Elevated cTn, D-Dimer, and CRP May Identify Risk for Adverse Events in Hospitalized Patients With COVID-19

A combination of biomarkers including CRP, cardiac troponin, and D-dimer effectively provided prognostic information for patients hospitalized with COVID-19.

A multiple biomarker strategy that risk stratifies hospitalized patients with 2019 coronavirus disease (COVID-19) based on elevated cardiac troponin (cTn), D-dimer, and C- reactive protein (CRP) levels was effective for measuring risk for in-hospital adverse events, according to a study published in Circulation.

A team of researchers from the New York University Langone Health (NYULH) system identified 2895 consecutive adults hospitalized with COVID-19 in their system between March and April 2020. Only patients who had cTn, D-dimer, and CRP measured were included in this study.

Approximately 98.5% of the patients had an initial CRP concentration above the upper limit of normal, with the investigators defining increased inflammation as a CRP >50 mg/L (n=2261). The investigators assessed comorbidities and all-cause in-hospital mortality.

At admission, the median cTn, D-Dimer, and CRP values were 0.015 ng/mL, 403 ng/mL, and 113 mg/L, respectively. Separate associations were found between continuous CRP (C-statistic 0.611; 95% CI, 0.587-0.634), D-dimer (C-statistic, 0.639; 95% CI, 0.615-0.664), and troponin (C-statistic, 0.680; 95% CI, 0.655-0.705) concentrations and mortality.

Stepwise increases in the risk of adverse events were observed in patients with 1, 2, or 3 elevated biomarkers.

Although the number of elevated biomarkers produced a C-statistic of 0.672 (95% CI, 0.649-0.696) for mortality, there was no difference in model performance compared with continuous data for all the studied biomarkers (C-statistic, 0.657; 95% CI, 0.633-0.681; P =.17). When the investigators added the number of elevated biomarkers to an adjusted model, the C-statistic improved (C-statistic, 0.765; 95% CI, 0.745-0.785 to 0.789; 95% CI, 0.770-0.807; P <.001), as well as the appropriate risk reclassification for mortality (NRI, 0.227; 95% CI, 0.141-0.313).

Limitations of this study included its retrospective nature and the inclusion of patients with COVID-19 from a single center.

“The combination of abnormalities across these pathobiological axes of disease provided incremental prognostic information for risk stratification,” the study authors concluded.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Smilowitz NR, Nguy V, Aphinyanaphongs Y, et al. Multiple biomarker approach to risk stratification in COVID-19. Published online February 15, 2021. Circulation. doi:10.1161/CIRCULATIONAHA.120.053311