Patients who are hospitalized with coronavirus disease 2019 (COVID-19) and have an elevated vs normal troponin levels were found to be at higher risk for death, according to a study published in the American Journal of Cardiology.
Researchers reviewed data for all patients with COVID-19 who were admitted to hospitals within the Northwell Health system in New York between March 1, 2020 and April 27, 2020, and had a troponin assessment within 48 hours of admission. They used logistic regression to calculate odds ratios (ORs) for mortality during hospitalization and controlled for demographic factors, comorbidities, and inflammation markers.
Of 11,159 patients hospitalized with COVID-19, 6247 (median age, 66; 60% men) had their troponin levels measured within 48 hours. Within this group, 4426 patients (71%) had normal troponin levels, 919 (15%) had mildly elevated troponin, and 902 (14%) had severely elevated troponin. Acute phase and inflammatory markers were significantly increased in patients who had mildly and severely elevated vs normal troponin levels.
The odds of death among patients with mildly and severely elevated vs normal troponin levels were greater (mild elevation: adjusted OR, 2.06; 95% CI, 1.68-2.53; P <.001; severe elevation: OR, 4.51; 95% CI, 3.66-5.54; P <.001), independent of increases in inflammatory marker levels.
The researchers suggested that multiple mechanisms of myocardial injury may be associated with COVID-19, including injury related to inflammation and cytokine storm, direct viral-mediated injury, hypoxic respiratory failure, downregulation of angiotensin-converting enzyme 2 receptors, hypercoagulability, diffuse myocardial endothelial injury, and acute plaque rupture.
“While we did not measure changes in troponin over time, elevations in troponin likely reflected imbalance between myocardial oxygen supply and demand,” noted the investigators. “However, direct myocardial involvement cannot be excluded and myocarditis associated with COVID-19 remains poorly defined.”
Study limitations include its retrospective and observational design, and the fact that troponin assessments were not conducted on all patients, which may affect the strength of the association between troponin and mortality.
“We observed that patients hospitalized with COVID-19 and elevated troponin had a significant increase in the risk [for] death, and that patients with severely elevated troponin fared worse than those with mildly elevated troponin,” noted the study authors. “The risk [for] death was independent of cardiovascular disease and elevated acute phase and inflammatory markers, but it was not associated with electrocardiogram evidence of acute myocardial infarction.”
The researchers recommended that patients who are admitted with COVID-19 should have an assessment of troponin to assist in risk stratification and to identify those who may need further evaluation and a higher level of care.
Majure DT, Gruberg L, Saba SG, et al; for the Northwell Health COVID-19 Research Consortium. Usefulness of elevated troponin to predict death in patients with COVID-19 and myocardial injury. [published online October 12, 2020]. Am J Cardiol. doi: https://doi.org/10.1016/j.amjcard.2020.09.060