer in patients with cardiovascular events in both African American and white COVID-19 patients (11 vs. 5 days for African Americans and 9 vs. 5 days for white) (Table 3) . However, there was no difference between African American and white groups. Days to mortality was significantly shorter in African American COVID-19 patients with cardiovascular events when compared to white patients with cardiovascular events (6 vs. 12 days) (Table 3) , however the difference (6 vs. 10 days) was not significant anymore after adjusting confounding variables using propensity score matching method (Table 4) . 19 for the Entire Cohort: we found the following factors were highly associated with the odds of new onset cardiovascular events (patients with vs. without cardiovascular events) in our sample population: advanced age, males, white, pulmonary comorbidities, cardiovascular comorbidities, renal disease, diabetes, neoplastic/immune compromised diseases (Table 1A) . Multiple clinical and laboratory biomarkers also showed significant differences between COVID-19 patients with and without CV events (Table 1B) .

Multiple logistics regression analysis was used to examine the joint effect of these risk factors (Table 6 ), which suggested that gender (male), race (African American compared with Hispanic patients), lower SaO2/FiO2, higher serum potassium, lower serum albumin, and number of cardiovascular co-morbidities were highly associated with the occurrence of cardiovascular events in COVID-19 patients.

African American patients with COVID-19 was performed that included 41 patients with cardiovascular events and 179 patients without cardiovascular events. Demographics, laboratory variables, and co-morbidities were compared between African American patients with cardiovascular events and those without cardiovascular events. The following factors were highly associated with the odds of suffering cardiovascular events for African American COVID-19 patients (described as patients with vs. without cardiovascular events): advanced age males, cardiovascular comorbidities (in particular with 2 or more cardiovascular comorbidity conditions), diabetes, neoplastic/immune compromised diseases (Table 5A) . Multiple clinical and laboratory biomarkers also showed significant differences between African American COVID-19 patients with and without CV events (Table 5B) .

We carried out similar analyses for white COVID-19 patients, and compared African American to white patients with and without cardiovascular events (see the column "p-values without CV events" and "p-values with CV events"). There were several important differences between the white and African American races in terms of risk factors for cardiovascular events in COVID-19. Neoplastic/immune compromised patients, higher WBC, higher glucose level, lower albumin, lower bilirubin, higher AST were risk factors in African American COVID-19 patients, but not in white patients. Pulmonary comorbidity, renal disease, AST/ALT ratio and lower hemoglobin were risk factors for white COVID-19 patients, but not for African American patients (Table 5A ). Glucose and creatinine differed significantly between white and African American COVID-19 patients with cardiovascular events (Table 5B ). Cardiovascular comorbidity, renal disease, neutrophil/lymphocyte ratio, AST/ALT ratio, SaO2/FiO2 ratio, hemoglobin, and creatinine differed significantly between white and African American patients without cardiovascular events (Table 5B ). The similarities and differences in risks factors for African American and white COVID-19 patients were summarized in Figure 2 .

Multiple logistics analysis was used to examine the joint effect of the risk factors ( 

Our study is unique in several ways. First, this is a large database of 700 hospitalized COVID-19 patients from one metropolitan city in the United States. The geography, medical care, and socioeconomic status is relatively uniform/known so that we can focus on individual level risk factors for cardiovascular events in COVID-19. Second, over 31% of the cohort patients were African Americans allowing adequate sample size to compare African American to white races in subgroup outcomes and risk factors analysis. Third, we included DVT, PE and CVA in our analysis because they shared similar pathogenic factors as cardiac injuries.

The median length of hospitalization among survivors was 10 to 13 days in the United States. in COVID-19 patients without CV events and 9±10.74 patients with CV events. In severe or nonsurvival patients with COVID-19, the lymphocytes count decreases progressively, while the neutrophils count gradually increases. This may be due to excessive inflammation and immune suppression caused by SARS CoV-2 infection. Recent meta-analysis suggested that NLR can not only be a good biomarker predicting disease severity in patients with COVID-19, but also have value in predicting mortality. The NLR cutoff to predict disease severity was 4.5 and the cutoff to predict mortality was 6.5 18 .

An observational study by Guo et al showed a 6-fold higher in-hospital mortality in patients with elevated cardiac troponin T (a marker of cardiac injury) in comparison to patients with normal cardiac troponin T level 5 . A study of 169 patients from Wuhan, China found that acute myocardial injury significantly increased the death risk 8 . Another study from China showed cardiac injury was common (19.7%) in 416 hospitalized COVID-19 patients and associated with higher risk of in hospital mortality 9 . Hypertension, diabetes, coronary disease, heart failure, and cerebrovascular disease were found to be more prevalent in patients with cardiac injury 10 . The same authors described that older age, comorbidities (e.g. hypertension, coronary heart disease, chronic renal failure, and chronic obstructive pulmonary disease), and high levels of Creactive protein were predictors of myocardial injury using multivariable logistic regression 11 .

Salvatici demonstrated that increased troponin levels were associated with elevated mortality in patients with COVID-19 and found it to be a useful biomarker of disease progression and worse prognosis in patients with COVID-19 12 . In a study of 113 patients, a logistic regression model identified pre-existing hypertension and higher sequential organ failure assessment (SOFA) score as independent risk factors for patients with COVID-19 in developing cardiac injury 13 . In all cited studies, cardiac injury has been defined as serum levels of cardiac biomarkers above the 99th percentile reference limit, regardless of abnormalities on electro and/or echocardiography. However, critically ill patients could have elevated cardiac markers from mismatch between myocardial oxygen supply and demand without structural cardiovascular abnormalities. The prevalence of cardiac injury was reported to be 19% in total COVID-19 patients, 36% in severe COVID-19 patients, and 48% in non-survivors 19 . Furthermore, cardiac injury was found to be associated with a significant increase in the risk of poor outcomes, severe disease, admission to ICU, and mortality 18 . Another study reported 21.7% cardiac injury incidence and identified age, hypertension, chronic heart failure, diabetes, chronic obstructive pulmonary disease/asthma as risk factors for cardiac injury in COVID-19. Outcomes for patients with cardiovascular injuries were worse including increased incidence of mechanical ventilation, acute respiratory distress syndrome, acute kidney injury, anemia and death 20 29 . Furthermore, pericytes were suspected to be target host cells of SARS-CoV-2 and could lead to coronary microvascular dysfunction and cardiac injury. Recent pathology reports found that endothelial inflammation could contribute to the destabilization of coronary plaques, atherothrombosis, and vascular disease 30, 31 . Type II myocardial infarction due to the imbalance of myocardial oxygen supply and demand as well as stress cardiomyopathy can also occur in COVID-19 due to the hyperdynamic response to hypoxia and stress 10 . shown that pre-existing cardiovascular disease was associated with worse outcomes and increased risk of death in patients with COVID-19 33, 34, 35 . Those with neoplastic disease and immunocompromise represent a patient subgroup that is likely susceptible to viral infections secondary to an altered immune response.

Multiple studies have suggested disparities between African Americans and other populations in relation to COIVD-19 outcomes. African Americans are overrepresented among reported COVID-19 deaths in the United States 36 . In addition, African Americans have a disproportionally higher incidence of underlying health conditions like diabetes mellitus, hypertension, obesity, asthma, and cardiovascular disease 37 . Given the known risk factors for COVID-19 complications, the confluence of hypertension, diabetes, obesity, and the higher prevalence of cardiovascular disease among African Americans may help explain their worsened COVID-19 outcomes. African American residents were at the highest risk of death from COVID-19, and Hispanic/Latino residents died from COVID-19 at an appreciably younger age than all other ethnic groups. Higher COVID-19 mortality was seen in neighborhoods with heightened barriers to social distancing and low health insurance coverage 38 

York City characterized neighborhood traits associated with COVID-19 infection and found that housing value, housing density, and income were protective against infection, while crowded households were associated with increased risks 39 .

We found several important similarities and differences between the white and African American races in terms of outcomes and risk factors of cardiovascular events in COVID-19. For clinical outcomes, there was no difference in mortality, length of stay for survivors, and days to mortality for non-survivors between African American and white COVID-19 patients after propensity score matching. This is different from several previous studies and could be from the relatively standard of cares once patients are hospitalized regardless of races. Genetic and social economic differences between races might be masked by the serious damages from the cardiovascular events.

In terms of risk factors, glucose and creatinine differed significantly between African American and white COVID-19 patients with cardiovascular events. Neoplastic/immune compromised patients, higher WBC, higher glucose level, lower albumin, lower bilirubin, and higher AST were cardiovascular event risk factors for African American COVID-19 patients, but not in white patients. Pulmonary comorbidities, renal disease, AST/ALT ratio and hemoglobin were risk factors for white COVID-19 patients, but not in African American patients. Cardiovascular comorbidity, renal disease, neutrophil/lymphocyte ratio, AST/ALT ratio, SaO2/FiO2 ratio, hemoglobin, and creatinine differed significantly between white and African American patients without cardiovascular events. Multiple logistics analysis suggested that lower serum albumin and neoplastic/immune compromised diseases count were highly associated with cardiovascular events in African American COVID-19 patients. SaO2/FiO2 ratio and cardiovascular comorbidity were significantly associated with cardiovascular events for white patients. These similar and differential risk factors between African American and white COVID-19 patients might reflect common pathophysiology of COVID-19 and potentially unique disease states or management strategy differences between races. In particular, glucose and creatinine were significantly higher in African American patients with cardiovascular events, which could reflect underlying or poorly controlled diabetes or renal diseases, delayed medical care due to socioeconomic factors, and or different medication regimens. Particularly, the increased creatinine in African American COVID-19 patients could be due to poor control of hypertension, differences in anti-hypertension treatment algorithms (ACE inhibitors (ACEI), angiotensin receptor blockers, (ARB) calcium channel blockers, diuretics) and the combination of ACEI/ARB, diuretic(s) + non-steroidal anti-inflammatory drugs, which could severely impair renal functions and be linked to acute renal failure episodes in older COVID-19 adults.

A recent study using cardiovascular magnetic resonance imaging (MRI) revealed cardiac involvement in 78% patients and ongoing myocardial inflammation in 60% patients independent of preexisting conditions, severity and overall course of the acute illness, and time from the original diagnosis 4 . Another study of 26 recovered patients that had all been hospitalized for COVID-19 showed myocardial edema on MRI in 57% of patients 40 . Due to the high mortality with cardiovascular events in COVID-19, patients with preexisting cardiovascular comorbidities should be monitored closely with a low threshold for performing diagnostic studies. Patients recovering from COVID-19 need to be followed for long term cardiovascular complications. Our study revealed common and unique risk factors for African American COVID-19 patients, which could be used to guide prediction and management of individual patients. However, whether modifying and treating these risks factors could reduce cardiovascular events or mortality is unknown and should be studied further.

This study has several limitations. First, due to the retrospective study design nature, there are missing laboratory values in some patients, which could not be obtained for analysis. Second, reports of comorbidities were obtained from the EMRs and relied on accurate medical record documentation. Third, treatment details, which may have contributed to the outcomes reported, were not analyzed in this manuscript. However, local COVID-19 management patterns were relatively consistent in Louisville, KY. Fourth, we don't have the long-term follow-up data on these events and the long-term sequela of COVID-19 on cardiac health, thus long-term mortality could not be assessed. Fifth, only hospitalized COVID-19 patients were studied and nonhospitalized patients were not included.

One of the strengths of the present study is that it was a population-based large COVID-19 cohort study with 700 patients. Another strength was a large African American population within the study cohort that allowed for further subgroup analysis.

Cardiovascular events were prevalent and associated with worse outcomes in hospitalized patients with COVID-19. Outcomes of cardiovascular events in African American and white COVID-19 patients were similar. There were common and unique risk factors for cardiovascular events in African American COVID-19 patients when compared with white patients.

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. <0.001 Abbreviations: ABG, arterial blood gas; ALT, alanine transaminase; AST, aspartate transaminase; BNP, Brain-type natriuretic peptide; BUN, blood urea nitrogen; CRP, C-reactive protein; CV, cardiovascular; D-dimer, domain-dimer; Fi02, fraction of inspired oxygen; INR, international normalized ratio; NT-proBNP, N-terminal pro hormone brain-type natriuretic peptide; Sa02, saturation of oxygen in arterial blood; WBC, white blood cell count. Table 3 Death, Length of Stay, and Days to Mortality Between African Americans and Whites COVID-19 Patients With and Without Cardiovascular Events (N=644). Especially, in the last columns, we compared between African American COVID-19 patients without CV events and Whites COVID-19 patients without CV events and found no significant outcome difference. We then compared between African American COVID-19 patients with CV events and Whites COVID-19 patients with CV events and found no significant outcome difference except days to mortality for nonsurvivors. Abbreviations: FiO2, fraction of inspired oxygen; SaO2, saturation of oxygen in arterial blood

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Note: Within each race, the patients with cardiovascular events were compared with those without CV events. African American and White patients were also compared among those without events (see the column "p value without CV"), and among those with CV events (see the column "p value with CV"), respectively. Abbreviation: CV, cardiovascular. Abbreviations: ABG, arterial blood gas; ALT, alanine transaminase; AST, aspartate transaminase; BNP, Brain-type natriuretic peptide; BUN, blood urea nitrogen; CRP, C-reactive protein; CV, cardiovascular; D-dimer, domain-dimer; Fi02, fraction of inspired oxygen; INR, international normalized ratio; NT-proBNP, N-terminal pro hormone brain-type natriuretic peptide; Sa02, saturation of oxygen in arterial blood; WBC, white blood cell count.

Glucose @ (mg/dl)