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Is heart failure risk increased following COVID-19 infection?

Incident heart failure risk is significantly increased after an acute COVID-19 infection and directly influenced by age and prior hypertension

Heart failure risk has been found to be significantly elevated within 9 months of an acute COVID-19 infection and directly related to both age and a previous history of hypertension, according to a systematic review and meta-analysis by Italian researchers.

Although COVID-19 is primarily a respiratory infection, myocardial injury is a significant pathogenic feature and associated with worse in-hospital outcomes. In fact, it has become recognised that in addition to acute COVID-19-related cardiac complications such as myocarditis or pericarditis, follow-up studies also suggest an increased incidence of arrhythmia, acute coronary syndrome, right ventricular dysfunction, myocardial fibrosis, hypertension and diabetes mellitus. One condition which has not fully explored, although identified as a potential adverse sequelae following infection with COVID-19, is incident heart failure (HF) risk. In the present study, the Italian team undertook a systematic review and meta-analysis of all studies, either retrospective or prospective, published at any time up to September 1, 2022 and which reported on the mid/long-term risk (defined as > 4 months) of incident HF in COVID-19 recovered patients. The researchers set the pooled incidence of HF in recovered patients as the primary outcome and the secondary outcome was the risk of incident HF compared to contemporary control group patients, i.e., those without COVID-19 infection.

Heart failure risk following COVID-19 infection

The analysis identified only 5 relevant and retrospective studies. These studies involved 21,463,173 patients with mean age 54.5 years (58.7% males), of whom, 1,628,424 had confirmed COVID-19 infection while the remaining 19,834,749 represented the controls.

A random effect model revealed a pooled incidence of post COVID-19 HF in 1.1% of cases (95% CI 0.7 – 1.6). After a mean follow-up of 9.2 months, recovered COVID-19 patients had a significantly elevated incident heart failure risk (Hazard ratio, HR = 1.90, 95% CI 1.54 –3.24, p < 0.0001) in comparison to non-infected controls.

In addition, a meta-regression analysis showed a significant and direct relationship for the risk of incident HF using age (p  =  0.001) and a previous history of hypertension (p  =  0.02) as moderators. Interestingly, there was an indirect association observed when the follow-up length was adopted as moderating variable (p = 0.01), suggesting that this risk was higher in the early post-acute phase of the infection.

The authors concluded that COVID-19 survivors had an additional 90% risk of developing HF following infection, especially in the early post-acute phase of the infection.

Zuin M et al. Risk of incident heart failure after COVID-19 recovery: a systematic review and meta-analysis. Heart Fail Rev 2022