Higher risk of mortality in hospitalized patients with COVID-19-associated cardiac injury
Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, ChinaLiterature - Shi S, Qin M, Shen B et al. - JAMA Cardiol. 2020, doi: 10.1001/jamacardio.2020.0950.
Introduction and methods
It has been reported that 12% of COVID-19 patients had COVID-19-associated acute cardiac injury . Cardiac implications of COVID-19 have also been addressed in the American Collage of Cardiology clinical bulletin . However, the association between COVID-19-associated cardiac injury and mortality is unclear.
This retrospective single-center study explored the association between cardiac injury and mortality in COVID-19 patients in Wuhan, China. The total study population included 416 patients hospitalized with confirmed COVID-19. The median age was 64 years (21-95 years) and 50.7% were female. Cardiac injury was defined as high-sensitivity troponin I (hs-TNI) blood levels above the 99th-percentile upper reference limit, regardless of new abnormalities in electrocardiography and echocardiography. 82 patients (19.7%) had cardiac injury and 334 patients (80.3%) had no cardiac injury.
Patient characteristics, clinical laboratory, radiological, and treatment data were compared between COVID-19 patients with and without cardiac injury, and the association between cardiac injury and mortality was analyzed.
- Comorbidities were more prevalent among patients with cardiac injury compared to those without cardiac injury ( hypertension 59.8% vs 23.4%, diabetes 24.4% vs 12.0%, coronary heart disease 29.3% vs 6.0%, cerebrovascular disease 15.9% vs 2.7%, chronic heart failure 14.6% vs 1.5%, chronic obstructive pulmonary disease 7.3% vs 1.8%, cancer 8.5% vs 0.6%, all P<0.001).
- Patients with cardiac injury had higher median leukocyte count, C-reactive protein levels, procalcitonin, CKMB, myohemoglobin, hs-TNI, NT-proBNP, asparate aminotransferase and creatinine, but lower median lymphocyte count, platelet count and albumin levels during hospitalization compared to patients without cardiac injury (all P<0.001).
- Bilateral pneumonia, and multiple mottling and ground-glass opacity were more prevalent in patients with cardiac injury compared to those without cardiac injury (bilateral pneumonia: 91.5% vs 70.7%, multiple mottling and ground-glass opacity 64.4% vs 4.5%, both P<0.001).
- Patients with cardiac injury required more noninvasive and invasive ventilation, compared to those without cardiac injury (noninvasive ventilation 46.3% vs 3.9%, invasive mechanical ventilation 22.0% vs 4.2%, both P<0.001).
- Use of antibiotic treatment, glucocorticoids and intravenous immunoglobulin treatment was more prevalent in patients with than without cardiac injury (antibiotic treatment: 82.9% vs 50.0%, glucocorticoids: 87.8% vs 69.5%, intravenous immunoglobulin: 82.9% vs 57.2%, all P<0.001).
- In addition to anemia, other complications that were more prevalent in patients with vs without cardiac injury included ARDS (58.5% vs. 14.7%, P<0.001), acute kidney injury (8.5% vs 0.3%, P<0.001), electrolyte disturbances (15.9% vs 5.1%, P=0.003), hypoproteinemia (13.4% vs 4.8%, P=0.01) and coagulation disorders (7.3% vs 1.8%, P=0.02).
- A higher mortality rate was observed among patients with cardiac injury compared to those without cardiac injury (51.2% vs 4.5%, P<0.001), with HR: 4.26 (95%CI 1.92-9.49) during time from symptom onset, or HR: 3.41 (95%CI 1.62-7.16) during time from admission to study end point, after multivariable adjustment.
- ARDS was also an independent risk factor for mortality with COVID-19, either during time from symptom onset (HR 7.89, 95%CI 3.73-16.66), or time from admission to study end point (HR 7.11, 95%CI 3.31-15.25), after multivariable adjustment.
In this retrospective cohort study in Wuhan, China, cardiac injury occurred in 19.7% of hospitalized COVID-19 patients and these hospitalized COVID-19 patients with cardiac injury had a higher risk of in-hospital mortality compared to COVID-19 patients without cardiac injury.