You are here

  • Home
  • Archive
  • Volume 13, Issue 4
  • Clinical spectrum of COVID-19 complications in young adults: combined analysis of the American Heart Association COVID-19 Cardiovascular Disease Registry and the Outcomes Registry for Cardiac Conditions in Athletes

Article Text

Article menu

Download PDFPDF

Epidemiology
Original research
Clinical spectrum of COVID-19 complications in young adults: combined analysis of the American Heart Association COVID-19 Cardiovascular Disease Registry and the Outcomes Registry for Cardiac Conditions in Athletes
  1. Aakash Bavishi1,
  2. Stephanie A Kliethermes2,
  3. Bradley Petek3,
  4. Nathaniel Moulson4,
  5. Pranav Mellacheruvu5,
  6. Timothy W Churchill3,
  7. Kimberly Harmon6,
  8. Manesh R Patel7,
  9. Aaron L Baggish8,
  10. Jonathan A Drezner9,
  11. Raja Kannan Mutharasan1
  1. 1Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
  2. 2Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin, USA
  3. 3Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
  4. 4Department of Cardiology, The University of British Columbia Library Vancouver Campus, Vancouver, British Columbia, Canada
  5. 5Department of Internal Medicine, Washington State University Elson S Floyd College of Medicine, Spokane, Washington, USA
  6. 6Department of Family Medicine, University of Washington, Seattle, Washington, USA
  7. 7Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
  8. 8Department of Sports Science, University of Lausanne, Lausanne, Switzerland
  9. 9Department of Family Medicine, Washington State University Spokane, Spokane, Washington, USA
  1. Correspondence to Dr Raja Kannan Mutharasan; kannanm{at}northwestern.edu

Abstract

Background While young adults 18–24 years old bear a significant proportion of COVID-19 diagnoses, the risk factors for hospitalisation and severe COVID-19 complications in this population are poorly understood.

Objective The objective of this study was to identify risk factors for hospitalisation and other COVID-19 complications across the health spectrum of young adults diagnosed with COVID-19 infection.

Study design Retrospective cohort study.

Participants Young adults (aged 18–24) with confirmed COVID-19 infection from the American Heart Association (AHA) COVID-19 Cardiovascular Disease Registry of hospitalised patients and the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA) study of collegiate athletes. The AHA registry included 636 young adults from 152 hospitals. The ORCCA registry consisted of 3653 competitive college athletes from 42 colleges and universities.

Intervention None (exposure to COVID-19).

Primary and secondary outcome measures Main outcomes included hospitalisation, death, major adverse cardiovascular events (MACE) and other severe clinical events.

Results In comparison to the ORCCA registry, patients in the AHA registry were more likely to be female (59% vs 33%); had higher average body mass index (BMI) (32.4 vs 25.6); and had increased prevalence of diabetes (10% vs 0.4%), hypertension (7% vs 0.6%), chronic kidney disease (2% vs 0%) and asthma (14% vs 8%), all with p<0.01. There were eight (2%) deaths in the AHA hospitalised registry compared with zero in the ORCCA cohort. BMI was a statistically significant predictor of death in the hospitalised cohort (OR 1.05, 95% CI 1.00, 1.10). No significant predictors of MACE or other severe clinical events were identified.

Conclusions The risk of cardiac events in young adults aged 18–24 diagnosed with COVID-19 infection is low. Patients who were hospitalised (AHA registry) were more likely to have pre-existing medical comorbidities and higher BMI than healthy collegiate athletes (ORCCA registry). Once hospitalised, elevated BMI is associated with increased mortality although other drivers of MACE and other severe clinical events remain unclear.

  • PUBLIC HEALTH
  • Adult cardiology
  • COVID-19

Data availability statement

No data are available. No additional data available.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2022-069943

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • Through a comparison between two large independent cohorts, cardiac and other severe complications of COVID-19 in young adults between the ages of 18 and 24 were able to be identified.

    • Cross-comparisons between cohorts are limited as these are two independent cohorts with two different criteria for entry.

    • The low prevalence of basic cardiovascular testing in the American Heart Association cohort likely leads to underascertainment of major adverse cardiac events.

    Introduction

    COVID-19 infection has manifested in a wide array of clinical complications including but not limited to respiratory failure, systemic inflammation, thromboembolic events and cardiovascular events.1–3 While older age and comorbidities including chronic kidney disease have been identified as significant risk factors for increased morbidity and mortality in patients infected with COVID-19, severe complications of COVID-19 have been reported across all age groups including young adults aged 18–24.4–6 Although these individuals bear a significant proportion of COVID-19 infections, the spectrum and risk of COVID-19 complications in this age group remain understudied.

    The issue of cardiovascular complications and the necessity of screening following COVID-19 infection in young adults has been the source of significant debate.7 8 While the vast majority of young adults recover with minor or no cardiovascular injury, several case reports and case series have demonstrated the potential cardiac impact of COVID-19 in healthy young adults.9 Reported sequelae include myocardial infarction, myocarditis, sudden-onset biventricular heart failure requiring mechanical support and sudden cardiac death.10–12 Multi-inflammatory response syndrome with multiorgan failure has also been noted in young adults.13 14 The reasons why certain individuals have such devastating cardiovascular consequences of COVID-19 infection are not known.

    Our study aims to better define the clinical spectrum of COVID-19 cardiac and non-cardiac complications in young adults by using two registries representing the ‘bookends’ of health: the American Heart Association COVID-19 Cardiovascular Disease Registry (AHA COVID-19 CVD Registry) of hospitalised patients and the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA) study of previously healthy collegiate athletes. Through a combined analysis and comparison of these two registries, our primary aim is to evaluate both the prevalence of serious cardiac and non-cardiac complications and the risk factors for hospitalisation and severe complications in these young adults. Our secondary aim is to examine the utility of diagnostic testing for cardiac involvement along the health spectrum of young adults diagnosed with COVID-19.

    Methods

    Data sources

    The AHA COVID-19 CVD Registry is a retrospective registry of consecutive patients collected by 152 hospitals and centres participating in this quality improvement registry. Eligible patients are all patients hospitalised with a diagnosis of COVID-19. All adults 18–24 years of age were included from the AHA registry between 1 March 2020 and 19 April 2021. The registry captures baseline demographics, testing, laboratory results and health outcomes.

    The ORCCA study consists of National Collegiate Athletic Association (NCAA) athletes with confirmed COVID-19 infection from 1 September 2020 to 1 June 2021. Eligibility criteria and data collection methods have been described previously.15 Patient demographics, COVID-19 symptoms, cardiac evaluations and cardiac outcomes were captured in the registry. Evaluations were performed per the discretion of local institutions and included a clinical assessment with or without cardiac testing such as a 12-lead ECG, cardiac troponin assay, transthoracic echocardiogram (TTE) and cardiac MRI (CMR). Results were communicated to the patients and if necessary were referred for further evaluation.

    In both cohorts, individual participant consent was waived as only deidentified data were used.

    Definition of primary outcomes

    Primary outcomes included hospitalisation, death, major adverse cardiovascular events (MACE) and other severe clinical events. An MACE was defined as the occurrence of one or more of the following events: ischaemic stroke, myocardial infarction, sustained ventricular arrhythmias, cardiogenic shock, new-onset heart failure, myocarditis/myocardial involvement, requirement of permanent pacemaker or pulmonary embolism/deep vein thrombosis. Other severe clinical events included new haemodialysis or continuous renal replacement therapy (CRRT), requirement of mechanical ventilation or non-cardiogenic shock. COVID-19 myocardial involvement was defined in the current study as probable or definitive myocardial or myopericardial involvement per previous definitions.15 Follow-up was requested from participating institutions periodically throughout the study period by the ORCCA investigators. There was no follow-up beyond the initial hospitalisation in the AHA COVID-19 Registry. The median duration of hospitalisation was 4 days. Because hospitalisation was an entry criterion for the AHA registry, hospitalisation rates were assessed only for ORCCA study participants.

    Statistical analysis

    Standard descriptive statistics were used to describe patient characteristics, symptoms, cardiac testing and incidence of MACE and other severe clinical complications in both cohorts. Asymptomatic patients, including female patients admitted for labour and delivery, were removed from the AHA cohort as COVID-19 likely was an incidental finding and not the cause of hospitalisation. Means and SD summarise continuous variables. Frequencies and percentages summarise categorical variables. Two-sample t-tests were used for continuous comparisons, while χ2 tests or Fisher’s exact tests were used for categorical comparisons, as appropriate. To account for the small number of observed events, univariable Firth logistic regression models were created to assess potential predictors of death, MACE and other severe clinical events. ORs and 95% CIs are provided for all models. We followed the Strengthening the Reporting of Observational Studies in Epidemiology checklist for reporting of cohort studies.16 The AHA Precision Medicine Platform (https://precision.heart.org/) was used for data analysis. IQVIA (Parsippany, New Jersey) serves as the data collection and coordination centre. All statistical analyses were conducted in SAS V.9.4 (SAS Institute).

    Patient and public involvement

    No patient was involved.

    Results

    Baseline characteristics

    Baseline characteristics of participants in the AHA and ORCCA registries are shown in table 1.

    View this table:
    Table 1

    Baseline characteristics in the AHA and ORCCA cohorts of young adults with COVID-19

    A total of 3653 individuals were included in the ORCCA cohort with mean age of 19.9 (SD=1.42) years with 33% female, 65% white, 28% black and 3% Hispanic. 636 individuals were included in the AHA cohort with mean age of 21.4 (SD=1.91) years with 59% female, 31% white, 27% black and 32% Hispanic. Body mass index (BMI) was significantly higher in the hospitalised AHA registry (32.4 kg/m2, SD=10.6) compared with the ORCCA registry (25.6 kg/m2, SD=4.7), p<0.001. The frequencies of diabetes mellitus (10% vs 0.4%), hypertension (7% vs 0.6%), chronic kidney disease (2% vs 0.0%), obesity (51% vs 13%) and asthma (14% vs 8%) were greater in the AHA cohort compared with ORCCA cohort, all with p<0.01. Participants in the ORCCA cohort were more likely to have no significant medical history compared with the AHA cohort (70% vs 62%, p<0.01). In those participants with no medical history, participants in the ORCCA study were more likely to be non-obese (BMI<30 kg/m2) compared with the AHA registry (87% vs 52%, p<0.01%).

    Initial symptoms

    The initial symptoms of both groups are shown in table 2.

    View this table:
    Table 2

    Initial symptoms and cardiac testing performed

    The AHA cohort had greater proportions of fever/chills (43%), cough (41%), shortness of breath (38%), nausea/vomiting or diarrhoea (32%) and chest pain (7%) compared with the ORCCA cohort (19%, 17%, 6%, 5% and 3%, respectively), all p<0.01. In contrast, the ORCCA cohort had greater proportions of headache (23%), loss of sense of smell/taste (23%), sore throat (18%) and nasal congestion (18%) compared with the AHA cohort (12%, 6%, 8% and 5%, respectively) (all p<0.01).

    Cardiac testing

    Cardiac testing for the AHA and ORCCA cohorts is depicted in table 2 and figure 1. There was significantly more cardiac testing including CMR (14% vs 0.3%), ECG (95% vs 52%), troponin assay (87% vs 33%) and TTE (82% vs 7%) in the ORCCA cohort compared with the AHA cohort (all p<0.001).

    Figure 1
    Figure 1

    Comparision of cardiac testing in the AHA and ORCCA Cohorts. AHA, American Heart Association; ORCCA, Outcomes Registry for Cardiac Conditions in Athletes.

    Death, MACE and other severe clinical events

    Clinical outcomes

    Table 3 depicts the incidence of death, MACE and secondary clinical events in the ORCCA cohort and AHA cohort.

    View this table:
    Table 3

    Incidence of major adverse cardiovascular events and other severe clinical events in young adults with COVID-19

    There were 12 (2%) deaths in the AHA cohort compared with 0 death in the ORCCA cohort.

    With respect to MACE, there were 22 (0.6%) overall events in the ORCCA cohort, with 1 (0.03%) case of pulmonary embolism and 21 (0.6%) cases of COVID-19 myocardial involvement. The range of the events occurred from August 2020 to February 2021. In the AHA cohort, 22 (3.5%) patients experienced an MACE. There were 6 (1%) cases of ischaemic stroke, 4 (0.6%) cases of pulmonary embolism, 5 (0.8%) cases of new-onset heart failure, 3 (0.5%) events of sustained ventricular arrhythmias, 3 (0.5%) cases of myocarditis and 1 (0.2%) myocardial infarction. There were no other severe clinical events in the ORCCA group. There were 104 (16.4%) other severe clinical events in the AHA registry with 60 (9%) young adults requiring ventilation, 19 (3%) meeting criteria for shock and 4 (0.6%) requiring haemodialysis or CRRT.

    There were four (0.1%) hospitalisations for COVID-19 in the ORCCA cohort, while all patients in the AHA cohort by definition were hospitalised. The median follow-up for the ORCCA cohort was 411 (IQR: 387, 447) days; given the cross-sectional design of the AHA registry, no follow-up was conducted on those patients.

    Univariable analysis

    Results of univariable analyses to identify predictors for death, MACE and other severe clinical events in the AHA cohort are provided in table 4.

    View this table:
    Table 4

    Univariable predictors of death, MACE and other severe clinical events in AHA cohort

    A higher BMI was associated with death (OR 1.05, 95% CI 1.00, 1.10; p=0.04). No significant predictors of MACE or other severe clinical events were identified.

    Discussion

    The purpose of this study was to define the clinical spectrum of disease and identify cardiac and other severe complications of COVID-19 in young adults between the ages of 18 and 24 from two established registries on potentially opposite sides of the disease severity continuum. The patients in the AHA registry were more likely to have medical comorbidities including diabetes mellitus, hypertension, chronic kidney disease and asthma compared with patients in the ORCCA study. Importantly, there were racial disparities in the two cohorts with the ORCCA cohort being 65% white and only 3% Hispanic, while the AHA cohort was 31% white and 32% Hispanic. There were also sex differences which may have a role in COVID-19 outcomes, with 59% of patients in the AHA cohort being female versus 35% in the ORCCA cohort.17 Initial symptoms differed between the groups, with more severe symptom presentations in hospitalised patients from the AHA cohort such as shortness of breath, fever and vomiting compared with symptoms in the ORCCA registry, perhaps indicating an eventual more severe illness course. It should be noted that the ORCCA study does not represent the general population aged 18–24 years but rather a young, athletic population. This is the first analysis of health outcomes in young adults hospitalised with COVID-19 from the AHA COVID-19 CVD Registry. Importantly, we observed: (1) more pre-existing comorbidities in hospitalised patients, (2) a mortality rate of 2% and (3) a higher risk of death with higher BMI. This study also highlights the low rate of cardiac testing in the AHA hospitalised patient cohort, in contrast with frequent cardiac testing and high-resource utilisation in the ORCCA study collegiate athlete cohort. Unlike initial studies of older adults hospitalised with COVID-19, this study did not find a similarly high rate of myocardial injury or MACE.18–20

    Prior studies of young adults demonstrate low mortality rates for patients hospitalised with COVID-19, though point estimates range from 0.2% for 18–29 year-olds in a large academic health system to 2.7% in a large series of 18–34 year-olds derived from insurance data.21 22 Our findings confirm that obesity is a risk factor for COVID-19-related mortality in young adults.21 While heterogeneity exists for mortality in younger individuals hospitalised with COVID-19, the mortality rate in the young is strikingly lower than that of elderly individuals, estimated by Nguyen et al to be 26.6% in individuals aged 80 and older.23

    Comparison to data from the National Health and Nutrition Examination Survey (NHANES) puts the prevalence of comorbidities found in the AHA hospitalised COVID-19 cohort in context.24 While prevalence of asthma (14%) in young adults hospitalised with COVID-19 seems high, this is similar to the 18% prevalence seen in the overall population of 18–24 year-olds.24 In contrast, the incidences of diabetes mellitus (10%) and hypertension (7%) are higher than those seen in the overall population according to NHANES data (0.5% and 4%, respectively).24 Despite the high comorbidity burden compared with non-hospitalised collegiate athletes, 62% of patients in the AHA hospitalised cohort still had no remarkable medical history, highlighting that COVID-19 adverse outcomes can affect any patient and that risk factors are hard to predict and incompletely understood.

    Our analysis juxtaposing an athletic young adult cohort with a hospitalised young adult cohort highlights the heterogenous nature of BMI as a risk predictor. BMI has been identified as a risk factor for hospitalisation and mortality following hospitalisation across all age groups.25–27 However, in the ORCCA data set involving collegiate athletes, BMI was not found to be associated with COVID-19 myocardial involvement.15 Notably, however, the elevated BMI of an elite athlete is different from the elevated BMI of a non-athlete as the traditional BMI metric does not take into account muscle mass, body composition and bone density.28 Therefore, the limitations of using BMI should be considered before extrapolating the risks of elevated BMI in the general population to athletes with COVID-19. A more detailed assessment of adiposity in conjunction with BMI is an important area of future study.

    The utilisation of cardiac testing was starkly different between the ORCCA cohort and the AHA cohort. Initial concerns for myocardial inflammation from COVID-19 infection and an elevated risk of sudden death in competitive athletes drove initial consensus recommendations to err on the side of early detection with the potential for overdiagnosis.29 Thus, institutions participating in the ORCCA study used protocols aimed at sensitivity, with 93.4% of athletes receiving at least one of troponin, ECG or TTE, and 6.6% of participants receiving mandatory CMR screening.15 In the AHA cohort, cardiac diagnostic testing was likely to be more specific, driven by clinical suspicion and the need to minimise healthcare worker exposure or the transport of critically ill patients. For hospitalised patients, there was a lower than expected rate of cardiac testing with only 49% of patients receiving ECG, 35% troponin testing, 7% TTE and 0.2% CMR. With over 42% of patients in the AHA cohort experiencing shortness of breath or chest pain, the use of TTE in only 7% of patients is significantly lower than in previous studies of hospitalised patients with similar symptoms.30 31 Similarly, an ECG in less than 50% of patients is much lower than previously described in hospitalised patients given patient comorbidities, symptom description, early concerns around myocarditis and the frequency with which QTC prolonging medications were used for the treatment of COVID-19.32–34 A desire to minimise patient contact and the scarcity of personal protective equipment early in the pandemic likely limited cardiac testing in the hospital. These lower rates of cardiac testing also may have been due to an underappreciation of the cardiac manifestations of COVID-19, or errors and discrepancies in reporting cardiac testing in the AHA registry. Our findings raise the possibility that underutilisation of cardiac testing in hospitalised patients may have led to underdiagnosis of cardiac involvement, while overutilisation of cardiac testing in competitive athletes may have led to overdiagnosis.

    There are several important limitations to this study. First, this is a comparison of two independent cohorts with two different criteria for entry: participation in NCAA athletics for the ORCCA cohort versus hospitalisation for COVID-19 in the AHA cohort. These differences limit cross-comparisons between cohorts. Second, the AHA cohort relies on registry abstraction and may be overweighted towards hospitals and hospital systems with resources sufficient to populate these registries. Thus, outcomes in the AHA cohort may not fully reflect the outcomes experienced for young adult patients hospitalised with COVID-19 across all hospitals in the USA. Third, in contrast to the ORCCA study with greater than 1 year of follow-up, there is no follow-up beyond the initial hospitalisation in the AHA COVID-19 CVD Registry. This limits the accurate assessment of the true incidence of severe events, MACE and mortality related to COVID-19 hospitalisation. The rates of CT scanning were not included in the AHA registry which may affect the rates of pulmonary embolism diagnosis. Fourth, registry capture in the AHA cohort was incomplete, with 27% of patients not having documented presenting symptoms. Fifth, the low prevalence of basic cardiovascular testing in the AHA cohort likely leads to underascertainment of MACE. Another important consideration is that data were collected in these registries before widespread availability of the COVID-19 vaccination, which has shown to be effective in reducing severe complications and hospitalisation from COVID-19 infection. Last, with the relatively low prevalence of mortality, MACE and severe COVID-related adverse events, and the relatively small sample size of patients aged 18–24 years hospitalised for COVID-19, our study is underpowered for detailed modelling of risk factors associated with poorer outcomes in the setting of COVID-19 illness.

    In conclusion, this study compared clinical outcomes in young adult patients across the health spectrum with COVID-19 infection. We found a significantly higher burden of comorbidities and lower rates of cardiac testing in hospitalised patients as compared with competitive athletes with COVID-19. Nine per cent of hospitalised young adults with COVID-19 required mechanical ventilation, 3.5% suffered an MACE and 2% died. Importantly, elevated BMI predicted mortality in hospitalised patients. Additional research is needed to better elucidate risk factors for severe health outcomes in young adults afflicted with COVID-19.

    Data availability statement

    No data are available. No additional data available.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by the Massachusetts General Hospital Review Board (Reference ID: 2020P002667). Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    The Get With The Guidelines programmes are provided by the American Heart Association. Special thanks to the participating institutions, site investigators and collaborators for the ORCCA study.

    References

    1. ↵
      1. Long B,
      2. Brady WJ,
      3. Koyfman A, et al
      . Cardiovascular complications in COVID-19. Am J Emerg Med 2020;38:1504–7. doi:10.1016/j.ajem.2020.04.048
      OpenUrlCrossRefPubMed
    2. ↵
      1. Marini JJ,
      2. Gattinoni L
      . Management of COVID-19 respiratory distress. JAMA 2020;323:2329–30. doi:10.1001/jama.2020.6825
      OpenUrlPubMed
    3. ↵
      1. Terpos E,
      2. Ntanasis-Stathopoulos I,
      3. Elalamy I, et al
      . Hematological findings and complications of COVID-19. Am J Hematol 2020;95:834–47. doi:10.1002/ajh.25829
      OpenUrlCrossRefPubMed
    4. ↵
      1. O’Driscoll M,
      2. Ribeiro Dos Santos G,
      3. Wang L, et al
      . Age-specific mortality and immunity patterns of SARS-cov-2. Nature 2021;590:140–5. doi:10.1038/s41586-020-2918-0
      OpenUrlCrossRefPubMed
    5. ↵
      1. Biswas M,
      2. Rahaman S,
      3. Biswas TK, et al
      . Association of sex, age, and comorbidities with mortality in COVID-19 patients: a systematic review and meta-analysis. Intervirology 2021;64:36–47. doi:10.1159/000512592
      OpenUrlCrossRef
    6. ↵
      1. Bonanad C,
      2. García-Blas S,
      3. Tarazona-Santabalbina F, et al
      . The effect of age on mortality in patients with COVID-19: a meta-analysis with 611,583 subjects. J Am Med Dir Assoc 2020;21:915–8. doi:10.1016/j.jamda.2020.05.045
      OpenUrlCrossRefPubMed
    7. ↵
      1. Baggish A,
      2. Drezner JA,
      3. Kim J, et al
      . Resurgence of sport in the wake of COVID-19: cardiac considerations in competitive athletes. Br J Sports Med 2020;54:1130–1. doi:10.1136/bjsports-2020-102516
      OpenUrlFREE Full Text
    8. ↵
      1. Goergen J,
      2. Bavishi A,
      3. Eimer M, et al
      . COVID-19: the risk to athletes. Curr Treat Options Cardiovasc Med 2021;23:68.:68. doi:10.1007/s11936-021-00941-2
      OpenUrl
    9. ↵
      1. Leidman E,
      2. Duca LM,
      3. Omura JD, et al
      . COVID-19 trends among persons aged 0-24 years - united states, march 1-december 12, 2020. MMWR Morb Mortal Wkly Rep 2021;70:88–94. doi:10.15585/mmwr.mm7003e1
      OpenUrlCrossRefPubMed
    10. ↵
      1. Chau VQ,
      2. Giustino G,
      3. Mahmood K, et al
      . Cardiogenic shock and hyperinflammatory syndrome in young males with COVID-19. Circ Heart Fail 2020;13:10.:e007485. doi:10.1161/CIRCHEARTFAILURE.120.007485
      OpenUrl
    11. ↵
      1. Popov AF,
      2. Berger R,
      3. Schlensak C, et al
      . Mechanical circulatory support for cardiovascular complications in a young COVID-19 patient. J Card Surg 2020;35:3173–5. doi:10.1111/jocs.14916
      OpenUrlPubMed
    12. ↵
      1. Blaivas M
      . Unexpected finding of myocardial depression in 2 healthy young patients with COVID-19 pneumonia: possible support for COVID-19-related myocarditis. J Am Coll Emerg Physicians Open 2020;1:375–8. doi:10.1002/emp2.12098
      OpenUrl
    13. ↵
      1. Chow EJ
      . The multisystem inflammatory syndrome in adults with SARS-cov-2 infection-another piece of an expanding puzzle. JAMA Netw Open 2021;4:e2110344. doi:10.1001/jamanetworkopen.2021.10344
    14. ↵
      1. Patel P,
      2. DeCuir J,
      3. Abrams J, et al
      . Clinical characteristics of multisystem inflammatory syndrome in adults. JAMA Netw Open 2021;4:e2126456. doi:10.1001/jamanetworkopen.2021.26456
    15. ↵
      1. Moulson N,
      2. Petek BJ,
      3. Drezner JA, et al
      . SARS-cov-2 cardiac involvement in young competitive athletes. Circulation 2021;144:256–66. doi:10.1161/CIRCULATIONAHA.121.054824
      OpenUrlCrossRefPubMed
    16. ↵
      Strobe checklist. Available: https://www.strobe-statement.org/checklists/ [Accessed 29 Oct 2022].
    17. ↵
      1. Cereda A,
      2. Toselli M,
      3. Palmisano A, et al
      . The hidden interplay between sex and COVID-19 mortality: the role of cardiovascular calcification. Geroscience 2021;43:2215–29. doi:10.1007/s11357-021-00409-y
      OpenUrl
    18. ↵
      1. Guo T,
      2. Fan Y,
      3. Chen M, et al
      . Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (covid-19). JAMA Cardiol 2020;5:811–8. doi:10.1001/jamacardio.2020.1017
      OpenUrl
    19. ↵
      1. Metkus TS,
      2. Sokoll LJ,
      3. Barth AS, et al
      . Myocardial injury in severe COVID-19 compared with non-COVID-19 acute respiratory distress syndrome. Circulation 2021;143:553–65. doi:10.1161/CIRCULATIONAHA.120.050543
      OpenUrlCrossRef
    20. ↵
      1. Smilowitz NR,
      2. Jethani N,
      3. Chen J, et al
      . Myocardial injury in adults hospitalized with COVID-19. Circulation 2020;142:2393–5. doi:10.1161/CIRCULATIONAHA.120.050434
      OpenUrl
    21. ↵
      1. Cunningham JW,
      2. Vaduganathan M,
      3. Claggett BL, et al
      . Clinical outcomes in young US adults hospitalized with COVID-19. JAMA Intern Med 2021;181:379. doi:10.1001/jamainternmed.2020.5313
      OpenUrl
    22. ↵
      1. Sandoval M,
      2. Nguyen DT,
      3. Vahidy FS, et al
      . Risk factors for severity of COVID-19 in hospital patients age 18-29 years. PLoS One 2021;16:e0255544. doi:10.1371/journal.pone.0255544
    23. ↵
      1. Nguyen NT,
      2. Chinn J,
      3. Nahmias J, et al
      . Outcomes and mortality among adults hospitalized with COVID-19 at US medical centers. JAMA Netw Open 2021;4:e210417. doi:10.1001/jamanetworkopen.2021.0417
    24. ↵
      1. Centers for Disease Control and Prevention (CDC)
      ,. National health and nutrition examination survey data. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2021.
    25. ↵
      1. Bhasin A,
      2. Nam H,
      3. Yeh C, et al
      . Is BMI higher in younger patients with COVID-19? association between BMI and COVID-19 hospitalization by age. Obesity (Silver Spring) 2020;28:1811–4. doi:10.1002/oby.22947
      OpenUrl
    26. ↵
      1. Gao M,
      2. Piernas C,
      3. Astbury NM, et al
      . Associations between body-mass index and COVID-19 severity in 6·9 million people in england: a prospective, community-based, cohort study. The Lancet Diabetes & Endocrinology 2021;9:350–9. doi:10.1016/S2213-8587(21)00089-9
      OpenUrl
    27. ↵
      1. Poly TN,
      2. Islam MdM,
      3. Yang HC, et al
      . n.d. Obesity and mortality among patients diagnosed with COVID-19: a systematic review and meta-analysis. Front Med;8. doi:10.3389/fmed.2021.620044
    28. ↵
      1. Kok P,
      2. Seidell JC,
      3. Meinders AE
      . The value and limitations of the body mass index (BMI) in the assessment of the health risks of overweight and obesity. Ned Tijdschr Geneeskd 2004;148:2379–82.
      OpenUrlPubMed
    29. ↵
      1. Rajpal S,
      2. Tong MS,
      3. Borchers J, et al
      . Cardiovascular magnetic resonance findings in competitive athletes recovering from COVID-19 infection. JAMA Cardiol 2021;6:116–8. doi:10.1001/jamacardio.2020.4916
      OpenUrl
    30. ↵
      1. Pack QR,
      2. Priya A,
      3. Lagu TC, et al
      . Inpatient echocardiography use for common cardiovascular conditions. Circulation 2018;137:1745–7. doi:10.1161/CIRCULATIONAHA.117.032256
      OpenUrlFREE Full Text
    31. ↵
      1. Papolos A,
      2. Narula J,
      3. Bavishi C, et al
      . U.S. hospital use of echocardiography. J Am Coll Cardiol 2016;67:502–11. doi:10.1016/j.jacc.2015.10.090
      OpenUrlFREE Full Text
    32. ↵
      The prognostic value of electrocardiogram at presentation to emergency department in patients with COVID-19. Mayo Clinic Proceedings; Elsevier, 2020
    33. ↵
      1. Getchell WS,
      2. Larsen GC,
      3. Morris CD, et al
      . Epidemiology of syncope in hospitalized patients. J Gen Intern Med 1999;14:677–87. doi:10.1046/j.1525-1497.1999.03199.x
      OpenUrlCrossRefPubMedWeb of Science
    34. ↵
      1. Mokhtari A,
      2. Dryver E,
      3. Söderholm M, et al
      . Diagnostic values of chest pain history, ecg, troponin and clinical gestalt in patients with chest pain and potential acute coronary syndrome assessed in the emergency department. Springerplus 2015;4:219. doi:10.1186/s40064-015-0992-9

    Footnotes

    • Twitter @PranavM9

    • Contributors AB, SAK, BP, NM, TWC, KH, MRP, ALB, JAD and RKM participated in study design, data collection, statistical analysis and preparation of manuscript. PM participated in data collection. KM is acting as guarantor.

    • Funding AHA suite of registries is funded by multiple industry sponsors. AHA COVID-19 CVD Registry is partially supported by the Gordon and Betty Moore Foundation. The ORCCA study is partially supported by the American Medical Society for Sports Medicine.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.