Cardiovascular Disease and COVID-19
Multiple retrospective analyses including those from China, the USA, and Italy have shown that there is high cardiovascular disease (CVD) prevalence in patients that develop COVID-19 and particularly those that have more severe disease and worse outcomes. The mechanism by which cardiovascular patients have a higher risk of contracting COVID-19 and developing more severe disease is unknown, but potentially may be due to poor cardiovascular reserve, a greater associated age with the cardiovascular conditions, and dysregulated immunity and existing inflammation from their underlying diseases such as hypertension and diabetes [16]. An observational database of the Surgical Outcomes Collaborative registry, which comprised of 8910 hospitalized COVID-19 patients from 169 hospitals in Asia, Europe, and North America, found that an age greater than 65, and diagnosis of history coronary artery disease, heart failure, and/or cardiac arrhythmias were independently associated with increased risk of in-hospital death, with 5.8% (n = 515) of this cohort dying in the hospital [17]. Further studies analyzing risk factors and associated clinical outcomes by geography are further described below.

China
A meta-analysis of 6 Chinese studies evaluating 1527 affected patients showed that the most prevalent cardiovascular metabolic comorbidities included hypertension (17.1%), cardiac and/or cerebrovascular disease (16.4%), and diabetes (9.7%). Most importantly, patients with hypertension and cardiac and/or cerebrovascular disease significantly accounted for more ICU cases compared with non-ICU cases with prevalence of 28.8% (RR 2.03) for hypertension, and 16.7% (RR 3.30) for cardiac and/or cerebrovascular disease [18]. Data from the World Health Organization and Chinese Center for Disease Control and Prevention confirm that patients with comorbidities have a higher case fatality rate (CFR) than those without comorbidities [19, 20]. Of the 55,924 laboratory-confirmed cases in China, there was a 3.8% CFR and higher rates were seen with those with CVD (13.2%), diabetes (9.2%), and hypertension (8.4%) [19•]. A cohort study of 201 patients from Wuhan Jinyintan Hospital showed that hypertension was significantly associated with patients progressing to Acute Respiratory Distress Syndrome (ARDS) (27.4% vs. 13.7%; p = 0.02) and later death (36.4% vs. 17.5%; p = 0.05) [21].

Italy
As of March 17, 2020, the CFR in Italy is 7.2%. from a total of 22,512 cases of which a detailed chart review of a subsample of 355 deceased patients found high underlying disease prevalence of ischemic heart disease (30%), diabetes (35.5%), atrial fibrillation (24.5%), and cancer (20.3%) [22]. A case series of patients with COVID-19 in the ICUs in the Lombardy region demonstrated that hypertension was the most common comorbidity (49%) and cardiovascular disease (21%) was the second. Furthermore, there was a statistically significant higher prevalence of hypertension among patients who died compared with those who were discharged from the ICU (63% vs. 40%; p < 0.001) [14].

USA
While epidemiologic data in the USA remains dynamic with limited studies to date in major urban centers, a report of 167 confirmed cases linked to a long-term facility in Washington State also conferred similar findings showing high underlying disease prevalence with hypertension (44.3%), cardiac disease (40.7%), and diabetes (22.8%) [23]. A large New York study examined a total of 5700 patients, with median age being 63 years age. The New York cohort found hypertension in 56.6% patients, obesity in 41.7% patients, and diabetes in 33.8% of patients. Of the patients who died, those with diabetes were more likely to have been mechanically ventilated or be hospitalized in the ICU [15•]. Another case series of 393 patients admitted to New York hospitals found that 50.1% of patients had hypertension and 21% had cardiovascular disease [24]. Not all studies detailed specifics of what defined cardiac disease; therefore, it is difficult to delineate COVID-19 direct associations with coronary artery disease, cardiomyopathy, or heart failure from a large sample size standpoint. However, a case series from Seattle, Washington did state that 42.9% of the 21 critically ill patients with COVID-19 had underlying congestive heart failure [25].