Increased in-hospital mortality in COVID-19 patients with myocardial injury and echocardiographic abnormalities
Characterization of Myocardial Injury in Patients With COVID-19Literature - Giustino G, Croft LB, Stefanini GG, et al. - J Am Coll Cardiol. 2020; 76:2043-2055. doi: 10.1016/j.jacc.2020.08.069
Introduction and methods
A significant number of COVID-19 patients that required hospitalization showed myocardial injury, which is associated with increased morbidity and mortality. Identification of myocardial injury in previous studies only occurred by necrotic biomarker detection, and lack CV imaging data to determine structural and functional cardiac abnormalities in COVID-19 patients [1-3].
To address this gap in current knowledge, this study assessed the underlying cardiac abnormalities in hospitalized COVID-19 patients with evidence of myocardial injury by an extensive characterization of myocardial injury using laboratory, electrocardiographic (ECG), and echocardiographic data.
The Cardiac Injury Research in COVID-19 (CIRC-19) registry is an international, multicenter (7 clinical sites at New York City and 2 at Milan), retrospective, cohort study of hospitalized patients with SARS-CoV-2 infection, who had a transthoracic echocardiography (TTE) between March 5 and May 2, 2020. SARS-CoV-2 infection was confirmed by PCR or serological testing. Patients with only a cardiac ultrasound were excluded. Myocardial injury was defined as serum cardiac troponin concentration above the upper reference limit for the used assay. Major echocardiographic abnormalities were defined as the composite of LV wall motion abnormalities, LV global dysfunction, LV grade II or III diastolic dysfunction, RV dysfunction, or presence of a small or larger pericardial effusion. The trial population consisted of 305 patients with a median age of 63 years and 67.2% were men.
The primary endpoint was in-hospital all-cause mortality. Secondary endpoint included: admission to IC-unit, need for mechanical ventilator, acute respiratory distress syndrome (ARDS), stroke, acute kidney injury (AKI), shock, and ventricular fibrillation or tachycardia. Median number of days patients spend in hospital (to discharge, death, or still in hospital) was 14 (IQR: 7-23 days).
- Biomarker evidence of myocardial injury was present in 190 (62.6%) COVID-19 patients. In addition, these patients had significant elevated levels of natriuretic peptides, inflammatory markers (interleukin-6, c-reactive protein, ferritin), serum creatinine, coagulation biomarkers (D-dimer), and peak serum lactate.
- Of the 190 individuals with a myocardial injury, 118 persons had the injury at the time of hospitalization and 72 developed it during their hospital stay.
- ECG-data revealed that more patients with myocardial injury had ST-segment elevation or depression compared to non-myocardial injured COVID-19 patients (P<0.001). The most common ST-segment changes occurred regionally (P=0.001). Other abnormalities that occurred more frequently in patients with myocardial injury compared to those without myocardial injury were low voltage (12.2% vs. 5.2%, P=0.04) or conduction disturbances (20.5% vs 8.7%, P=0.006).
- Patients with myocardial injury also had an increased risk of developing major echocardiographic abnormalities compared to those without myocardial injury (63.2% vs. 21.7%, OR 6.17, 95% CI:3.62-10.51, P<0.0001). Prevalence of major abnormalities that were different between the two groups were global LV dysfunction (P=0.01), regional LV wall motion abnormalities (P<0.0001), grade II or III diastolic dysfunction (P=0.001), RV dysfunction (P=0.004), and pericardial effusions (P=0.02).
- Patients with myocardial injury had an increased risk for in-hospital all-cause death compared to those without myocardial injury (26.8% vs. 5.2%, respectively, P<0.0001), as well as an elevated risk for admission to IC-unit, need for mechanical ventilator, ARDS, stroke, AKI, shock, and ventricular fibrillation or tachycardia (P<0.0001).
- The rates of in-hospital death were 5.2% among patients without myocardial injury with or without structural abnormalities, 21.0% in persons with myocardial injury but without cardiac abnormalities, and 31.2% in individuals with myocardial injury and echocardiographic abnormalities (trend aOR 2.27, 95% CI: 1.3-3.94, P=0.004).
- Multivariable analysis showed an increased risk of mortality in COVID-19 patients with myocardial injury and echocardiographic abnormalities compared to patients without myocardial injury and cardiac abnormalities (aOR 3.87, 95% CI: 1.27-11.80, P=0.02). Patients with myocardial injury without echocardiographic abnormalities had no increased risk of mortality compared to patients without myocardial injury and cardiac abnormalities (aOR 1.00, 95%CI: 0.27-3.71).
In a cohort study of 305 COVID-19 patients, two-third of hospitalized patients showed biomarker evidence of myocardial injury. Of patients with myocardial injury approximately two-third had structural cardiac abnormalities, which was associated with an increased risk for all-cause in-hospital mortality.
The authors recommend TTE in patients with COVID-19 and evidence of myocardial injury to characterize the underlying cardiac substrate for further risk stratification and treatment guidance.