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COVID-19 Evidence Alerts
from McMaster PLUSTM

Current best evidence for clinical care (more info)

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NB: This article has been retracted by the authors because of concerns about the database and procedures used in this study.
Etiology Mehra MR, Desai SS, Kuy S, et al. Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19. N Engl J Med. 2020 Jun 18;382(25):e102. doi: 10.1056/NEJMoa2007621. Epub 2020 May 1.
Abstract

BACKGROUND: Coronavirus disease 2019 (Covid-19) may disproportionately affect people with cardiovascular disease. Concern has been aroused regarding a potential harmful effect of angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) in this clinical context.

METHODS: Using an observational database from 169 hospitals in Asia, Europe, and North America, we evaluated the relationship of cardiovascular disease and drug therapy with in-hospital death among hospitalized patients with Covid-19 who were admitted between December 20, 2019, and March 15, 2020, and were recorded in the Surgical Outcomes Collaborative registry as having either died in the hospital or survived to discharge as of March 28, 2020.

RESULTS: Of the 8910 patients with Covid-19 for whom discharge status was available at the time of the analysis, a total of 515 died in the hospital (5.8%) and 8395 survived to discharge. The factors we found to be independently associated with an increased risk of in-hospital death were an age greater than 65 years (mortality of 10.0%, vs. 4.9% among those =65 years of age; odds ratio, 1.93; 95% confidence interval [CI], 1.60 to 2.41), coronary artery disease (10.2%, vs. 5.2% among those without disease; odds ratio, 2.70; 95% CI, 2.08 to 3.51), heart failure (15.3%, vs. 5.6% among those without heart failure; odds ratio, 2.48; 95% CI, 1.62 to 3.79), cardiac arrhythmia (11.5%, vs. 5.6% among those without arrhythmia; odds ratio, 1.95; 95% CI, 1.33 to 2.86), chronic obstructive pulmonary disease (14.2%, vs. 5.6% among those without disease; odds ratio, 2.96; 95% CI, 2.00 to 4.40), and current smoking (9.4%, vs. 5.6% among former smokers or nonsmokers; odds ratio, 1.79; 95% CI, 1.29 to 2.47). No increased risk of in-hospital death was found to be associated with the use of ACE inhibitors (2.1% vs. 6.1%; odds ratio, 0.33; 95% CI, 0.20 to 0.54) or the use of ARBs (6.8% vs. 5.7%; odds ratio, 1.23; 95% CI, 0.87 to 1.74).

CONCLUSIONS: Our study confirmed previous observations suggesting that underlying cardiovascular disease is associated with an increased risk of in-hospital death among patients hospitalized with Covid-19. Our results did not confirm previous concerns regarding a potential harmful association of ACE inhibitors or ARBs with in-hospital death in this clinical context. (Funded by the William Harvey Distinguished Chair in Advanced Cardiovascular Medicine at Brigham and Women's Hospital.).

Ratings
Discipline / Specialty Area Score
Cardiology
Hospital Doctor/Hospitalists
Internal Medicine
Intensivist/Critical Care
Infectious Disease
Comments from MORE raters

Cardiology rater

This was 1 of 3 articles on the same topic in the same NEJM issue with the same conclusion.

Cardiology rater

This is an exciting acknowledgement by the NEJM that RCTs may not be necessary when the capabilities of big data may provide significant information. In that sense, this is a landmark article. Uniquely, it does not delve into the methodology in detail. Surgisphere seems to have used just one technique called QuartzClinical. Other methods of machine learning probably could have also been used.

Cardiology rater

This article is very informative since it confirms previous studies that showed cardiovascular risk factors are associated with worse prognosis among patients with COVID-19. It also disputes the concerns regarding the use of ACEI/ARB among patients with COVID-19.

Hospital Doctor/Hospitalists rater

Again, this is useful information which clarifies some of the earlier misconceptions about covid19 risk factors.

Hospital Doctor/Hospitalists rater

Although this article does not bring out any new risk factors, it is useful to have risk quantitation. Since this is information from a registry, we need caution around possible selection bias.

Internal Medicine rater

This is a retrospective analysis of 8910 COVID-19 patients admitted to hospitals in Europe (65%), Asia, and North America who died or were discharged alive by March 28, 2020. No "new" news: death rates were higher in patients >65 and those with underlying CV disease, COPD, or current smokers. They found no adverse effect of ACEI or ARB use.

Internal Medicine rater

Large international observational study examining the association between cardiovascular disease and COVID19.

Internal Medicine rater

The information on the effect of ACE-I and ARBs is probably the most important concern. It will be reassuring to physicians to know that they do not need to alter or stop these medications.