Table 2.

Competing Influences of COVID-19 on CV Event Rates

Effects on Events	Type of Event
	Nonfatal CV Events	Fatal CV Events
Reduction in event rates	•Fear of hospitalization and contracting COVID-19 in the inpatient setting (↓ CV and HF hospitalizations, ↓ myocardial infarctions) •Hospitalization attributed to COVID-19 (↓ CV and HF hospitalizations, even with concurrent exacerbation) •Decreased patient physical activity and provoked symptoms (↓ clinical visits and hospitalizations)	•Fear of hospitalization, reducing adjudication (↓ CV and HF deaths) •Sicker patients may reside in skilled nursing facilities with exposure to COVID-19 (↑ COVID-19 deaths with ↓ CV and HF deaths) •Financial incentive to attribute death to COVID-19 in the United States (↓ CV and HF deaths)
	•Potential increased adherence to CV therapies (↓ CV and HF fatal and nonfatal events)
Increase in event rates	•COVID-19 infection & inflammation increases risk of underlying HF exacerbation (↑ CV and HF events including ↑ myocardial infarctions) •Increased thrombosis associated with COVID-19 (↑ CV events) •COVID-19 increases risk of renal injury (↑ renal injury)	•Delayed presentations to medical care (↑ deaths)
	•Concern that cardiovascular medications such as angiotensin system antagonists may increase risk for or worsen COVID-19 (↑ CV and HF events and ↑ CV and HF deaths) •Inability to obtain therapies, including due to cost (due to loss of employment) or fear of contracting COVID-19 (↑ CV events, ↑ outpatient worsening HF events, ↑ CV and HF deaths)
Unclear effect on event rates	•Overlapping biomarker or clinical profiles of HF and CV diseases with COVID-19 (↓ or ↑ CV and HF events including myocardial infarctions)
Increased missing events or events of unknown cause	•Increased comingled events at home without documentation or reporting •Decline or reassignment of study personnel with decreased source documentation and data collection •Undiagnosed COVID-19

COPD = chronic obstructive pulmonary disease; COVID-19 = coronavirus disease-2019; CV = cardiovascular; HF = heart failure.