Thursday, February 03, 2022

American Heart Assoc: Stroke Risk Among Older Adults Highest in First 3 Days After COVID-19 Diagnosis


While most people think of SARS-CoV-2 infection as primarily a respiratory illness, it is also has been strongly linked to increased strokes (see Stroke risk higher than expected among COVID-19 patients), heart arrhythmias and heart attacks (see JAMA: Two Studies Linking SARS-CoV-2 Infection To Cardiac Injury), and blood clots (see EID Journal: Pulmonary Embolism and Increased Levels of d-Dimer in COVID-19 Patients).

This association has been so pronounced, that last spring ten researchers from Brazil's well-respected FIOCRUZ (Fundação Oswaldo Cruz) published a paper where they proposed that COVID-19 should be classified as a `Viral Thrombotic Fever', as opposed to a SARS-like disease.

Today the American Heart Association has announced data - to be presented at the American Stroke Association International Stroke Conference later this month - indicating that the risk of stroke in older adults goes up 10-fold during the first few days after a COVID diagnosis. 

First, the press release from the AHA, after which I'll have a brief postscript. 

Stroke risk among older adults highest in first 3 days after COVID-19 diagnosis

American Stroke Association International Stroke Conference, Presentation TMP16

Embargoed until 4 a.m. CT/5 a.m. ET Thursday, Feb. 3, 2022

NEW ORLEANS, Feb. 3, 2022 — The risk of stroke among older adults diagnosed with COVID-19 was highest within the first three days of diagnosis, according to preliminary research to be presented at the American Stroke Association’s International Stroke Conference 2022, a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health to be held in person in New Orleans and virtually, Feb. 8-11, 2022.

“Stroke following the diagnosis of COVID-19 is a possible complication of COVID-19 that patients and clinicians should be aware of,” said Quanhe Yang, Ph.D., lead study author and senior scientist in the Division for Heart Disease and Stroke Prevention at the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta. “Vaccination and other preventive measures for COVID-19 are important to reduce the risk of infection and complications including stroke.”

Previous studies have examined the risk of stroke among adults with COVID-19; however, findings were inconsistent, and few focused specifically on older adults, who are at greater risk of stroke.

This study examined the risk of ischemic stroke, which is a stroke due to a blocked blood vessel, among older adults diagnosed with COVID-19 by examining the health records of 37,379 Medicare beneficiaries ages 65 and older. The patients were diagnosed with COVID-19 between April 1, 2020 through February 28, 2021 and were hospitalized for stroke from January 1, 2019 through February 28, 2021. Stroke hospitalizations could occur before or after the diagnosis of COVID-19, however, those that occurred 7 days before diagnosis or 28 days after diagnosis served as a control period.
The participants were, on average, 80 years old when diagnosed with COVID-19, and 57% were women. More than 75% were non-Hispanic white adults; more than 10% were non-Hispanic Black adults; less than 10% were Hispanic adults, and the remainder were adults from other racial or ethnic groups. The study compared stroke risk in the days immediately before and after COVID-19 diagnosis to the risk during the other days of the study, or the control period.

The analysis found:
  • The greatest risk of stroke occurred during the first three days after COVID-19 diagnosis - 10 times higher than during the control period.
  • Following the first three days after COVID-19 diagnosis, the stroke risk quickly declined yet remained higher compared to the control period. Specifically, between days 4-7 the stroke risk was 60% higher, and between days 8-14, the stroke risk was 44% higher compared to the control period. The lowest stroke risk occurred after 15-28 days when the risk of stroke was 9% higher than during the control period.
  • A younger subset of participants, those ages 65-74 years old, had a greater risk of stroke after COVID-19 diagnosis, compared to those ages 85 and older, and among those without a history of stroke.
  • There were no differences in stroke risk related to sex, or race and ethnicity.
“These findings can inform diagnosis, treatment and care of stroke among patients with COVID-19,” Yang said. “Further studies are needed to clarify the age-dependent risk of stroke associated with COVID-19.”

The 5th leading cause of death in the U.S., stroke is a medical emergency that occurs when a blood vessel to the brain becomes blocked or bursts, preventing oxygen and nutrients from reaching the brain. Stroke is a major cause of long-term disability. Rapid treatment is critical to prevent brain damage or death, so it is important to recognize the warning signs of stroke and the correct action. The abbreviation F.A.S.T. stands for face drooping, arm weakness, speech difficulty, time to call 9-1-1.

The American Heart Association and Centers for Disease Control and Prevention support COVID-19 vaccination including boosters as the best way to reduce the risk of COVID-19 infection and to prevent severe disease or death, especially among people with cardiovascular disease or other medical conditions.

The study’s limitations include the possibility of misclassification from the use of Medicare real-time preliminary claims, and the dates of COVID-19 diagnosis may be incorrect due to limited test availability, particularly early in the pandemic. Later, COVID-19 testing of hospitalized patients became standard, which may have contributed to the finding of a greater risk of stroke in the days immediately following a COVID-19 diagnosis. Finally, the study’s results may not apply to adults who are not beneficiaries in Medicare’s fee-for-service system.

Study co-authors are Xin Tong, M.P.H.; Mary G. George, M.D.; Anping Chang, M.S.; and Robert K. Merritt II, M.A. The list of authors’ disclosures is available in the abstract.

          (Continue . . . )

It is worth noting that these findings are based on patient data collected during the first year of the pandemic (April 1, 2020 through February 28, 2021), which was dominated by the original `wild-type' COVID; before Alpha, Delta, or Omicron began their world tours. 

How the emergence of more severe Delta variant last spring - or the more recent arrival of a `less severe' Omicron variant - will impact the numbers for the bulk of 2021, remains to be seen. 

Even without a clearly defined cardiovascular complication - such as a stroke or heart attack - the long-term impact of COVID infection on individual health remains of concern. Some experts have suggested we may see huge increases in COVID-19 related heart failure and neurological diseases in the years ahead.

Emily A. Troyer, Jordan N. Kohn, and Suzi Hong 

Poorly defined, `Long COVID' or `Post-COVID Syndrome' plagues a large percentage of `recovered' COVID patients. Last September the CDC's MMWR carried a report (see Post-Acute Sequelae of SARS-CoV-2 Infection Among Adults Aged ≥18 Years — Long Beach, California, April 1–December 10, 2020) that found:

In a random sample of recovered COVID-19 patients in Long Beach, California, one third of participants reported post-acute sequelae 2 months after their positive test result, with higher rates reported among persons aged ≥40 years, females, persons with preexisting conditions, and Black persons.

Some of these sequelae are mild, and will probably dissipate over time, while others may become permanent disabilities or lead to premature death.  A few recent blogs on these concerns include:

CMAJ: Even Mild COVID-19 May Have Long-term Brain Impacts

CDC Science Update: COVID-19 and Persistent Symptoms

COCA Call (Tomorrow, June 17th): Evaluating and Caring for Patients with Post-COVID Conditions 

While it is true that since Omicron arrived, fewer people are suffering severe illness - and this `milder'  variant may have reduced some of the risk of contracting `long COVID' - we probably won't know by how much for several more more months. 

All of which makes it premature to start trivializing COVID infections, as if they are `no worse' than the flu.