Characterization of Myocardial Injury in Patients With COVID-19
Gennaro GiustinoLori B. CroftGiulio StefaniniRenato BragatoJeffrey J. SilbigerMarco VicenziTatyana DanilovNina KukarNada M. ShabanAnnapoorna KiniAnton CamajSolomon BienstockEman RashedKarishma RahmanConnor P. OatesSamantha BuckleyLindsay ElbaumDerya E. ArkonacRyan FiterRanbir SinghEmily LiVictor RazukSam RobinsonMichael S. MillerBenjamin BierValeria DonghiMarco PisanielloRiccardo MantovaniGiuseppe PintoIrene RotaMauro ChiaritoFabio FazzariIgnazio CusmanoMirko CurziRichard RoWaqas MalickMazullah KamranRoopa Kohli‐SethAdel Bassily‐MarcusEric NeibartGregory SerraoGila PerkDonna ManciniVivek Y. ReddySean PinneyGeorge DangasFrancesco BlasiSamin K. SharmaRoxana MehranGianluigi CondorelliGregg W. StoneValentı́n FusterStamatios LerakisMartin E. Goldman
Key result
Myocardial injury with echocardiographic abnormalities in COVID-19 linked to ~6-fold higher in-hospital mortality.
- n=305
Journal of the American College of Cardiology published a graphical abstract
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Why the study?
Myocardial injury is frequent in hospitalized COVID-19 patients and linked to poor prognosis, but mechanisms and cardiovascular imaging data remain unclear.
Does myocardial injury, and the presence of echocardiographic abnormalities, affect in-hospital mortality in hospitalized patients with COVID-19?
Key Points
- To characterize echocardiographic abnormalities associated with myocardial injury and determine their prognostic impact on mortality in hospitalized COVID-19 patients.
- Conducted an international multicenter cohort study across seven hospitals in New York City and Milan analyzing hospitalized patients with laboratory-confirmed COVID-19 (N=305; mean age 63 years, 67.2% male).
- Evaluated patients using transthoracic echocardiography (TTE) and electrocardiograms; myocardial injury was defined as elevated cardiac troponin at baseline or during index hospitalization.
- Myocardial injury occurred in 62.3% of patients (190/305) and correlated with higher inflammatory markers, left and right ventricular dysfunction, wall motion abnormalities, and pericardial effusions.
- In-hospital mortality was 5.2% in patients without myocardial injury, 18.6% in those with myocardial injury without TTE abnormalities, and 31.7% in those with both myocardial injury and TTE abnormalities.
- After multivariable adjustment, myocardial injury with TTE abnormalities was significantly associated with higher risk of death, whereas myocardial injury without TTE abnormalities was not.
Study Design
Type
Cohort (n=305)
Multicenter
Yes
Structured PICO
Does myocardial injury, and the presence of echocardiographic abnormalities, affect in-hospital mortality in hospitalized patients with COVID-19?
P
Population
305 hospitalized patients (mean age 63, 32.8% female) with laboratory-confirmed COVID-19 who underwent TTE and ECG during index hospitalization.
E
Exposure
Myocardial injury (defined as any elevation in cardiac troponin at the time of clinical presentation or during hospitalization) with and without TTE abnormalities.
C
Comparator
Patients without myocardial injury.
O
Outcome
Echocardiographic abnormalities and in-hospital mortality.hard clinical
Main Result
Absolute Event Rate: 31.7% vs 5.2%
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Understanding the substrate gives you information on whether you need further diagnostic workup or if you need to adopt specific treatments. If you have wall motion abnormalities, that can be secondary to thrombosis in the epicardial coronary arteries or in the microcirculation. If you have global dysfunction, that would be, perhaps, myocarditis. If you have right ventricular dysfunction, that can be very bad respiratory failure or pulmonary embolism. All that starts to give you some sense of what is happening pathophysiologically to a patient.”
“This is one of the first studies to provide detailed echocardiographic and electrocardiographic data in hospitalized patients with COVID-19 and laboratory evidence of myocardial injury. We found that among COVID-19 patients who underwent transthoracic echocardiography, these cardiac structural abnormalities were diverse and present in nearly two-thirds of patients.”
VFValentin FusterDirector of Mount Sinai Heart, Mount Sinai Hospital
“Early detection of structural abnormalities may dictate more appropriate treatments, including anticoagulation and other approaches for hospitalized and post-hospitalized patients.”
Implication
Among patients hospitalized with COVID-19, myocardial injury is highly prevalent and is associated with structural cardiac abnormalities and significantly increased in-hospital mortality.
Abstract
Background Myocardial injury is frequent among patients hospitalized with coronavirus disease-2019 (COVID-19) and is associated with a poor prognosis. However, the mechanisms of myocardial injury remain unclear and prior studies have not reported cardiovascular imaging data. Objectives This study sought to characterize the echocardiographic abnormalities associated with myocardial injury and their prognostic impact in patients with COVID-19. Methods We conducted an international, multicenter cohort study including 7 hospitals in New York City and Milan of hospitalized patients with laboratory-confirmed COVID-19 who had undergone transthoracic echocardiographic (TTE) and electrocardiographic evaluation during their index hospitalization. Myocardial injury was defined as any elevation in cardiac troponin at the time of clinical presentation or during the hospitalization. Results A total of 305 patients were included. Mean age was 63 years and 205 patients (67.2%) were male. Overall, myocardial injury was observed in 190 patients (62.3%). Compared with patients without myocardial injury, those with myocardial injury had more electrocardiographic abnormalities, higher inflammatory biomarkers and an increased prevalence of major echocardiographic abnormalities that included left ventricular wall motion abnormalities, global left ventricular dysfunction, left ventricular diastolic dysfunction grade II or III, right ventricular dysfunction and pericardial effusions. Rates of in-hospital mortality were 5.2%, 18.6%, and 31.7% in patients without myocardial injury, with myocardial injury without TTE abnormalities, and with myocardial injury and TTE abnormalities. Following multivariable adjustment, myocardial injury with TTE abnormalities was associated with higher risk of death but not myocardial injury without TTE abnormalities. Conclusions Among patients with COVID-19 who underwent TTE, cardiac structural abnormalities were present in nearly two-thirds of patients with myocardial injury. Myocardial injury was associated with increased in-hospital mortality particularly if echocardiographic abnormalities were present.
Discussion
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Cite This Study
Giustino et al. (2020) conducted a cohort in COVID-19 (n=305). Myocardial injury with echocardiographic abnormalities vs. No myocardial injury was evaluated on In-hospital mortality. Among hospitalized patients with COVID-19, myocardial injury with echocardiographic abnormalities was associated with an in-hospital mortality rate of 31.7%, compared with 5.2% in those without injury.