Characterization of Myocardial Injury in Patients With COVID-19

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.

Keywords: COVID-19; echocardiography; myocardial infarction; myocardial injury.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Figures

Graphical abstract

Central Illustration

Spectrum of Echocardiographic Abnormalities in Patients With Biomarker Evidence of Myocardial Injury and Coronavirus Disease-2019 Among patients with coronavirus disease-2019 (COVID-19) who underwent transthoracic echocardiography (TTE), cardiac structural abnormalities were present in nearly two-thirds of patients with myocardial injury. Cardiac structural abnormalities included right ventricular dysfunction, left ventricular (LV) wall motion abnormalities, global left ventricular dysfunction, diastolic dysfunction, and pericardial effusions.

Figure 1

In-Hospital Mortality in Patients With COVID-19, Myocardial Injury, and Echocardiographic Abnormalities Kaplan-Meier curves for all-cause mortality in patients with versus without myocardial injury (A) and in patients with versus without myocardial injury according to the presence or absence of major echocardiographic abnormalities (B). Includes wall motion abnormalities, global left ventricular dysfunction, diastolic dysfunction, right ventricular dysfunction, and presence of pericardial effusion. Event rates are censored at 20 days from hospital admission. TTE = transthoracic echocardiography.

Figure 2

Independent Predictors of In-Hospital Death From Multivariable Logistic-Regression Analysis Results are reported as odds ratios (ORs) and 95% confidence intervals (CIs). The following variables were included in the final model: age, sex, race, history of heart failure, acute respiratory distress syndrome, acute kidney injury stage II or III, cardiocirculatory shock, myocardial injury (with or without major echocardiographic abnormalities), and center identifier. ∗Includes wall motion abnormalities, global left ventricular dysfunction, diastolic dysfunction, right ventricular dysfunction, or presence of mild or more severe pericardial effusion.