Abstract
Using Mt. Sinai (New York City) EMR health system data, we retrospectively analyzed a cohort of 8438 COVID-19 patients seen between March 1 and April 22, 2020. Risk of intubation and of death rose as a function of increasing age and as a function of greater cardiovascular comorbidity. Combining age and specific comorbidity markers showed patterns suggesting that cardiovascular comorbidities increased relative risks for adverse outcomes most substantially in the younger subjects with progressively diminishing relative effects at older ages.
Research letters
Coronavirus disease 2019 (COVID-19) caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2, has spread all around the world since December 2019.1 As of April 22, its epicenter is New York.2 Previous studies demonstrated that cardiac injury or comorbidities increased the risk of in-hospital mortality in patients with COVID-19.3 , 4 The aim of this study is to investigate whether cardiovascular disease or cardiac injury increased the risk of mechanical ventilation or mortality using the electronic medical records (EMR) of Mount Sinai Health System in New York City.5
We analyzed the EMR of COVID19 positive patients from Mount Sinai Health System which used EPIC electronic health record system from March 1st to April 22nd, 2020. Mount Sinai health system combines 7 hospitals with more than 3800 beds and more that 410 ambulatory practices across metropolitan New York. Among 8438 patients, 54.7% of patients (N = 4616) were admitted to these hospitals. Analysis was performed on April 30th, 2020, which included patients who remained in the hospitals.
Age, coronary artery disease (CAD), peripheral artery disease (PAD), heart failure, and cardiac injury as well as necessity of mechanical ventilation and mortality among patients with positive polymerase chain reaction test of COVID-19 were extracted. Cardiac injury was defined as troponin I elevation which was defined as 99th percentile upper reference limit. Patients with cardiac injury were compared with those without troponin I elevation among a total of 5320 patients' measurements (63.0%).6 Mount Sinai Health System waived institutional review board approval since this research used only deidentified, aggregate-level data.5 No extramural funding was used to support this work and the authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the paper and its final contents.
Among 8438 patients with COVID-19, 8.6% of patients had CAD, 8.1% of patients had PAD, 6.9% of patients had heart failure. Table I shows baseline characteristics of this cohort. 43.5% of patients had troponin I elevation among patients who had troponin I measurements. Table II shows the crude rates of mechanical ventilation and mortality. Patients with a CAD, PAD, or heart failure had significantly higher rates of mechanical ventilation and mortality. Notably, cardiac injury demonstrated significantly higher relative risk (RR) of mechanical ventilation (3.45 [95% confidence interval 2.87-4.14]) and of mortality (5.07 [4.45-5.76]) (Table II). We detected higher rates of mechanical ventilation and mortality in patients with CAD, PAD and heart failure in all age groups except >80 years, with relatively higher RR in younger population (Table II).
Table I.
Baseline characteristics of total cohort
| Number of patients: % (patient number) 8438 patients |
|
|---|---|
| Age median [IQR] | 59 [43, 71] |
| Male | 53.9% (4544) |
| White | 25.8% (2179) |
| African American | 22.7% (1913) |
| Hypertension | 28.2% (2380) |
| Hyperlipidemia | 17.1% (1446) |
| Diabetes Mellitus | 19.0% (1606) |
| Coronary artery disease | 8.6% (723) |
| Peripheral artery disease | 8.1% (680) |
| Heart failure | 6.9% (584) |
| Chronic kidney disease | 12.4% (1049) |
| Dialysis | 1.7% (140) |
| Chronic obstructive lung disease | 2.4% (200) |
| Asthma | 8.7% (735) |
| Cancer | 7.0% (589) |
| Human Immunodeficiency Virus | 1.4% (121) |
Table II.
Incidence of intubation and mortality for patients with cardio-vascular diseases for COVID-19 patients
| Intubation, % (event/total) |
Death, % (event/total) |
|||||
|---|---|---|---|---|---|---|
| Age Group | With CAD | Without CAD | RR (95% CI) | With CAD | Without CAD | RR (95% CI) |
| All ages | 11.6% (84/723) | 6.2% (475/7715) | 1.88 (1.52-2.35) | 30.2% (218/723) | 13.4% (1035/7715) | 2.24 (1.98-2.55) |
| ≤ 50 | 16.0% (4/25) | 3.2% (90/2851) | 5.07 (2.02-12.7) | 8.0% (2/25) | 2.0% (56/2851) | 4.07 (1.05-15.8) |
| 51-65 | 11.7% (21/179) | 7.1% (158/2237) | 1.66 (1.08-2.55) | 19.0% (34/179) | 10.4% (233/2237) | 1.82 (1.32-2.53) |
| 66-80 | 13.8% (45/327) | 9.4% (165/1751) | 1.46 (1.07-1.99) | 31.5% (103/327) | 21.8% (382/1751) | 1.44 (1.20-1.73) |
| ≥ 80 | 7.3% (14/192) | 7.1% (62/876) | 1.03 (0.59-1.80) | 41.1% (79/192) | 41.6% (364/876) | 0.99 (0.82-1.19) |
| With PAD | Without PAD | RR (95% CI) | With PAD | Without PAD | RR (95% CI) | |
| All ages | 11.3% (77/680) | 6.2% (482/7758) | 1.82 (1.45-2.29) | 23.2% (158/680) | 14.1% (1095/7758) | 1.64 (1.42-1.91) |
| ≤ 50 | 7.5% (5/67) | 3.2% (89/2809) | 2.36 (0.99-5.61) | 7.5% (5/67) | 1.9% (53/2809) | 3.96 (1.63-9.58) |
| 51-65 | 13.0% (25/192) | 6.9% (154/2224) | 1.88 (1.27-2.79) | 15.6% (30/192) | 10.7% (237/2224) | 1.47 (1.03-2.08) |
| 66-80 | 13.3% (37/278) | 9.6% (173/1800) | 1.38 (0.99-1.93) | 25.9% (72/278) | 22.9% (413/1800) | 1.13 (0.91-1.40) |
| ≥ 80 | 7.0% (10/143) | 7.1% (66/925) | 0.98 (0.52-1.86) | 35.7% (51/143) | 42.4% (392/925) | 0.84 (0.67-1.06) |
| With HF | Without HF | RR (95% CI) | With HF | Without HF | RR (95% CI) | |
| All ages | 14.6% (85/584) | 6.0% (474/7854) | 2.41 (1.94-2.99) | 34.2% (200/584) | 13.4% (1053/7854) | 2.55 (2.25-2.90) |
| ≤ 50 | 18.8% (9/48) | 3.0% (85/2828) | 6.24 (3.34-11.7) | 10.4% (5/48) | 1.8% (53/2828) | 5.56 (2.33-13.3) |
| 51-65 | 14.1% (20/142) | 7.0% (159/2274) | 2.01 (1.31-3.11) | 24.6% (35/142) | 10.2% (232/2274) | 2.42 (1.77-3.30) |
| 66-80 | 19.4% (45/232) | 8.9% (165/1846) | 2.17 (1.61-2.93) | 39.2% (91/232) | 21.3% (394/1846) | 1.84 (1.53-2.21) |
| ≥ 80 | 6.8% (11/162) | 7.2% (65/906) | 0.95 (0.51-1.75) | 42.6% (69/162) | 41.3% (374/906) | 1.03 (0.85-1.25) |
| With Cardiac Injury | Without Cardiac Injury | RR (95% CI) | With Cardiac Injury | Without Cardiac Injury | RR (95% CI) | |
| All | 16.7% (387/2312) | 4.9% (146/3008) | 3.45 (2.87-4.14) | 41.3% (954/2312) | 8.1% (245/3008) | 5.07 (4.45-5.76) |
| ≤ 50 | 26.8% (40/149) | 5.4% (44/819) | 5.00 (3.38-7.39) | 23.4% (35/149) | 2.7% (22/819) | 8.74 (5.28-14.5) |
| 51-65 | 22.5% (126/561) | 4.4% (46/1050) | 5.13 (3.72-7.07) | 33.0% (185/561) | 6.7% (70/1050) | 4.95 (3.83-6.38) |
| 66-80 | 17.4% (157/902) | 5.5% (47/860) | 3.18 (2.33-4.35) | 42.5% (383/902) | 10.0% (86/860) | 4.25 (3.43-5.26) |
| ≥ 80 | 9.1% (64/700) | 3.2% (9/279) | 2.83 (1.43-5.62) | 50.1% (351/700) | 24.0% (67/279) | 2.09 (1.67-2.61) |
CAD, coronary artery disease; CI, Confidential interval; HF, heart failure; PAD, peripheral artery disease; RR, relative risk.
Our study revealed increased risk of mechanical ventilation and mortality in patients with cardiovascular comorbidities or cardiac injury. Since we present crude event rates, further study is needed to confirm our findings.
Footnotes
Disclosure: none
References
- 1.Zhu N., Zhang D., Wang W. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med. 2020;382:727–733. doi: 10.1056/NEJMoa2001017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Coronavirus COVID-19 Global Cases by the Center for Systems Science and Enginerring at Johns Hopkins University. https://coronavirus.jhu.edu/map.html
- 3.Shi S., Qin M., Shen B. China; JAMA Cardiol: 2020. Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Yang J., Zheng Y., Gou X. Prevalence of comorbidities and its effects in patients infected with SARS-CoV-2: a systematic review and meta-analysis. Int J Infect Dis. 2020;94:91–95. doi: 10.1016/j.ijid.2020.03.017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Miyashita H, Mikami T, Chopra N, Yamada T, Chernyavsky S, Rizk D, Cruz C. Do patients with Cancer Have a Poorer Prognosis of COVID-19? An Experience in New York City. Annals of Oncology In Press 10.1016/j.annonc.2020.04.006 [DOI] [PMC free article] [PubMed]
- 6.Hartikainen T.S., Sorensen N.A., Haller P.M. Clinical application of the 4th Universal Definition of Myocardial Infarction. Eur Heart J. 2020 doi: 10.1093/eurheartj/ehaa035. [DOI] [PubMed] [Google Scholar]