Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Podcasts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Podcasts
  • Subscriptions

Arterial hypertension and the risk of severity and mortality of COVID-19

Carlos Enrique Leiva Sisnieguez, Walter Gastón Espeche, Martín Rogelio Salazar
European Respiratory Journal 2020 55: 2001148; DOI: 10.1183/13993003.01148-2020
Carlos Enrique Leiva Sisnieguez
Faculty of Medical Sciences, National University of La Plata, Buenos Aires, Argentina, and Argentinian Society of Arterial Hypertension (SAHA)
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Carlos Enrique Leiva Sisnieguez
  • For correspondence: cleiva@med.unlp.edu.ar
Walter Gastón Espeche
Faculty of Medical Sciences, National University of La Plata, Buenos Aires, Argentina, and Argentinian Society of Arterial Hypertension (SAHA)
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Martín Rogelio Salazar
Faculty of Medical Sciences, National University of La Plata, Buenos Aires, Argentina, and Argentinian Society of Arterial Hypertension (SAHA)
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

Arterial hypertension implies the risk of a hard COVID-19 outcome. This may be explained by potential confounding factors, such as age and cardiovascular disease. https://bit.ly/2Kr6Ax4

To the Editor:

We read with great interest the recently published study by Guan et al. [1]. To the best of our knowledge this is the first large-scale study that focuses on independent clinical risk factors associated with a composite outcome (death, use of a ventilator, or intensive care unit (ICU) requirement), using a Cox regression model.

The study found that arterial hypertension was the most prevalent comorbidity (16.9%), followed by diabetes (8.2%), cardiovascular disease (3.7%), cerebrovascular disease (1.9%), COPD (1.5%) and malignancy (1.1%). In the Cox regression model, after adjustment for age and smoking status, the independent risk factors associated with the composite outcome were malignancy (hazard ratio (HR) 3.5, 95% CI 1.60–7.64), COPD (HR 2.68, 95% CI 1.42–5.05), diabetes (HR 1.59, 95% CI 1.03–2.45) and hypertension (HR 1.58, 95% CI 1.07–2.32).

We have some concerns about the results of that analysis, especially those related to arterial hypertension. Initial Chinese epidemiological studies suggested that cardiovascular diseases (including arterial hypertension) and diabetes were associated with mortality or severity in patients affected by coronavirus disease 2019 (COVID-19). Wu and McGoogan [2] stated that in 44 672 patients with confirmed COVID-19, the overall case fatality rate was 2.3%, and that this was elevated in comorbid conditions: 10.5% for cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory disease and 6% for hypertension. Guan et al. [3] found that in 1099 patients with confirmed COVID-19, hypertension was a more prevalent condition in those who lead the primary composite end-point (admission to ICU, the use of mechanical ventilation or death; 35.8% versus 13.7%) and in those with severe disease (23.7% versus 13.4%). Ruan et al. [4] also described that in 150 patients with confirmed COVID-19, cardiovascular disease and hypertension were more frequent in cases who died compared with those who were discharged (19% versus 0%, p<0.001, and 43% versus 28%, p=0.07, respectively). Moreover, a systematic review and meta-analysis that included 46 248 infected patients found that the most prevalent comorbidity was hypertension (mean±sd 17±7%; 95% CI 14–22%) and that, compared with non-severe patients, the pooled odds ratios of hypertension and cardiovascular disease were OR 2.36 (95% CI 1.46–3.83) and OR 3.42 (95% CI 1.88–6.22), respectively [5]. All the evidence seems to be concordant. Remarkably, none of these studies performed a multivariable adjustment. The effect of arterial hypertension on the severity or mortality outcome could be explained by potential confounders.

To address this unsolved issue, we conducted a medical literature search in PubMed on 8 April 2020, using the following strategy:

(COVID-19[tiab] OR SARS-CoV-2[tiab]) AND (mortality[tiab] OR severity[tiab])

We included in the analysis the papers that were designed to find clinical predictors of mortality or severity for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The data form these articles is shown in table 1.

View this table:
  • View inline
  • View popup
TABLE 1

Studies that evaluated arterial hypertension and its association with severity or mortality in coronavirus disease 2019 using a multivariate logistic regression model

Both studies shown in table 1 found that, like hypertension, age and history of coronary artery disease were predictors of COVID-19 severity or mortality in the univariate analysis. But in both studies, hypertension was not included in the final multivariate logistic regression model. The first study included the following in the final multivariate model to predict critical COVID-19: elevated troponin I (TnI) (OR 26.91, 95% CI 4.09–177.23; p=0.001) and history of coronary artery disease (OR 16.61, 95% CI 2.29–120.58; p=0.005) [6]. The multivariable regression performed to predict COVID-19 death in the second study [7] included age (OR 1.10, 95% CI 1.03–1.17; p=0.0043), a higher sequential organ failure assessment score (OR 5.65, 95% CI 2.61–12.23; p<0.001) and D-dimer >1 µg·mL−1 on admission (OR 18.42, 95% CI 2.64–128.55; p=0.003).

As previously mentioned, prevalent cardiovascular disease is associated with higher mortality and severity of COVID-19 in the univariate analysis [2, 4, 5]. Thus, the association is also maintained in at least one of the multivariate models discussed, but not between hypertension and hard COVID-19 outcomes. In this sense, it is well known that: 1) the prevalence of essential hypertension and coronary artery disease increases with age; and 2) coronary disease and hypertension frequently coexist in the same patient. In this way, the association between hypertension and COVID-19 mortality or severity could be partly explained by the increased age and higher prevalence of cardiovascular disease. Both are well-known risk factors for mortality in critical patients. Furthermore, it has been suggested that patients with cardiac injury (elevated TnI) have a worse prognosis, suggesting specific target organ damage by SARS-CoV-2 [8]. This finding could explain why patients with prevalent cardiovascular disease are associated with worse COVID-19 outcomes.

For these reasons, we suggest that in order to conclude that hypertension could be an independent predictor of COVID-19 mortality or severity, the model should be adjusted for cardiovascular disease, to exclude its potential confounding effect.

Shareable PDF

Supplementary Material

This one-page PDF can be shared freely online.

Shareable PDF ERJ-01148-2020.Shareable

Footnotes

  • Conflict of interest: C.E. Leiva Sisnieguez has nothing to disclose.

  • Conflict of interest: W.G. Espeche has nothing to disclose.

  • Conflict of interest: M.R. Salazar has nothing to disclose.

  • Received April 12, 2020.
  • Accepted April 15, 2020.
  • Copyright ©ERS 2020
http://creativecommons.org/licenses/by-nc/4.0/

This version is distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.

References

  1. ↵
    1. Guan W-J,
    2. Liang W-H,
    3. Zhao Y, et al.
    Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis. Eur Respir J 2020, 55: 2000547.
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Wu Z,
    2. McGoogan JM
    . Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020; 13: 1239–1242.
    OpenUrl
  3. ↵
    1. Guan WJ,
    2. Ni ZY,
    3. Hu Y, et al.
    Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020; 382: 1708–1720.
    OpenUrlPubMed
  4. ↵
    1. Ruan Q,
    2. Yang K,
    3. Wang W, et al.
    Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med 2020; 46: 846–848.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Yang J,
    2. Zheng Y,
    3. Gou X, et al.
    Prevalence of comorbidities and its effects in coronavirus disease 2019 patients: a systematic review and meta-analysis. Int J Infect Dis 2020; 94: 91–95. 10.1016/j.ijid.2020.03.017.
    OpenUrlPubMed
  6. ↵
    1. Chen C,
    2. Chen C,
    3. Yan JT, et al.
    Analysis of myocardial injury in patients with COVID-19 and association between concomitant cardiovascular diseases and severity of COVID-19. Zhonghua Xin Xue Guan Bing Za Zhi 2020; 48: E008. doi:10.3760/cma.j.cn112148-20200225-00123
    OpenUrlCrossRefPubMed
  7. ↵
    1. Zhou F,
    2. Yu T,
    3. Du R, et al.
    Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395: 1054–1062. doi:10.1016/S0140-6736(20)30566-3
    OpenUrlCrossRefPubMed
  8. ↵
    1. Shi S,
    2. Qin M,
    3. Shen B, et al.
    Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol 2020; in press [https://doi.org/10.1001/jamacardio.2020.0950].
PreviousNext
Back to top
View this article with LENS
Vol 55 Issue 6 Table of Contents
European Respiratory Journal: 55 (6)
  • Table of Contents
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Arterial hypertension and the risk of severity and mortality of COVID-19
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Arterial hypertension and the risk of severity and mortality of COVID-19
Carlos Enrique Leiva Sisnieguez, Walter Gastón Espeche, Martín Rogelio Salazar
European Respiratory Journal Jun 2020, 55 (6) 2001148; DOI: 10.1183/13993003.01148-2020

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Arterial hypertension and the risk of severity and mortality of COVID-19
Carlos Enrique Leiva Sisnieguez, Walter Gastón Espeche, Martín Rogelio Salazar
European Respiratory Journal Jun 2020, 55 (6) 2001148; DOI: 10.1183/13993003.01148-2020
del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Shareable PDF
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

Agora

  • Erythrocytes are altered in PAH
  • Long COVID symptoms, from an imaginary condition to a recognised syndrome
  • Dupilumab in patients with asthma and blood eosinophils ≥500 cells·µL−1
Show more Agora

Correspondence

  • The association between immunosuppressant and the outcome of COVID-19
  • Wider access to quality-assured rifapentine-based regimens is needed to accelerate tuberculosis prevention and care globally
  • The alarmin(g) effect of interleukin-5 blockade on residual eosinophil function is of clinical consequence
Show more Correspondence

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERJ

  • Journal information
  • Editorial board
  • Reviewers
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • Podcasts
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN:  0903-1936
Online ISSN: 1399-3003

Copyright © 2022 by the European Respiratory Society