Abstract
Background
Post-COVID Sequelae are considered as the signs and symptoms that develop during or after an infection consistent with COVID-19 which continue for more than 12 weeks and are not explained by alternative diagnosis. The prevalence of post-COVID cardiac sequelae ranges from 2% to 71% across the globe and it is reported to be around 22% in India. With this background, the study was conducted to assess the prevalence of probable post-COVID cardiac sequelae (PCCS) and delay in health-seeking for post-COVID cardiac sequelae among healthcare workers.
Methods
A facility-based cross-sectional study was conducted among health workers and students in a medical educational institute in Karnataka from May 2022 to July 2022. Health workers and students who had a past history of COVID-19 during the COVID pandemic were included in the study. Socio-demographic details, clinical profile, symptoms of post-COVID cardiac sequelae, and health-seeking behavior were collected. Data were collected in Epicollect5 and analyzed using STATA statistical software. The prevalence of probable PCCS was expressed with 95% confidence interval. Univariate binomial logistic regression was done to assess the determinants of probable post-COVID sequelae.
Results
A total of 336 health workers were included in the study with a mean (SD) age of 25.6 (8.6) years. A majority (68.2%) of them were females and only 25 (7.4%) belonged to the age group of 45–60 years. The prevalence of probable post-COVID cardiac sequelae among health workers and medical students was 11.9% (95% CI: 8.76–15.7). Among the 40 participants who had probable post-COVID cardiac sequelae, 55% (95% CI: 40%–70%) were not evaluated further which was their treatment-seeking behavior. Females, hypertensive individuals, and those who had moderate-severe disease during acute COVID-19 disease were at higher risk of developing probable post-COVID cardiac sequelae.
Conclusion
Around one out of ten individuals had experienced probable post-COVID cardiac sequelae, but only half of them got evaluated for it. An appropriate screening program for post-COVID cardiac sequelae needs to be implemented along with awareness-raising activities about long COVID to prevent the morbidity and mortality associated with it.
Keywords: Post-COVID sequelae, Post-COVID cardiac Sequelae, Long COVID, Risk factors
1. Introduction
The Pandemic of COVID 19 is one of the major health concerns in recent times with the number of people affected exceeding the millions. After two years of the pandemic, it is found that many people are suffering from long-term sequelae of COVID-19 disease.1 National Institute for Health and Care Excellence has defined these symptoms as ‘long COVID’.2 National Comprehensive Guidelines for Management of Post-COVID Sequelae defines the post-COVID sequelae (PCS) as signs and symptoms that develop during or after an infection consistent with COVID-19 which continue for more than 12 weeks and are not explained by alternative diagnosis.1 This PCS can involve almost all the systems in the body. Involvement of the cardiovascular system (CVS) is more common, as more than 30% of the people with COVID have shown involvement of CVS which was life-threatening.1
The prevalence of post-COVID cardiac sequelae ranges from 2% to 71% across the globe and it is reported to be around 22% in India.3, 4, 5, 6, 7, 8 People with comorbidities like obesity, dyslipidemia, diabetes, hypertension, and chronic kidney disease are at higher risk of developing Post-COVID cardiac sequelae.1 The commonly reported symptoms of cardiac sequelae are chest pain, dyspnea, and palpitation.1 During the pandemic, it is observed that delay in seeking care among patients with cardiac conditions is leading to increased mortality and morbidity. As post-COVID cardiac sequelae cases are increasing we need to reduce the delay in seeking care for cardiac-related symptoms.
Health or care-seeking behavior has been defined as any action undertaken by individuals who perceive themselves to have a health problem or to be ill to find an appropriate remedy.9 Even though there is literature describing health-seeking behavior during the COVID pandemic,10 , 11 no literature was found that reported health-seeking behavior in the post-COVID period. There is a substantial delay in health seeking among health workers due to various reasons like informal advice, self-treatment, return to work, family commitments, neglect, etc.11 There are studies that estimated the prevalence of post-COVID cardiac sequelae but none of them have assessed the delay in care for post-COVID cardiac sequelae. With this background, this study was conducted to assess the prevalence of probable post-COVID cardiac sequelae and delay in health-seeking for post-COVID cardiac sequelae. We also assessed the determinants of probable post-COVID sequelae.
2. Materials and methods
A facility-based cross-sectional study was conducted among health workers and students in a medical educational institute in Karnataka from May 2022 to July 2022. Health workers and students in the institute who had a past history of COVID-19 during the COVID pandemic were included in the study. The study was conducted after taking permission from the administrative authority of the Institute.
2.1. Sample size calculation and sampling technique
The sample size was calculated to be 341 using OpenEpi software12 with the expected prevalence of post-COVID cardiac sequelae to be 22%,13 4.4% absolute precision, and 95% confidence level. The list of eligible participants was obtained from the administrative authority of the institute, and they were divided into three strata based on age (i.e: Strata 1: 18 years–45 years, Strata 2: 46 years–60 years, Strata 3: more than 60 years). Only three individuals in strata-3 and 22 individuals in strata-2 had a history of microbiologically confirmed COVID-19. Therefore we used simple random sampling for choosing participants in strata-1 and universal sampling in strata-2 and strata-3.
2.2. Study procedure
Informed consent was taken from the eligible study participants and they were interviewed. A pre-tested semi-structured questionnaire was used to collect the socio-demographic details, clinical profile, and symptoms of post-COVID cardiac sequelae. The data were collected using Epicollect5 software.14 The STEPS instrument was used to capture the data regarding possible risk factors.15 The Alcohol Use Disorder Identification Test (AUDIT-C) was used to assess the severity of alcohol use among the individuals.16 Blood pressure was measured in a sitting position on the chair with both arms resting on the armrest. The metabolic equivalent of task (MET) score was derived from the duration and type of physical activity. The formula used to derive the MET score per week was
| MET = k × number of days of activity in a week × Average duration of activity in a day |
k – Constant.
The value of k is 3.3, 4, and 8 for walking, moderate intensive activity, and highly intensive activities, respectively.
2.3. Operational definition
2.3.1. Probable post-COVID cardiac sequelae
If the person was having symptoms of post cardiac sequelae (chest pain, dyspnea, palpitation) and the onset of symptoms was after contracting COVID-19, then they were considered to suffering from probable post-COVID cardiac sequelae.1
2.3.2. Physical activity
Physical activity was categorized into three groups. Participants were grouped into low physical activity, moderate, and highly active if their MET score per week was less than 600, 600 to 3000 and more than 3000, respectively.
2.3.3. Statistical methods
The data was exported from Epicollect5 and analyzed using STATA statistical software version 14 (StataCorp LCC, Lakeway Drive College Station, Texas, USA). The continuous variables were summarized using mean with standard deviation or median with interquartile range based on the distribution of data. The categorical variables were summarized as proportions. The proportion of healthcare workers with post-COVID cardiac sequelae and people not evaluated for the same is expressed in percentage with 95% confidence interval. The Chi-square test was used to test the statistical significance of association with dependent and independent categorical variables. Univariate binomial logistic regression was done to assess the determinants of probable post-COVID sequelae. p value less than 0.05 was considered statistically significant.
2.3.4. Ethical consideration
The study was conducted after obtaining permission from the Institutional Ethical committee. Informed consent was obtained before enrolling the participants. The data were anonymized during analysis and other information was kept confidential.
3. Results
A total of 336 health workers and students who had COVID were included in the study with a mean (SD) age of 25.6 (8.6) years. A majority (68.2%) of them were females and only 25 (7.4%) belonged to the age group of 45–60 years (Table 1 ). Seventy-four percent of the study participants belonged to the Hindu religion, 286 (85.1%) belonged to the Nuclear family and 270 (80.4%) were never married. Among 336 study participants, 11 (5.7%) had hypertension, 5 (4.6%) had diabetes mellitus, 6 (1.8%) had past history of myocardial infarction, 12 (20%) had history of hypercholesterolemia and 114 (33.9%) had obesity.
Table 1.
Bivariate analysis of association of various socio-demographic and clinical characteristics among the study participants with probable post-COVID-19 cardiac sequelae (N = 336).
| Variables | Category | Frequency | Probable post-COVID cardiac sequelae n = 40 Frequency (%) |
OR (95% CI) | p-value |
|---|---|---|---|---|---|
| Sex | Male | 107 (31.8) | 4 (3.7) | 1 | 0.002 |
| Female | 229 (68.2) | 36 (15.7) | 4.8 (1.6–13.8) | ||
| Age | 18–44 years | 311 (92.6) | 37 (11.9) | 1 | 0.99 |
| 45–60 years | 25 (7.4) | 3 (12.0) | 1.009 (0.2–3.5) | ||
| Religion | Hindu | 251 (74.7) | 27 (10.8) | 1 | 0.58 |
| Muslim | 30 (8.9) | 4 (13.3) | 1.3 (0.4–3.9) | ||
| Christian | 53 (15.8) | 9 (17.0) | 1.7 (0.7–3.8) | ||
| Othersa | 2 (0.6) | 0 (0.0) | – | ||
| Marital status | Never married | 270 (80.4) | 30 (11.1) | 1 | 0.53 |
| Currently married | 65 (19.3) | 9 (13.8) | 1.3 (0.6–2.8) | ||
| Divorced | 1 (0.3) | 1 (100.0) | – | ||
| Type of Family | Nuclear | 286 (85.1) | 31 (10.8) | 1 | 0.10 |
| Joint | 41 (12.2) | 6 (14.6) | 1.4 (0.5–3.6) | ||
| Three Generation | 9 (2.7) | 3 (33.3) | 4.1 (0.9–17.2) | ||
| History of Hypertension | Yes | 11 (5.7) | 6 (54.5) | 10.9 (3.1–39.4) | <0.001 |
| History of Diabetes Mellitus | Yes | 5 (4.6) | 2 (40) | 4.6 (0.7–30.6) | 0.47 |
| History of Myocardial Infarction | Yes | 6 (1.8) | 4 (66.7) | 16.3 (2.9–92.3) | <0.001 |
| High cholesterol level | Yes | 12 (20) | 1 (8.3) | 1.6 (0.2–14.7) | 0.67 |
| Ever used tobacco | Yes | 45 (13.4) | 3 (6.7) | 0.49 (0.1–1.7) | 0.25 |
| Adequate physical activity | Yes | 80 (23.8) | 15 (18.8) | 2.1 (1.1–4.3) | 0.03 |
| Harmful use of alcohol | Present | 15 (4.5) | 38 (11.8) | 0.8 (0.2–4.0) | 0.86 |
| Eats at least 5 servings of fruit intake | Yes | 86 (25.6) | 14 (16.3) | 1.7 (0.8–3.4) | 0.15 |
| BMI | Underweight | 30 (8.9) | 3 (10) | 0.8 (0.2–3.2) | 0.15 |
| Normal BMI | 121 (36.0) | 14 (11.6) | 1 | ||
| Overweight | 71 (21.1) | 4 (5.6) | 0.4 (0.1–1.4) | ||
| Obese | 114 (33.9) | 19 (16.7) | 1.5 (0.7–3.2) |
Others in Religion include Sikh, Jain and Buddhists.
Among the study participants, 83.3% were treated at homecare, 6.5% were treated in Tertiary hospitals, 6% were treated in COVID-designated hospitals, 3% in COVID-care centers, and 1.2% in COVID-designated health centers.
The prevalence of probable post-COVID cardiac sequelae among health workers and medical students is 11.9% (95% CI: 8.76–15.7). Among the 40 participants who had probable post-COVID cardiac sequelae, 55% (95% CI: 40%–70%) were not evaluated further which was their treatment-seeking behavior.
3.1. Association of various risk factors with probable post-COVID cardiac sequelae (Fig. 1)
Fig. 1.
Risk factors for probable post-COVID cardiac sequelae.
Females had 4.8 times (95% CI: 1.6–13.8) increased odds of probable post-COVID sequelae as compared to males and the association was statistically significant with a p-value of 0.002. Other variables like age, religion, marital status, and type of family were tested for association with probable post-COVID cardiac sequelae but not shown significant association (Table 1).
Among the clinical characteristics, participants with history of hypertension had 10.9 times (95% CI of OR: 3.1–39.4) higher odds of developing post-COVID cardiac sequelae and the association was statistically significant. Participants with history of myocardial infarction also had higher odds of symptoms suggestive of post-COVID cardiac sequelae (OR = 16.3; 95% CI: 2.9–92.3), but could not be attributed to COVID-related complications. Other variables like history of diabetes, and high cholesterol were evaluated for possible association but were not shown statistically significant (Table 1).
Among the behavioral risk factors, adequate physical activity was significantly associated (OR = 2.1; 95% CI: 1.1–4.3) with experiencing symptoms of post-COVID sequelae. Other risk factors like tobacco use, alcohol, and obesity were assessed for possible association but were not shown to be statistically significant.
Study participants who received oxygen as a part of COVID treatment and were admitted to ICU had a higher risk of developing probable post-COVID cardiac sequelae with odds ratios (OR = 6.1; 95% CI: 0.9–41.8) and (OR = 12.6; 95% CI: 1.9–134.2) respectively. People who had got treated in COVID-designated hospitals also had a higher risk (OR = 3.1; 95% CI: 1.1–9.3) of developing post-COVID cardiac sequelae (Table 2 ).
Table 2.
Bivariate analysis of association of various COVID-19 treatment characteristics among the study participants with probable post-COVID-19 cardiac sequelae (N = 336).
| Variables | Category | Total N = 336 |
Probable post-COVID cardiac sequelae n = 40 Frequency (%) |
OR (95% CI) | p-value |
|---|---|---|---|---|---|
| Place of treatment for COVID-19 | Home care | 280 (83.3) | 27 (9.6) | 1 | 0.055 |
| COVID Care Centre | 10 (2.9) | 3 (30) | 4.0 (0.9–16.4) | ||
| COVID Designated Health Centre | 4 (1.1) | 1 (25) | 3.1 (0.3–31.1) | ||
| COVID Designated Hospital | 20 (5.9) | 5 (25) | 3.1 (1.1–9.3) | ||
| Tertiary Hospital | 22 (6.5) | 4 (18.2) | 2.1 (1.1–9.26) | ||
| Treated with oxygen | Yes | 5 (1.5) | 3 (60.0) | 6.1 (0.9–41.8) | 0.041 |
| No | 51 (15.2) | 10 (19.6) | 1 | ||
| Received ICU treatment | Yes | 4 (1.1) | 3 (75.0) | 12.6 (1.9–134.2) | 0.011 |
| No | 52 (15.5) | 10 (19.2) | 1 | ||
| Received mechanical ventilation | Yes | 1 (0.3) | 0 | – | 0.58 |
| No | 55 (16.4) | 13 (23.6) | – |
4. Discussion
With the increase in COVID cases during the pandemic, post-COVID cardiac sequelae had become a major public health issue after the pandemic of COVID 19. Therefore we conducted the study with the objective of estimating the proportion of people with probable post-COVID cardiac sequelae, and factors associated with it. Around 11% of the individuals experienced post-COVID cardiac sequelae, among them, 55% of individuals neglected the symptoms and were not evaluated for it. Study participants who were female, had hypertension, history of myocardial infarction, and were treated with oxygen and admitted to ICU had a higher risk of post-COVID cardiac sequelae.
The proportion of probable post-COVID cardiac sequelae was estimated to be around 11% in the present study. The document released by the Government of India reported the prevalence of post-COVID cardiac sequelae to be around 22%.1 The low prevalence of post-COVID cardiac sequelae in our study might be due to the relatively younger age group among the study participants. Also, the study participants were health workers who were well aware of risk factors of cardiac conditions and would have practiced healthy behavior. However, the study noticed that around 55% of individuals with probable post-COVID cardiac sequelae were not evaluated. It shows that people can attribute these symptoms as non-specific and not get evaluated. This may be the reason for the delayed presentation of cardiac conditions. Even though the study participants were health workers, they neglected the post-COVID cardiac symptoms which need to be addressed appropriately.
4.1. Factors associated with Post-COVID cardiac sequelae
The present study shows that females had 4.8 times (95% CI: 1.6–13.8) higher odds of experiencing probable post-COVID cardiac sequelae. This is similar to the results reported from other studies globally. A study done by Wang W et al on long-term cardiovascular outcomes in post-COVID-19 sequelae has reported that women had 3.3 times (HR [95% CI] = 3.329 [1.901−5.829]) higher risk of myocarditis and 3.1 times (HR [95% CI] = 3.169 [2.459−4.085]) higher risk of ischemic cardiomyopathy.13 , 17 Increased cytokine expression, genetic factors like X-chromosome mosaicism, overexpression of the ACE2 gene, and hormonal actions of estrogen were considered to be the reasons for this increased risk of post-COVID cardiac sequelae in women.18 , 19
Among clinical characteristics, participants with a history of hypertension had 10.9 times (95% CI of OR: 3.1–39.4) higher odds of developing post-COVID cardiac sequelae and the association was statistically significant. There are literature reporting that among COVID-19 patients, 23% had hypertension.20 Among COVID-19 patients admitted to ICU, 58% had hypertension21 and 48% of COVID-19 patients who died had hypertension.22 Micro-vascular injury due to SARS CoV-2, myocarditis, acute coronary syndrome (ACS) and the interaction between S protein and ACE2 might be the reasons for the increased occurrence of post-COVID cardiac sequelae among hypertension patients.19 , 23 Participants with history of myocardial infarction also had higher odds of symptoms suggestive of post-COVID cardiac sequelae, but could not be attributed to COVID-related complications. These findings were in line with the existing literature except for the age group, where literature shows that older age groups had higher odds of experiencing symptoms of post-COVID cardiac sequelae.1 , 19 Current study reported that participants with ICU admission and oxygen treatment during the COVID infection had a higher risk of having post-COVID cardiac sequelae. This might be due to the severity of illness during the acute COVID-19 disease. Literature reports that COVID patients with severe disease have increased incidences of post-COVID cardiac sequelae.13 , 24 In the current study, we didn't find any association between age and post-COIVD cardiac sequelae. We assume that it was due to the younger age group contributing to the majority of the sample size.
There are some limitations to the study the confirmation of post-COVID cardiac sequelae was not done with diagnostic investigations among the probable post-COVID cardiac sequelae patients due to financial constraints. The extrapolation of results needs to be done with caution because most of the study participants were aged less than 45 years and the occurrence of predisposing co-morbidities like hypertension, diabetes, COPD etc are less. Majority of the study participants were females (68%) due to which interpretation of results on post-COVID cardiac sequelae needs to be done with caution. The interpretation of results for association needs to consider that the study was done among healthcare workers who had good awareness about their health-related behaviors. However, there are a few strengths to our study. First, our study was conducted among healthcare workers and medical students, who are well aware of the complications of COVID-19, which reduced the possible information bias in recalling the symptoms. Second, the data were collected using Epicollect5 software which had quality checks which minimized the error during data entry and data were directly entered during the time of the interview. Third, standardized instruments like the STEPs tool were used to collect the data regarding possible risk factors.
5. Conclusion
Around one out of ten individuals had experienced probable post-COVID cardiac sequelae, but only half of them got evaluated for it. Females, hypertensive individuals, and those who had moderate-severe disease during acute COVID-19 disease were at higher risk of developing probable post-COVID cardiac sequelae. An appropriate screening program for post-COVID cardiac sequelae needs to be implemented along with the awareness-raising activities about long COVID to prevent the morbidity and mortality associated with it.
Support
The study was approved under Short Term Studentship (STS) – ICMR Program.
Conflicts of interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:
The protocol was approved in the ICMR- Short Term Studentship (STS) program for the Co-author- Amal Anand.
References
- 1.Ministry of Health and Family Welfare G of I. National Comprehensive Guidelines for Management of Post-COVID Sequelae [Internet]. [cited 2022 Nov 27]. Available from: https://www.mohfw.gov.in/pdf/NationalComprehensiveGuidelinesforManagementofPostCovidSequelae.pdf.
- 2.National Institute for Health and Care Excellence (NICE) COVID-19 rapid guideline: managing the long-term effects of COVID-19 | Guidance | NICE [Internet] NICE. 2020 https://www.nice.org.uk/guidance/ng188 [cited 2022 Nov 27]. Available from: [PubMed] [Google Scholar]
- 3.Chopra N., Chowdhury M., Singh A.K., et al. Clinical predictors of long COVID-19 and phenotypes of mild COVID-19 at a tertiary care centre in India. Drug Discov Ther [Internet] 2021 Jun 30;15(3):156–161. doi: 10.5582/ddt.2021.01014. https://pubmed.ncbi.nlm.nih.gov/34234065/ [cited 2022 Nov 27]. Available from: [DOI] [PubMed] [Google Scholar]
- 4.Naik S., Haldar S.N., Soneja M., et al. Post COVID-19 sequelae: a prospective observational study from Northern India. Drug Discov Ther [Internet] 2021 Oct 31;15(5):254–260. doi: 10.5582/ddt.2021.01093. https://pubmed.ncbi.nlm.nih.gov/34719599/ [cited 2022 Nov 27]. Available from: [DOI] [PubMed] [Google Scholar]
- 5.Huang L., Yao Q., Gu X., et al. 1-year outcomes in hospital survivors with COVID-19: a longitudinal cohort study. Lancet (London, England) [Internet] 2021 Aug 28;398(10302):747–758. doi: 10.1016/S0140-6736(21)01755-4. https://pubmed.ncbi.nlm.nih.gov/34454673/ [cited 2022 Nov 27]. Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Huang C., Huang L., Wang Y., et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet (London, England) [Internet] 2021 Jan 16;397(10270):220–232. doi: 10.1016/S0140-6736(20)32656-8. https://pubmed.ncbi.nlm.nih.gov/33428867/ [cited 2022 Nov 27]. Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Evans R.A., McAuley H., Harrison E.M., et al. Physical, cognitive, and mental health impacts of COVID-19 after hospitalisation (PHOSP-COVID): a UK multicentre, prospective cohort study. Lancet Respir Med [Internet] 2021 Nov 1;9(11):1275–1287. doi: 10.1016/S2213-2600(21)00383-0. https://pubmed.ncbi.nlm.nih.gov/34627560/ [cited 2022 Nov 27]. Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Sudre C.H., Murray B., Varsavsky T., et al. Attributes and predictors of long COVID. Nat Med [Internet] 2021 Apr 1;27(4):626–631. doi: 10.1038/s41591-021-01292-y. https://pubmed.ncbi.nlm.nih.gov/33692530/ [cited 2022 Nov 27]. Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Olenja J. Health seeking behaviour in context. East Afr Med J [Internet] 2003 Feb;80(2):61–62. doi: 10.4314/eamj.v80i2.8689. https://pubmed.ncbi.nlm.nih.gov/16167716/ [cited 2022 Nov 26]. Available from: [DOI] [PubMed] [Google Scholar]
- 10.Onchonga D., Alfatafta H., Ngetich E., Makunda W. Health-seeking behaviour among pregnant women during the COVID-19 pandemic: A qualitative study. Heliyon [Internet] 2021 Sep 1;7(9) doi: 10.1016/j.heliyon.2021.e07972. [cited 2022 Nov 26]. Available from:/pmc/articles/PMC8432977/ [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.De Wilton A., Kilich E., Chaudhry Z., et al. Delayed healthcare seeking and prolonged illness in healthcare workers during the COVID-19 pandemic: a single-centre observational study. BMJ Open [Internet] 2020 Nov 26;10(11) doi: 10.1136/bmjopen-2020-040216. [cited 2022 Nov 26]. Available from:/pmc/articles/PMC7692003/ [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Dean A., Sullivan K., Soe M. Atlanta; USA: 2013. OpenEpi: Open Source Epidemiologic Statistics for Public Health [Internet]www.OpenEpi.com [cited 2020 Sep 7]. Available from: [Google Scholar]
- 13.Ramadan M.S., Bertolino L., Zampino R., et al. Cardiac sequelae after coronavirus disease 2019 recovery: a systematic review. Clin Microbiol Infect [Internet] 2021 Sep 1;27(9):1261. doi: 10.1016/j.cmi.2021.06.015. [cited 2022 Nov 28]. Available from:/pmc/articles/PMC8220864/ [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.What is Epicollect5 - Epicollect5 Data Collection User Guide [Internet]. [cited 2020 May 1]. Available from: https://docs.epicollect.net/.
- 15.World Health Organization. STEPwise approach to NCD risk factor surveillance (STEPS) [Internet]. [cited 2022 Oct 11]. Available from: https://www.who.int/teams/noncommunicable-diseases/surveillance/systems-tools/steps.
- 16.Bush K., Kivlahan D.R., McDonell M.B., Fihn S.D., Bradley K.A. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med [Internet] 1998 Sep 14;158(16):1789–1795. doi: 10.1001/archinte.158.16.1789. https://pubmed.ncbi.nlm.nih.gov/9738608/ [cited 2022 Nov 28]. Available from: [DOI] [PubMed] [Google Scholar]
- 17.Wang W., Wang C.Y., Wang S.I., Wei J.C.C. Long-term cardiovascular outcomes in COVID-19 survivors among non-vaccinated population: a retrospective cohort study from the TriNetX US collaborative networks. eClinicalMedicine [Internet] 2022 Nov 1;53 doi: 10.1016/j.eclinm.2022.101619. http://www.thelancet.com/article/S2589537022003492/fulltext [cited 2022 Dec 23]. Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Megiorni F., Pontecorvi P., Gerini G., Anastasiadou E., Marchese C., Ceccarelli S. Sex-related factors in cardiovascular complications associated to COVID-19. Biomolecules [Internet] 2022 Jan 1;12(1):21. doi: 10.3390/biom12010021. [cited 2022 Dec 28] Available from:/pmc/articles/PMC8773922/ [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Nishiga M., Wang D.W., Han Y., Lewis D.B., Wu J.C. COVID-19 and cardiovascular disease: from basic mechanisms to clinical perspectives. Nat Rev Cardiol [Internet] 2020 Sep 1;17(9):543–558. doi: 10.1038/s41569-020-0413-9. https://pubmed.ncbi.nlm.nih.gov/32690910/ [cited 2022 Dec 23]. Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Marimuthu Y., Kunnavil R., Anil N.S., et al. Clinical profile and risk factors for mortality among COVID-19 inpatients at a tertiary care centre in Bengaluru, India. Monaldi Arch chest Dis = Arch Monaldi per le Mal del torace [Internet] 2021 May 17;91(3) doi: 10.4081/monaldi.2021.1724. https://pubmed.ncbi.nlm.nih.gov/34006039/ [cited 2021 Jun 3]. Available from: [DOI] [PubMed] [Google Scholar]
- 21.Wang D., Hu B., Hu C., et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA [Internet] 2020 Mar 17;323(11):1061–1069. doi: 10.1001/jama.2020.1585. https://pubmed.ncbi.nlm.nih.gov/32031570/ [cited 2022 Dec 28] Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Zhou F., Yu T., 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 (London, England) [Internet] 2020 Mar 28;395(10229):1054–1062. doi: 10.1016/S0140-6736(20)30566-3. https://pubmed.ncbi.nlm.nih.gov/32171076/ [cited 2022 Dec 28]. Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Carfì A., Bernabei R., Landi F., Group GAC-19 P.-A.C.S. Persistent symptoms in patients after acute COVID-19. JAMA [Internet] 2020;324(6):603–605. doi: 10.1001/jama.2020.12603. https://jamanetwork.com/journals/jama/fullarticle/2768351 Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Rama B., Bluemke D.A., Lüscher T.F., Neubauer S. Long COVID: post-acute sequelae of COVID-19 with a cardiovascular focus. Eur Heart J [Internet] 2022;43(11):1157–1172. doi: 10.1093/eurheartj/ehac031. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8903393/#__ffn_sectitle Available from: [DOI] [PMC free article] [PubMed] [Google Scholar]