BACKGROUND AND PURPOSE:

• It appears that some patients with COVID-19 have acute cardiac injury
  • Ejection fraction decline | hs-TNI elevation
  • Unclear whether cardiac findings alter outcome
  • Shi et al. (JAMA Cardiology, 2020) examined the association between cardiac injury and mortality in patients with COVID-19

METHODS:

• Cohort study
• Setting
  • A hospital in Wuhan, China | From January 20 to February 10, 2020
• Participants
  • Consecutive inpatients with laboratory-confirmed COVID-19
• Study design
  • Clinical laboratory, radiological, and treatment data were collected and analyzed
  • Cardiac injury definition: Cardiac biomarkers (e.g., hs-TNI) above the 99th-percentile upper reference limit, regardless of new abnormalities in electrocardiography and echocardiography
  • Clinical outcomes compared between patients with and without cardiac injury, with focus on morality rates
  • Adjusted Cox proportional hazard regression model was used, with adjustment for multiple confounders, including age, preexisting cardiovascular, diabetes ARDS and other related disorders

RESULTS:

• 416 patients with confirmed COVID-19
  • Median Age: 64 years (range between 21 and 95 years) | 50.7% female
• Common symptoms
  • Fever: 80.3%
  • Cough: 34.6%
  • Shortness of breath: 28.1%
  • Additional symptoms included fatigue and muscle aches | Diarrhea, chest pain, sore throat. rhinorrhea and headache were also present, but much less common (frequency 3.8% or less)
  • Chest pain was significantly more frequent in cardiac injury group, but only occurred in a minority of patients (13.4% vs 0.9%)
• Cardiac injury: 19.7% of confirmed COVID-19 patients
• Patients with cardiac injury
  • Were older
    • Median age: 74 vs 60 years; P < 0.001
  • Had more comorbidities (eg, hypertension, diabetes, CAD etc.)
    • 59.8% vs 23.4%; P < 0.001
    • There were 7 patients who were pregnant, all in the non-cardiac injury cohort
  • Additional lab abnormalities: Leukocyte counts | CRP | Procalcitonin | CK–MB | Myohemoglobin | (hs-TNI) | N-terminal pro-B-type natriuretic peptide | Aspartate aminotransferase | Creatinine
• Chest radiographic findings were more common in those with cardiac injury
  • Multiple mottling and ground-glass opacity: 64.6% vs 4.5%; P<0.001
• A greater proportion of patients with cardiac injury received
  • Noninvasive mechanical ventilation: 46.3% vs 3.9%; P < 0.001
  • Invasive mechanical ventilation: 22.0% vs 4.2%; P < 0.001
• Complications were more common in patients with cardiac injury
  • 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
  • Coagulopathies: 7.3% vs 1.8%; P = 0.02
• Mortality Rate
  • Patients with cardiac injury had higher mortality: 51.2% vs 4.5%; P < 0.001
  • Mortality increased with hs-TNI levels | ARDS was an independent risk factor for mortality
  • After adjusting for confounders, those with cardiac injury were at higher risk of death
    • During time from symptom onset to study endpoint: Hazard ratio (HR) 4.26; 95% CI, 1.92-9.49
    • Time from admission to study end point: HR, 3.41; 95% CI, 1.62-7.16

CONCLUSION:

• Cardiac injury is common (approximately 20%) and associated with “an unexpected high risk of mortality during hospitalization”
• While the mechanism remains unclear, the authors caution that

…the findings presented here highlight the need to consider this complication in COVID-19 management

Learn More – Primary Sources:

Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China

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