Myocardial Injury in Severe COVID-19 Compared With Non-COVID-19 Acute Respiratory Distress Syndrome

Thomas S Metkus, Lori J Sokoll, Andreas S Barth, Matthew J Czarny, Allison G Hays, Charles J Lowenstein, Erin D Michos, Eric P Nolley, Wendy S Post, Jon R Resar, David R Thiemann, Jeffrey C Trost, Rani K Hasan, Thomas S Metkus, Lori J Sokoll, Andreas S Barth, Matthew J Czarny, Allison G Hays, Charles J Lowenstein, Erin D Michos, Eric P Nolley, Wendy S Post, Jon R Resar, David R Thiemann, Jeffrey C Trost, Rani K Hasan

Abstract

Background: Knowledge gaps remain in the epidemiology and clinical implications of myocardial injury in coronavirus disease 2019 (COVID-19). We aimed to determine the prevalence and outcomes of myocardial injury in severe COVID-19 compared with acute respiratory distress syndrome (ARDS) unrelated to COVID-19.

Methods: We included intubated patients with COVID-19 from 5 hospitals between March 15 and June 11, 2020, with troponin levels assessed. We compared them with patients from a cohort study of myocardial injury in ARDS and performed survival analysis with primary outcome of in-hospital death associated with myocardial injury. In addition, we performed linear regression to identify clinical factors associated with myocardial injury in COVID-19.

Results: Of 243 intubated patients with COVID-19, 51% had troponin levels above the upper limit of normal. Chronic kidney disease, lactate, ferritin, and fibrinogen were associated with myocardial injury. Mortality was 22.7% among patients with COVID-19 with troponin under the upper limit of normal and 61.5% for those with troponin levels >10 times the upper limit of normal (P<0.001). The association of myocardial injury with mortality was not statistically significant after adjusting for age, sex, and multisystem organ dysfunction. Compared with patients with ARDS without COVID-19, patients with COVID-19 were older and had higher creatinine levels and less favorable vital signs. After adjustment, COVID-19-related ARDS was associated with lower odds of myocardial injury compared with non-COVID-19-related ARDS (odds ratio, 0.55 [95% CI, 0.36-0.84]; P=0.005).

Conclusions: Myocardial injury in severe COVID-19 is a function of baseline comorbidities, advanced age, and multisystem organ dysfunction, similar to traditional ARDS. The adverse prognosis of myocardial injury in COVID-19 relates largely to multisystem organ involvement and critical illness.

Trial registration: ClinicalTrials.gov NCT04435184.

Keywords: COVID-19; respiratory distress syndrome; troponin.

Figures

Figure 1.
Figure 1.
Mortality within each category of troponin level and distribution of troponin stratified by survival status. A, Mortality within each category of troponin level (P<0.001 for difference in proportions and for trend). B, Distribution of troponin stratified by survival status (P<0.001 for difference in proportions). COVID-19 indicates coronavirus disease 2019; and ULN, upper limit of normal.
Figure 2.
Figure 2.
Kaplan-Meier survival curves for intubated patients with COVID-19. Kaplan-Meier survival curves for intubated patients with COVID-19 by presence of any myocardial injury (A) and by category of troponin level (B). COVID-19 indicates coronavirus disease 2019; and ULN, upper limit of normal.
Figure 3.
Figure 3.
Univariable and adjusted hazard ratios for intubated patients with COVID-19 by presence of any myocardial injury and by category of troponin level. Cox proportional hazard models adjusted first for age and sex and then for age, sex, creatinine, bilirubin, Pao2/FIo2 ratio, vasopressor use, and lactate levels. COVID-19 indicates coronavirus disease 2019; and ULN, upper limit of normal.
Figure 4.
Figure 4.
Kaplan-Meier survival curves for COVID-19 versus ARDS pneumonia and presence or absence of myocardial injury. ARDS indicates acute respiratory distress syndrome; and COVID-19, coronavirus disease 2019.

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