{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T19:09:16Z","timestamp":1788808156416,"version":"build-2803163510"},"reference-count":34,"publisher":"Oxford University Press (OUP)","license":[{"start":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T00:00:00Z","timestamp":1788739200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"National Institute for Health Research Applied Research Collaboration East Midlands"},{"name":"The British Heart Foundation Data Science Centre","award":["SP\/19\/3\/34678"],"award-info":[{"award-number":["SP\/19\/3\/34678"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Individuals with cardiovascular disease (CVD) experienced high mortality during coronavirus disease 2019 (COVID-19), yet most live with multiple long-term conditions (MLTCs). We examined the association between MLTCs burden and mortality following COVID-19 among people with CVD.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In this population-based cohort study, linked national electronic health records from England were analysed. Adults aged \u226518\u00a0years with CVD and a positive COVID-19 test between 31 January 2020 and 31 October 2022 were included. MLTCs burden was defined as the number of additional long-term conditions beyond CVD (0, 1, 2, or\u00a0\u22653). One-year mortality was assessed using adjusted flexible parametric Royston\u2013Parmar models.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>In 1 081 695 individuals with CVD and COVID-19, 89.7% had at least one long-term condition (LTC) and 67.9% had two or more. Increasing MLTC burden showed a dose\u2013response association with mortality. Compared to individuals without additional LTCs, mortality risk was doubled for those with one LTC (adjusted hazard ratio: 1.86, 95% CI: 1.76\u20131.96), tripled among those with two LTCs (3.00, 2.85\u20133.16), and five-fold higher in those with \u22653 LTCs (5.00, 4.75\u20135.27). Associations were consistent across CVD subtypes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>MLTCs burden was a stronger determinant of mortality risk than CVD subtype alone. Findings support moving beyond single-disease models towards integrated, MLTC-informed care, and pandemic preparedness.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/pubmed\/fdag062","type":"journal-article","created":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T19:01:26Z","timestamp":1788807686000},"source":"Crossref","is-referenced-by-count":0,"title":["Increasing burden of multiple long-term conditions and mortality risk following COVID-19 diagnosis: a national cohort study of one million adults with cardiovascular disease in England"],"prefix":"10.1093","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6777-0064","authenticated-orcid":false,"given":"Yogini V","family":"Chudasama","sequence":"first","affiliation":[{"name":"Leicester Real World Evidence Unit, Diabetes Research Centre, Leicester General Hospital, University of Leicester , Gwendolen Road, Leicester, LE5 4PW ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2519-1240","authenticated-orcid":false,"given":"Sharmin","family":"Shabnam","sequence":"additional","affiliation":[{"name":"Leicester Real World Evidence Unit, Diabetes Research Centre, Leicester General Hospital, University of Leicester , Gwendolen Road, Leicester, LE5 4PW ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2343-7099","authenticated-orcid":false,"given":"Kamlesh","family":"Khunti","sequence":"additional","affiliation":[{"name":"Leicester Real World Evidence Unit, Diabetes Research Centre, Leicester General Hospital, University of Leicester , Gwendolen Road, Leicester, LE5 4PW ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3597-2945","authenticated-orcid":false,"given":"Cameron","family":"Razieh","sequence":"additional","affiliation":[{"name":"Leicester Real World Evidence Unit, Diabetes Research Centre, Leicester General Hospital, University of Leicester , Gwendolen Road, Leicester, LE5 4PW ,","place":["UK"]},{"name":"NIHR Leicester Biomedical Research Centre, Diabetes Research Centre , Gwendolen Road, Leicester LE5 4PW ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8417-9700","authenticated-orcid":false,"given":"Clare L","family":"Gillies","sequence":"additional","affiliation":[{"name":"Leicester Real World Evidence Unit, Diabetes Research Centre, Leicester General Hospital, University of Leicester , Gwendolen Road, Leicester, LE5 4PW ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3982-4325","authenticated-orcid":false,"given":"Nazrul","family":"Islam","sequence":"additional","affiliation":[{"name":"Primary Care Research Centre, University of Southampton , University Road, Southampton SO17 1BJ ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5724-5178","authenticated-orcid":false,"given":"Thomas","family":"Yates","sequence":"additional","affiliation":[{"name":"NIHR Leicester Biomedical Research Centre, Diabetes Research Centre , Gwendolen Road, Leicester LE5 4PW ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8741-3411","authenticated-orcid":false,"given":"Amitava","family":"Banerjee","sequence":"additional","affiliation":[{"name":"Institute of Health Informatics, University College London , 222 Euston Road, London NW1 2DA ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5027-5481","authenticated-orcid":false,"given":"Nathalie","family":"Conrad","sequence":"additional","affiliation":[{"name":"Nuffield Department of Women\u2019s and Reproductive Health, University of Oxford , Level 3, Women's Centre, John Radcliffe Hospital, Oxford, OX3 9DU,","place":["UK"]},{"name":"Department of Cardiovascular Sciences , KU Leuven , UZ Herestraat 49, Box 911, 3000 Leuven,","place":["Belgium"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9612-7791","authenticated-orcid":false,"given":"Spiros","family":"Denaxas","sequence":"additional","affiliation":[{"name":"Institute of Health Informatics, University College London , 222 Euston Road, London NW1 2DA ,","place":["UK"]},{"name":"Interdisciplinary Transformation University , Altenberger Stra\u00dfe 66c, A-4040 Linz,","place":["Austria"]},{"name":"National and Kapodistrian University of Athens , 30 Panepistimiou Street, Athens 106 79,","place":["Greece"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0127-5236","authenticated-orcid":false,"given":"Claire","family":"Lawson","sequence":"additional","affiliation":[{"name":"Leicester Real World Evidence Unit, Diabetes Research Centre, Leicester General Hospital, University of Leicester , Gwendolen Road, Leicester, LE5 4PW ,","place":["UK"]},{"name":"Department of Cardiovascular Sciences, University of Leicester , Cardiovascular Research Centre, Glenfield Hospital, Groby Road, Leicester, LE3 9QP ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2636-6487","authenticated-orcid":false,"given":"Francesco","family":"Zaccardi","sequence":"additional","affiliation":[{"name":"Leicester Real World Evidence Unit, Diabetes Research Centre, Leicester General Hospital, University of Leicester , Gwendolen Road, Leicester, LE5 4PW ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,9,7]]},"reference":[{"key":"2026090715012354600_ref1","volume-title":"Coronavirus and Heart & Circulatory Diseases Factsheet","author":"British Heart Foundation","year":"2022"},{"key":"2026090715012354600_ref2","doi-asserted-by":"publisher","first-page":"1239","DOI":"10.1001\/jama.2020.2648","article-title":"Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72\u00a0314 cases from the Chinese Center for Disease Control and Prevention","volume":"323","author":"Wu","year":"2020","journal-title":"JAMA"},{"key":"2026090715012354600_ref3","doi-asserted-by":"publisher","first-page":"110230","DOI":"10.1016\/j.biopha.2020.110230","article-title":"Advances in the relationship between coronavirus infection and cardiovascular diseases","volume":"127","author":"Zhao","year":"2020","journal-title":"Biomed Pharmacother"},{"key":"2026090715012354600_ref4","doi-asserted-by":"publisher","first-page":"e2020018","DOI":"10.23750\/abm.v91i3.9718","article-title":"Cardiovascular system is at higher risk of affecting by COVID-19: COVID-19 and CVD","volume":"91","author":"Nejadghaderi","year":"2020","journal-title":"Acta Biomed"},{"key":"2026090715012354600_ref5","doi-asserted-by":"publisher","first-page":"2327","DOI":"10.1136\/bmj.p2327","article-title":"Multiple long term conditions, multimorbidity, and co-morbidities: we should reconsider the terminology we use","volume":"383","author":"Khunti","year":"2023","journal-title":"BMJ"},{"key":"2026090715012354600_ref6","doi-asserted-by":"publisher","first-page":"336","DOI":"10.1177\/01410768241261507","article-title":"COVID-19-related morbidity and mortality in people with multiple long-term conditions: a systematic review and meta-analysis of over 4 million people","volume":"117","author":"Salisu-Olatunji","year":"2024","journal-title":"J R Soc Med"},{"key":"2026090715012354600_ref7","doi-asserted-by":"publisher","first-page":"1915","DOI":"10.1111\/dom.14124","article-title":"Prevalence of co-morbidities and their association with mortality in patients with COVID-19: a systematic review and meta-analysis","volume":"22","author":"Singh","year":"2020","journal-title":"Diabetes Obes Metab"},{"key":"2026090715012354600_ref8","doi-asserted-by":"publisher","first-page":"334","DOI":"10.1038\/s41591-022-02156-9","article-title":"Comorbidities, multimorbidity and COVID-19","volume":"29","author":"Russell","year":"2023","journal-title":"Nat Med"},{"key":"2026090715012354600_ref9","doi-asserted-by":"publisher","first-page":"100128","DOI":"10.1016\/j.dialog.2023.100128","article-title":"The impact of multimorbidity on severe COVID-19 outcomes in community and congregate settings","volume":"2","author":"Kone","year":"2023","journal-title":"Dialogues Health"},{"key":"2026090715012354600_ref10","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1177\/01410768211051715","article-title":"Association between multimorbidity and mortality in a cohort of patients admitted to hospital with COVID-19 in Scotland","volume":"115","author":"Agrawal","year":"2022","journal-title":"J R Soc Med"},{"key":"2026090715012354600_ref11","volume-title":"General Practice Extraction Service (GPES) Data for Pandemic Planning and Research (GDPPR): A Guide for Analysts and Users of the Data","author":"NHS England Digital"},{"key":"2026090715012354600_ref12","volume-title":"SGSS and SARI Watch Data","author":"NHS England Digital"},{"key":"2026090715012354600_ref13","volume-title":"COVID-19 Second Generation Surveillance System (SGSS)","author":"NHS England Digital"},{"key":"2026090715012354600_ref14","volume-title":"Secure Data Environment","author":"NHS England Digital"},{"key":"2026090715012354600_ref15","volume-title":"CVD-COVID-UK\/COVID-Impact","author":"HDR UK"},{"key":"2026090715012354600_ref16","doi-asserted-by":"publisher","first-page":"n826","DOI":"10.1136\/bmj.n826","article-title":"Linked electronic health records for research on a nationwide cohort of more than 54 million people in England: data resource","volume":"373","author":"Wood","year":"2021","journal-title":"BMJ"},{"key":"2026090715012354600_ref17","doi-asserted-by":"publisher","first-page":"1599","DOI":"10.1093\/eurjpc\/zwaa155","article-title":"Excess deaths in people with cardiovascular diseases during the COVID-19 pandemic","volume":"28","author":"Banerjee","year":"2021","journal-title":"Eur J Prev Cardiol"},{"key":"2026090715012354600_ref18","doi-asserted-by":"publisher","first-page":"1545","DOI":"10.1093\/jamia\/ocz105","article-title":"UK phenomics platform for developing and validating electronic health record phenotypes: CALIBER","volume":"26","author":"Denaxas","year":"2019","journal-title":"J Am Med Inform Assoc"},{"key":"2026090715012354600_ref19","doi-asserted-by":"publisher","first-page":"e542","DOI":"10.1016\/S2589-7500(22)00091-7","article-title":"COVID-19 trajectories among 57 million adults in England: a cohort study using electronic health records","volume":"4","author":"Thygesen","year":"2022","journal-title":"Lancet Digit Health"},{"key":"2026090715012354600_ref20","doi-asserted-by":"publisher","first-page":"e000247","DOI":"10.1136\/bmjmed-2022-000247","article-title":"Measuring multimorbidity in research: Delphi consensus study","volume":"1","author":"Ho","year":"2022","journal-title":"BMJ Med"},{"key":"2026090715012354600_ref21","doi-asserted-by":"publisher","first-page":"908","DOI":"10.1186\/s12879-021-06600-y","article-title":"Patterns of multimorbidity and risk of severe SARS-CoV-2 infection: an observational study in the U.K","volume":"21","author":"Chudasama","year":"2021","journal-title":"BMC Infect Dis"},{"key":"2026090715012354600_ref22","first-page":"339","volume-title":"Flexible Parametric Survival Analysis Using Stata: Beyond the Cox Model","author":"Royston","year":"2011"},{"key":"2026090715012354600_ref23","volume-title":"Conditions Contributing to Deaths Involving COVID-19, by Age Group, United States","author":"CDC","year":"2020"},{"key":"2026090715012354600_ref24","volume-title":"International Comparisons of Possible Factors Affecting Excess Mortality","author":"Office for National Statistics","year":"2022"},{"key":"2026090715012354600_ref25","doi-asserted-by":"publisher","first-page":"1715","DOI":"10.1016\/S0140-6736(20)30854-0","article-title":"Estimating excess 1-year mortality associated with the COVID-19 pandemic according to underlying conditions and age: a population-based cohort study","volume":"395","author":"Banerjee","year":"2020","journal-title":"Lancet"},{"key":"2026090715012354600_ref26","volume-title":"Multiple Long-Term Conditions (Multimorbidity): Making Sense of the Evidence","author":"NIHR NIHR Evidence","year":"2021"},{"key":"2026090715012354600_ref27","doi-asserted-by":"crossref","first-page":"e031736","DOI":"10.1161\/JAHA.123.031736","article-title":"Frailty and cardiovascular health","volume":"13","author":"James","year":"2024","journal-title":"J Am Heart Assoc"},{"key":"2026090715012354600_ref28","volume-title":"COVID-19: Guidance for People whose Immune System Means they are at Higher Risk","author":"GOV.UK","year":"2024"},{"key":"2026090715012354600_ref29","doi-asserted-by":"publisher","first-page":"10","DOI":"10.1177\/01410768221131897","article-title":"Using national electronic health records for pandemic preparedness: validation of a parsimonious model for predicting excess deaths among those with COVID-19-a data-driven retrospective cohort study","volume":"116","author":"Mizani","year":"2023","journal-title":"J R Soc Med"},{"key":"2026090715012354600_ref30","volume-title":"Multimorbidity: A Priority for Global Health Research Portland Place","author":"The Academy of Medical Sciences","year":"2018"},{"key":"2026090715012354600_ref31","doi-asserted-by":"publisher","first-page":"106597","DOI":"10.1016\/j.jinf.2025.106597","article-title":"Post-COVID-19 multimorbidity incidence by prior vaccination status in people with a pre-existing comorbidity: a population-based cohort study","volume":"91","author":"Liu","year":"2025","journal-title":"J Infect"},{"key":"2026090715012354600_ref32","doi-asserted-by":"publisher","first-page":"415","DOI":"10.1038\/s41576-021-00360-w","article-title":"Testing at scale during the COVID-19 pandemic","volume":"22","author":"Mercer","year":"2021","journal-title":"Nat Rev Genet"},{"key":"2026090715012354600_ref33","doi-asserted-by":"publisher","first-page":"e060838","DOI":"10.1136\/bmjopen-2022-060838","article-title":"A systematic review of strategies adopted to scale up COVID-19 testing in low-, middle- and high-income countries","volume":"12","author":"Muttamba","year":"2022","journal-title":"BMJ Open"},{"key":"2026090715012354600_ref34","doi-asserted-by":"publisher","first-page":"e001016","DOI":"10.1136\/bmjmed-2024-001016","article-title":"Combinations of multiple long term conditions and risk of hospital admission or death during winter 2021-22 in England: population based cohort study","volume":"3","author":"Islam","year":"2024","journal-title":"BMJ Med"}],"container-title":["Journal of Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/jpubhealth\/advance-article-pdf\/doi\/10.1093\/pubmed\/fdag062\/70985255\/fdag062.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/jpubhealth\/advance-article-pdf\/doi\/10.1093\/pubmed\/fdag062\/70985255\/fdag062.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,7]],"date-time":"2026-09-07T19:01:30Z","timestamp":1788807690000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jpubhealth\/advance-article\/doi\/10.1093\/pubmed\/fdag062\/8787472"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,7]]},"references-count":34,"URL":"https:\/\/doi.org\/10.1093\/pubmed\/fdag062","relation":{},"ISSN":["1741-3842","1741-3850"],"issn-type":[{"value":"1741-3842","type":"print"},{"value":"1741-3850","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,7]]},"article-number":"fdag062"}}