Cardiac Injury Common in Patients With COVID-19, Associated With Increased Mortality

Cardiac injury was found to be common in patients with coronavirus disease 2019 (COVID-19) hospitalized at a single center in Wuhan, China medical center, and to be associated with a greater risk for in-hospital mortality, according to a study published in JAMA Cardiology.

In this retrospective cohort analysis, the data of 416 patients hospitalized for COVID-19 (median age, 64 years; range, 21-95 years; 50.7% women) with available cardiac biomarker information who were treated at a single center between January 20, 2020 and February 10, 2020, and followed through February 15, 2020, were examined. Clinical, laboratory, radiographic, and therapeutic data were available on electronic medical records. Patient outcomes were compared in those with and without cardiac injury, and the relationship between rates of cardiac injury and in-hospital mortality was assessed using multivariable-adjusted Cox regression modeling.

In this cohort, the most common presenting symptoms were fever (n=334; 80.3%), cough (n=144; 34.6%), and shortness of breath (n=117; 28.1%). A total of 82 patients (19.7%; median age, 74 years; range, 34-95 years; 46.3% women) had cardiac injury, and 334 patients (80.3%; median age, 60 years; range, 21-90 years; 51.8% women) did not. Patients with vs without cardiac injury were older (P <.001), had more comorbidities, including hypertension (59.8% vs 23.4%, respectively; P <.001), diabetes mellitus (24.4% vs 12.0%, respectively; P =.008), and coronary heart disease (29.3% vs 6.0%, respectively; P <.001).

Patients with vs without cardiac injury also had elevated leukocyte counts (median, 9400; interquartile range [IQR], 6900-13,800 vs 5,500; IQR, 4200-7400, respectively) and higher levels of: creatinine (median, 1.15 mg/dL; IQR, 0.72-1.92 vs 0.64 mg/dL IQR, 0.54-0.78, respectively), aspartate aminotransferase (median, 40 U/L; IQR, 27-60 vs 29 U/L; IQR, 21-40, respectively), N-terminal pro-B-type natriuretic peptide (median, 1,689 pg/mL; IQR, 698-3,327 vs 139 pg/mL; IQR, 51-335, respectively), high-sensitivity troponin I (median, 0.19 𝜇g/L; IQR, 0.08-1.12 vs <0.006 𝜇g/L;  IQR, <0.006-0.009, respectively, myohemoglobin (median, 128 𝜇g/L; IQR, 68-305 vs 39 𝜇g/L; IQR, 27-65, respectively), creatinine kinase-myocardial band (median, 3.2 ng/mL; IQR, 1.8-6.2 vs 0.9 ng/mL; IQR, 0.6-1.3, respectively), procalcitonin (median, 0.27 ng/mL; IQR, 0.10-1.22 vs 0.06 ng/mL; IQR, 0.03-0.10, respectively), and C-reactive protein (median, 10.2 mg/dL; IQR, 6.4-17.0 vs 3.7 mg/dL; IQR, 1.0-7.3, respectively; P <.001 for all).

A greater percentage of patients with vs without cardiac injury had ground-glass infiltrates and multiple mottling, as assessed on chest x-ray or computed tomography (64.6% vs 4.5%, respectively; P <.001).

A larger percentage of patients with vs without cardiac injury required noninvasive mechanical ventilation (46.3% vs 3.9%, respectively) or invasive mechanical ventilation (22.0% vs 4.2%, respectively; P <.001 for both).

There were more frequent complications in patients with vs without cardiac injury, including acute respiratory distress syndrome (ARDS; 58.5% vs 14.7%, respectively) and acute renal injury (8.5% vs 0.3%, respectively), (P <.001 for both), as well as electrolyte disturbances (15.9% vs 5.1%, respectively; P =.003), hypoproteinemia (13.4% vs 4.8%, respectively; P =.01), and disorders of coagulation (7.3% vs 1.8%, respectively; P =.02).

The rate of in-hospital mortality was greater in patients with vs without cardiac injury (51.2% vs 4.5%, respectively; P <.001), and the risk for mortality was greater in patients with vs without cardiac injury, from symptom onset (hazard ratio [HR], 4.26; 95% CI, 1.92-9.49; P <.001) and hospital admission (HR, 3.41; 95% CI, 1.67-7.16; P =.001) to the end of follow-up. Independent associations were established between cardiac injury and in-hospital death and between the occurrence of ARDS and mortality (P <.001 for both).

Study limitations include its single-center setup, small sample size, and ongoing clinical observation for some patients.

“Although the exact mechanism of cardiac injury needs to be further explored, the findings presented here highlight the need to consider this complication in COVID-19 management,” noted the study authors.

Reference

Shi S, Qin M, Shen B, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol. March 2020:E1-E8. doi:10.1001/jamacardio.2020.0950