COVID-19 and enduring atherosclerotic cardiovascular risk: a population study

Background The risk of cardiovascular events is increased following COVID-19 infection, but the long-term impact of pandemic waves, reinfection, and vaccination status is not fully understood. Purpose We examined trends in the incidence and risk of atherosclerotic cardiovascular disease (ASCVD), including stroke, AMI, and ACS, among COVID-19 survivors in a population-based cohort. Methods We conducted a retrospective cohort study using linked statewide health datasets covering hospital and emergency department presentations from 2018 to 2025. Of 5,758,429 individuals tested for COVID-19, 2,848,580 adults with a PCR test and at least one hospital or emergency care record were included in the analysis. Excess hospitalisations were estimated using interrupted time-series analyses. ASCVD incidence, cumulative risk, and predictors were evaluated using Kaplan-Meier survival curves, Cox regression models, and Fine-Gray competing-risk models, accounting for death as a competing event. Results Among 2,848,580 individuals, 747,697 (26.3%) had COVID-19 infection. ASCVD hospitalisations increased following COVID-19 infection, peaking during the Delta wave (AMI: 50-60%, ACS: 50%, Stroke: 50% above pre-pandemic baseline), with persistent but attenuated elevations during Omicron (10-30% above baseline). Over a median 2.7 years, COVID-positive individuals had worse event-free survival for stroke, AMI, ACS, and ASCVD, with higher predicted 5-year ASCVD risk compared with those without infection (19% vs 15%). Multivariable analyses showed that older age, male sex, higher comorbidity burden, dyslipidaemia, ICU admission, repeated COVID-19 infections, and infection during later pandemic waves were associated with increased ASCVD risk. Three or more vaccine doses were associated with a 29% reduction in risk Conclusion Long-term ASCVD risk following COVID-19 infection remains elevated, particularly among older adults, males, individuals with comorbidities, and those with repeated infections. Vaccination reduces, but does not eliminate, this excess risk. These findings highlight the need for targeted preventive strategies, including early cardiovascular assessment and intervention, to reduce post-COVID cardiovascular burden in high-risk populations.