Ensuring Equitable Health Care Access for Patients With Heart Failure and COVID-19

The risk for severe symptoms and complications from coronavirus disease 2019 (COVID-19) is especially high in patients with underlying medical conditions including cardiovascular disease.^1,2 In addition, COVID-19 has been associated with myocardial injury and aggravated ventricular dysfunction, and thrombosis, further underscoring the vulnerability of patients with cardiovascular conditions in the context of the current pandemic.¹

In patients with heart failure, the pathophysiology of this condition may confer an even greater risk for severe COVID-19 presentation. “Upregulation of the neurohormonal axis, including [angiotensin-converting enzyme 2, ACE-2] activity, are central components of heart failure,” noted the authors of a study published in JACC: Heart Failure.¹ “As SARS-CoV-2 uses the ACE-2 receptor for host cell entry, patients with HF may have increased susceptibility to more severe forms of viral infection.”

To elucidate this issue, Ankeet S. Bhatt, MD, MBA, senior fellow in the division of cardiovascular medicine at Brigham and Women’s Hospital of Harvard Medical School in Boston, and colleagues examined baseline characteristics and outcomes of 132,312 patients with a history of heart failure who were hospitalized between April and September 2020 for acute heart failure (18.0%), COVID-19 (6.4%), or another reason (75.6%).

Hospitalizations for COVID-19 in patients with a history of heart failure occurred most frequently in older age categories, those identifying as Black or Hispanic, and in patients with comorbid diabetes or kidney disease (P <.001 for all).

Patients hospitalized for COVID-19 had higher rates of in-hospital mortality compared with those hospitalized for acute heart failure (24.2% vs 2.6%, respectively), with a stronger association noted for hospital admissions in April (adjusted odds ratio [OR], 14.48; 95% CI, 12.25-17.12) compared with the following months (OR, 10.11; 95% CI, 8.95-11.42; P <.001).

Factors associated with greater odds of in-hospital mortality in patients with COVID-19 and a history of heart failure included male sex (OR, 1.26; 95% CI, 1.13-1.40), morbid obesity (OR, 1.25; 95% CI, 1.07-1.46), older age (OR, 1.35; 95% CI, 1.29-1.42 per 10 years), diabetes (OR, 1.13; 95% CI, 1.01-1.26), and kidney disease (OR, 1.45; 95% CI, 1.30-1.62).

In addition, the use of in-hospital resources including intensive care unit, mechanical ventilation, and central venous catheter insertion was greater in patients with COVID-19 and a history of heart failure.  Patients with COVID-19 also required greater utilization of skilled nursing or rehabilitative care following hospitalization (41.0%) compared with patients with acute heart failure (13.0%) or those hospitalized for another reason (21.3%).

To discuss these observations and related implications, we interviewed Dr Bhatt and Nasrien E. Ibrahim, MD, a cardiologist in the Advanced Heart Failure and Transplant Section in the division of Cardiology at the Massachusetts General Hospital, and assistant professor of medicine at Harvard Medical School. Dr Ibrahim co-authored an editorial commentary on the Bhatt et al study, which appeared in the same journal issue.²

What do these results add to our understanding of the impact of COVID-19 on patients with heart failure?

Dr Bhatt: As is now well appreciated, the COVID-19 pandemic has swept across the globe with tremendous associated morbidity and mortality. We were most interested to see if there were certain populations—in this case, patients with a history of heart failure—who may be particularly vulnerable to morbidity and mortality if hospitalized with COVID-19. To date, there were few studies examining the effect of hospitalization with COVID-19 on this population, and most were limited to single or a few centers.

Our study utilized a large, all-payer administrative database (the Premier Healthcare Database) to examine patients with a history of heart failure who were hospitalized during the COVID-19 pandemic. Patients were categorized as being primarily hospitalized for acute heart failure, for COVID-19, or for other reasons. We found that patients with heart failure hospitalized for COVID-19 had a large risk for death, with nearly 1 in 4 dying during hospitalization! The odds of death were about 10-fold greater if a patient with heart failure was hospitalized with COVID-19 as compared with a patient hospitalized with acute heart failure during the same period.

Patients surviving hospitalization with COVID-19 had significantly increased resource utilization as compared with those hospitalized with acute heart failure and for other reasons, and nearly 40% of survivors required postacute care services. These results should be viewed with the limitations of using administrative data, but they suggest that among patients with heart failure hospitalized with COVID-19, death rates are exceedingly high.

Dr Ibrahim: What struck me after reading the study by Bhatt and colleagues was the 1 in 4 mortality rate for patients hospitalized with heart failure and COVID-19—a staggering statistic given the already high burden of morbidity and mortality in patients with heart failure. With COVID-19 ravaging Black, Hispanic, and other minorities, it is imperative to protect these communities from infection, especially in the setting of a diagnosis of heart failure. It is imperative to protect all patients with heart failure during the pandemic, but especially the most vulnerable patients.

What are the relevant recommendations for clinicians treating these patients?

Dr Bhatt: I think these data teach us clinicians a couple of important lessons. First, our patients with heart failure may be particularly susceptible to poor outcomes if they contract and eventually require hospitalization for COVID-19. Knowing this, it is then our responsibility to strongly advocate for infection control measures in this population. These efforts are paramount during the pandemic, of course, but may extend far beyond its conclusion to include promotion of other preventative measures such as annual influenza vaccination.

Dr Ibrahim: Many patients are afraid to come in for care right now, but I would urge them to not be afraid if they do have concerning symptoms. We have several tools including telehealth and remote monitoring to keep patients at home while staying connected with their healthcare team, but for this to work for all we must ensure this is equitable. Expanding broadband access, use of interpreters for telehealth visits when needed, and various accommodations for patients who may need them are important considerations.

What are some of the broader, long-term solutions that are needed to address these issues?

Dr Bhatt: We need to develop strategies to care for these high-risk patients in novel ways. As you know, during the early portion of the pandemic, there were multiple global reports of reductions in acute cardiovascular conditions including heart failure, acute coronary syndromes, and strokes. In fact, we examined these issues in our health system and showed dramatic reductions in these hospitalizations during March in Massachusetts.

These findings suggested delayed or deferred care during the early pandemic period. Our data suggest that we need to find new ways, possibly leveraging the explosion in virtual care, to continue to care for high-risk patients in ways that minimize their infectious risk.

Dr Ibrahim: With Food and Drug Administration approval of the COVID-19 vaccine, we also must ensure equitable access to the vaccine in the most disadvantaged communities, and it is the responsibility of the healthcare teams to earn trust with such communities who have justified apprehension about receiving the vaccine given historic and current racism in healthcare. Patients with heart failure are among a unique high-risk group and should receive the vaccine when available.

Disclosures: Bhatt et al noted various industry relationships and other disclosures in the full text of their paper; none were noted for Dr Ibrahim and her co-authors.

References

1. Bhatt AS, Jering KS, Vaduganathan M, et al. Clinical outcomes in patients with heart failure hospitalized with COVID-19. JACC Heart Fail. 2021;9(1):65-73. doi:10.1016/j.jchf.2020.11.003
2. DeFilippis EM, Psotka MA, Ibrahim NE. Promoting health equity in heart failure amid a pandemic. JACC Heart Fail. 2021;9(1):74-76. doi:10.1016/j.jchf.2020.11.002