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Hypertension and CVD Are Among Risk Factors for Severe COVID-19

In This Article

  • Epidemiologic risk factors for severe COVID-19 are still being defined, but early reports indicate that advanced age, history of hypertension and other cardiovascular disease, and diabetes are among them
  • According to a review of six reports published between January 29 and March 13, 2020, hypertension was present in substantial percentages—15% to 31%—of patients in China who were hospitalized for COVID-19
  • In one of those studies, a multivariable analysis of 171 patients from two hospitals, showed that risk factors for death from COVID-19 were older age, higher Sequential Organ Failure Assessment score and admission D-dimer > 1 mcg/mL

Health conditions and signs commonly seen by cardiologists—including diabetes, history of hypertension, history of cardiovascular disease and elevated troponin—are risk factors for severe COVID-19 in patients who become infected with SARS-CoV-2.

At a grand rounds session on March 18, 2020, titled COVID-19 and the Cardiovascular System, Gregory D. Lewis, MD, Heart Failure section head and medical director of Heart Transplantation, and Tomas Neilan, MD, MPH, director of the Cardio-Oncology Program, discussed which patients with COVID-19 are at particularly high risk of death.

Risk Factors for Severe COVID-19

On March 17, 2020, Mass General distributed guidance for frontline clinicians who are treating COVID-19. It sets out three categories of risk factors for severe disease. They are:

1. Epidemiologic

  • Age > 55
  • Pre-existing pulmonary disease
  • Chronic kidney disease
  • Diabetes with A1c > 7.6%
  • History of hypertension
  • Elevated troponin
  • History of cardiovascular disease
  • Use of a biologic medication
  • History of transplant or other immunosuppression
  • HIV infection, regardless of CD4 count

2. Vital signs

  • Respiratory rate > 24 breaths/min
  • Heart rate > 125 beats/min
  • SpO2 < 90% on ambient air

3. Laboratory test results

  • D-dimer > 1000 ng/mL
  • Creatine phosphokinase > twice the upper limit of normal
  • C-reactive protein > 100 mg/L
  • Lactate dehydrogenase > 245 U/L
  • Elevated troponin
  • Admission absolute lymphocyte count < 0.8/mcL
  • Ferritin > 300 mcg/L

Hypertension and Severe COVID-19

According to a review of six reports published between January 29 and March 13, 2020, hypertension was present in substantial percentages—15% to 31%—of patients in China who were hospitalized for COVID-19.

One of those reports, published in the New England Journal of Medicine, reported data from 1,099 patients admitted to 552 hospitals. Hypertension was present in 24% of patients with severe COVID-19 versus—14% of those with less severe disease. However, no multivariable analysis was conducted.

Risk Factors for Death

A report from China, published in The Lancet, included a multivariable analysis of risk factors for death from COVID-19. That study had complete data on 171 patients (53 non-survivors and 118 survivors) from two hospitals.

Characteristics associated with increased risk of death were:

  • Older age — OR, 1.10; 95% CI, 1.03–1.17; P = .043 (median age was 69 for non-survivors; 52 for survivors)
  • Higher Sequential Organ Failure Assessment score — OR, 5.65; 95% CI, 2.61–12.23; P < .0001 (median 4.5 in non-survivors vs. 1.0 in survivors)
  • D-dimer > 1 mcg/mL at admission — OR, 18.42; 95% CI, 2.64–128.55; P = .003

Attention to these factors could help clinicians identify patients with poor prognosis at an early stage.

In a companion report from the grand rounds session, Dr. Lewis and Dr. Neilan explain the controversy over the potential role of angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers in the pathogenesis of COVID-19. They discuss the implications of that issue for routine cardiology therapy as well as for patients with COVID-19. Their discussion cited several societal statements (including by ACC, HFSA and ESC) advising continuation of this class of medications in patients for whom there is an indication, though more research is required.

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Learn more about the Division of Cardiology at Mass General


On March 19, 2020, the Department of Medicine held held its second virtual Grand Rounds presentation related to COVID-19. Louise Ivers, MD, MPH, executive director of the Mass General Center for Global Health, along with other members of the Greater Boston and world medical community, presented on the global effects of the pandemic and helping countries that have inequities of care.


Routine use of ACE inhibitors and angiotensin II receptor blockers should be continued, but these drugs should not be started for patients who develop COVID-19.