Myocardial injury in patients hospitalized for SARS-CoV19: a maker or a marker of prognosis?

Abstract Background Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, literature data are progressively accumulating, attesting to the possible prognostic role of cardiac troponins in patients who need hospitalization because of COVID-19 infection. Purpose To assess whether myocardial injury (measured by high sensitivity troponins) is an independent cause of disease severity and prognosis. Methods We performed a patient-level metanalysis (PROSPERO ID: CRD42020213209) in unselected patients hospitalized because of COVID-19 infection in whom the severity of respiratory failure was also evaluated at admission. To allow for comparison, troponin values were normalized to their threshold levels to obtain a normalized troponin (nTn) value which was used as a continuous variable in all analysis. Results A total of 722 patients were included in the analysis. Of note, patients who had elevated troponins at hospital admission had a significantly lower oxygenation status than those with normal nTn (PaO2/FiO2 232±215 vs. 276±124 mmHg/%; p<0.001). On the contrary, those with cardiovascular comorbidities had similar PaO2/FiO2 but higher nTn than those without (5.6817 vs. 2.1110 ng/mL; p=0.002). After a median follow-up of 14 days, 180 deaths were observed. At multivariable regression analysis, age, male sex, moderate-severe renal dysfunction (eGFR <30 mL/min/m2) and lower PaO2/FiO2, were independent predictor of death (igure 1). The restricted cubic spline curves in Figure 2A and 2B show the hazard ratios (HRs) and 95% confidence interval for death according to nTn and PaO2/FiO2 levels as continuous variables. A linear increase in the HR is observed with lower PaO2/FiO2 values below the normal value of 300. On the contrary, the nTn spline curve is near-flat with large confidence interval for values above the normality thresholds. Conclusion In patients hospitalized for COVID-19, mortality is mainly driven by gender, age and respiratory failure while myocardial damage is not an independent predictor of worse survival when respiratory function is accounted for. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Figure 2

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Abstract 16790: Myocardial Injury is an Independent Predictor of Mortality in Patients With COVID-19

Circulation ◽

10.1161/circ.142.suppl_3.16790 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Matteo Nardin ◽

Davide Cao ◽

Mauro Chiarito ◽

Johny Nicolas ◽

Samantha Sartori ◽

...

Keyword(s):

Myocardial Injury ◽

Independent Predictor ◽

Tertiary Care ◽

Myocardial Damage ◽

High Sensitivity ◽

Adverse Outcomes ◽

Kinetics Parameters ◽

Stepwise Increase ◽

Comorbidity Burden ◽

Secondary Endpoints

Introduction: Recent reports on COVID-19 patients have shown that elevated troponin (Tn) levels on hospital admission are associated with adverse outcomes. However, no data exists on the predictive role of Tn kinetics parameters in COVID-19 patients. Aim: To analyze the incidence, clinical outcomes and predictors of Tn kinetics parameter, including rise/fall pattern and peak values, in a large cohort of COVID-19 hospitalized patients. Methods: All consecutive patients admitted to an urban tertiary-care health system between February and June 2020 with COVID-19 were included. Patients were grouped according to presence of myocardial injury defined as a high-sensitivity TnI level ≥0.1 ng/ml. A TnI level between 0.4-0.99 was defined as low positive range Tn elevation. Results: We included 5862 COVID-19 patients, 1558 (27%) of whom experienced myocardial injury. Advance age, male sex and higher comorbidity burden, including COPD, hypertension, CAD, atrial fibrillation, HF, CKD, and diabetes were more common in patients with myocardial injury. A total of 828/1558 (53.2%) of patients with myocardial injury died as compared to 634/4304 (14.7%) of those without (OR 6.57, 95% CI 5.76-7.48; p<0.001). After adjustment for baseline imbalances, myocardial injury remained an independent predictor of mortality (Adj.OR 5.26, 95% CI 4.57-6.05; p<0.001). Further stratification of patients into low positive range Tn elevation and myocardial injury groups showed a significant stepwise increase in mortality rates with increasing Tn values (Figure). Secondary endpoints, as shown in the Figure, occurred more frequently in patients with myocardial injury.Data on Tn kinetics parameters,such as rise/fall patterns,and associations with the outcomes will also be presented. Conclusions: Myocardial injury is an independent predictor of all-cause mortality in COVID-19 patients,with a stepwise increase in the risk of mortality reflecting increasing extent of myocardial damage.

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Elevated circulating high-sensitivity cardiac troponin t and cardiac remodeling in obesity

BMC Cardiovascular Disorders ◽

10.1186/s12872-021-02445-0 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Jiaojiao Huang ◽

Ming Liu ◽

Enyong Su ◽

Peng Yu ◽

Hong Jiang ◽

...

Keyword(s):

Coronary Heart Disease ◽

Heart Disease ◽

Myocardial Injury ◽

Troponin T ◽

High Sensitivity ◽

Coronary Intervention ◽

Continuous Variables ◽

Chi Square ◽

Chi Square Test ◽

The Impact

Abstract Background It is well established that body mass index (BMI) and troponins are independently associated. However, whether the obesity could cause myocardial injury independent of coronary heart disease (CHD) remains unclear. This study focuses on the relationship between BMI and troponins, and whether this relationship is being attenuated when CHD is accounted for. Methods In populations without acute ischemic events, 383 patients with coronary artery stenosis less than 75% were included, that is, people who have not yet reached the indications for coronary intervention, and of them 70 patients being obese according to BMI ≥ 28 kg/m2. Continuous variables were represented as mean ± SD or median(inter quartile range[IQR]). Chi-square test was adopted for categorical data. Correlations between variables were evaluated by Spearman analysis, multiple regression or logistic regression. Results The circulating hs-cTnT level was higher in the obese group [8(6,11) ng/L vs. 6(4,9) ng/L; p < 0.001). In subgroup analysis based on the presence or absence of coronary heart disease(CHD), the adjusted β(95%CI) for circulating hs-cTnT exhibited a proportional relationship with BMI when the non-obesity were defined as the reference[β; 2.22(95%CI, 0.73 to 3.71) in non-CHD, 5.58(95%CI, 0.70 to 10.46) in CHD, p < 0.05]. Additionally, the degree of coronary stenosis has shown a positive correlation with circulating hs-cTnT (rho = 0.1162; p < 0.05). Conclusion When CHD is taken into account, obesity is independently associated to the elevation of circulating hs-cTnT, a biomarker of myocardial injury, potentially indicating the impact of obesity on non-ischemic subclinical myocardial injury.

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Influence of myocardial damage on serum procalcitonin in ST-elevation myocardial infarction

European Heart Journal ◽

10.1093/ehjci/ehaa946.1560 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Reindl ◽

C Tiller ◽

M Holzknecht ◽

I Lechner ◽

B Henninger ◽

...

Keyword(s):

Myocardial Infarction ◽

Myocardial Injury ◽

Release Kinetics ◽

Myocardial Damage ◽

High Sensitivity ◽

St Elevation Myocardial Infarction ◽

Funding Source ◽

St Elevation ◽

Hs Crp ◽

Cmr Imaging

Abstract Background Myocardial tissue injury due to acute ST-elevation myocardial infarction (STEMI) initiates an inflammatory response with a release of systemic inflammatory biomarkers including C-reactive protein (CRP) and white blood cell count (WBCc), which, however, hampers the usefulness of these routine biomarkers to identify concomitant infections. The clinical role of Procalcitonin (PCT), a promising marker of bacterial infections, to detect concomitant infections in acute STEMI is unknown, mainly because it is unclear whether myocardial injury per se induces a systemic PCT release. Purpose To investigate release kinetics of serum PCT in the acute setting of STEMI and possible associations with myocardial injury markers as comprehensively assessed by cardiac magnetic resonance (CMR) imaging. Methods In this prospective observational study, we included 141 STEMI patients treated with primary percutaneous coronary intervention (PCI). Concentrations of PCT, high-sensitivity CRP (hs-CRP), WBCc and high-sensitivity cardiac troponin T (hs-cTnT) were measured serially at day 1 and day 2 after infarction. CMR imaging to assess infarct size (IS), extent of microvascular injury (MVI) and occurrence of intramyocardial haemorrhage (IMH) was performed within the first week following STEMI. Results Median concentrations of PCT were 0.07μg/l at both time points. In 140 patients (99%), both PCT values were within the normal range (≤0.5μg/l). Whereas hs-CRP, WBCc, and hs-TnT were significantly correlated with CMR markers of myocardial damage, PCT did not show significant correlations (all p>0.10) with IS (PCT24h: r=0.07; PCT48h: r=0.13) or MVI (PCT24h: r=−0.03; PCT48h: r=0.09). Furthermore, PCT failed to discriminate between large and small IS or MVI or between presence and absence of IMH (AUC values:0.46–0.55). Conclusions In the acute phase after PCI for STEMI, circulating PCT remained unaffected by the extent of myocardial and microvascular tissue damage as visualized by CMR imaging. These data highlight the clinical potential of PCT to identify concomitant infections and to guide antibiotic treatments in STEMI patients. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund, Tiroler Wissenschaftsförderung

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Association of SYNTAX score with myocardial injury in STEMI patients: a cardiac magnetic resonance study

10.21203/rs.3.rs-295060/v1 ◽

2021 ◽

Author(s):

Guangren Gao ◽

Lianrong Feng ◽

Jinguo Fu ◽

Zhaoyang Huo ◽

Lei Zhang ◽

...

Keyword(s):

Cardiac Magnetic Resonance ◽

Magnetic Resonance ◽

Confidence Interval ◽

Myocardial Injury ◽

Operating Characteristic ◽

High Sensitivity ◽

Syntax Score ◽

Myocardial Salvage ◽

Area At Risk ◽

Receiver Operating Characteristic Curves

Abstract SYNTAX score (SS) is positively correlated with postprocedural myocardial injury identified by high sensitivity cardiac troponin in patients undergone elective coronary artery intervention, evidences about the association of SS with myocardial injury in STEMI patients were still scarce. A total of 149 consecutive patients within 24 h of STEMI were enrolled in the study. Both angiography and cardiac magnetic resonance (CMR) were performed during hospitalization. The time was 7.05 h (4.44,95.91, IQR) from symptom to angiography and 7.31 ± 2.60 days from symptom to CMR. The total median SS was 17(9–25, IQR). In terms of myocardial injury parameters, there was a positive correlation between SS and infarct size (IS) (p < 0.001, Spearman r = 0.292), and negative correlation between SS and myocardial salvage index (MSI) (p < 0.001, Spearman r=-0.314). There was no significant correlation between SS and area at risk, microvascular obstruction or intramyocardial hemorrhage. According to SS, patients were divided into low SS (< 22) (LSS)(n = 96) or mediate-high SS (≥ 22) (MHSS)(n = 53) group. In the multivariable model, after adjustment for important known predictors of IS, MHSS was significantly associated with high IS (≥ mean 35.43) (odd ratio = 2.245, 95% confidence interval [1.002–5.053], p = 0.048), as a continuous variate, SS was also significant associated with high IS (odd ratio = 1.053, 95% confidence interval [1.014–1.095], p = 0.008). The areas under the receiver operating characteristic curves of SS for high IS and low MSI were 0.664 and 0.610. Conclusion: of STEMI patients who presented to hospital within 24h from symptom onset, SS was positively related with IS and negatively with MSI. SS was an independent predictor of IS after adjusting for important covariates.

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Impact of COVID-19 on the Cardiovascular System: A Review

Journal of Clinical Medicine ◽

10.3390/jcm9051407 ◽

2020 ◽

Vol 9 (5) ◽

pp. 1407 ◽

Cited By ~ 10

Author(s):

Kensuke Matsushita ◽

Benjamin Marchandot ◽

Laurence Jesel ◽

Patrick Ohlmann ◽

Olivier Morel

Keyword(s):

Public Health ◽

Cardiovascular System ◽

Myocardial Injury ◽

Distress Syndrome ◽

High Sensitivity ◽

Public Health Emergency ◽

Cardiovascular Comorbidities ◽

System A ◽

Recent Outbreak ◽

Acute Myocardial Injury

The recent outbreak of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 has been declared a public health emergency of international concern. COVID-19 may present as acute respiratory distress syndrome in severe cases, and patients with pre-existing cardiovascular comorbidities are reported to be the most vulnerable. Notably, acute myocardial injury, determined by elevated high-sensitivity troponin levels, is commonly observed in severe cases, and is strongly associated with mortality. Therefore, understanding the effects of COVID-19 on the cardiovascular system is essential for providing comprehensive medical care for critically ill patients. In this review, we summarize the rapidly evolving data and highlight the cardiovascular considerations related to COVID-19.

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“Acute Myocardial Infarction in the Time of COVID-19”: A Review of Biological, Environmental, and Psychosocial Contributors

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17207371 ◽

2020 ◽

Vol 17 (20) ◽

pp. 7371

Author(s):

Francesca Gorini ◽

Kyriazoula Chatzianagnostou ◽

Annamaria Mazzone ◽

Elisa Bustaffa ◽

Augusto Esposito ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Myocardial Injury ◽

Myocardial Damage ◽

Common Finding ◽

Complex Relationship ◽

Cardiac Events ◽

Plaque Instability ◽

Cardiovascular Comorbidities ◽

Patient Admissions

Coronavirus disease 2019 (COVID-19) has quickly become a worldwide health crisis.Although respiratory disease remains the main cause of morbidity and mortality in COVID patients,myocardial damage is a common finding. Many possible biological pathways may explain therelationship between COVID-19 and acute myocardial infarction (AMI). Increased immune andinflammatory responses, and procoagulant profile have characterized COVID patients. All theseresponses may induce endothelial dysfunction, myocardial injury, plaque instability, and AMI.Disease severity and mortality are increased by cardiovascular comorbidities. Moreover, COVID-19has been associated with air pollution, which may also represent an AMI risk factor. Nonetheless,a significant reduction in patient admissions following containment initiatives has been observed,including for AMI. The reasons for this phenomenon are largely unknown, although a real decreasein the incidence of cardiac events seems highly improbable. Instead, patients likely may presentdelayed time from symptoms onset and subsequent referral to emergency departments because offear of possible in-hospital infection, and as such, may present more complications. Here, we aim todiscuss available evidence about all these factors in the complex relationship between COVID-19and AMI, with particular focus on psychological distress and the need to increase awareness ofischemic symptoms.

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Redefining the Prognostic Value of High-Sensitivity Troponin in COVID-19 Patients: The Importance of Concomitant Coronary Artery Disease

Journal of Clinical Medicine ◽

10.3390/jcm9103263 ◽

2020 ◽

Vol 9 (10) ◽

pp. 3263 ◽

Cited By ~ 2

Author(s):

Marco Schiavone ◽

Alessio Gasperetti ◽

Massimo Mancone ◽

Aaron V. Kaplan ◽

Cecilia Gobbi ◽

...

Keyword(s):

Mortality Rate ◽

Hospital Mortality ◽

Myocardial Injury ◽

High Sensitivity ◽

Cardiovascular Comorbidities ◽

History Of ◽

Coronary Syndromes ◽

Artery Disease ◽

Poor Outcomes ◽

Concomitant Coronary Artery Disease

Background: Although studies assessing cardiovascular comorbidities and myocardial injury in Coronavirus disease 2019 (COVID-19) patients have been published, no reports focused on clinical outcomes of myocardial injury in patients with and without chronic coronary syndromes (CCS) are currently available. Methods: In this study, consecutive COVID-19 patients admitted to four different institutions were screened for enrolment. Patients were divided into two groups (CCS vs. no-CCS). Association with in-hospital mortality and related predictors represented the main study outcome; myocardial injury and its predictors were deemed secondary outcomes. Results: A total of 674 COVID-19 patients were enrolled, 112 (16.6%) with an established history of CCS. Myocardial injury occurred in 43.8% patients with CCS vs. 14.4% patients without CCS, as confirmed by high-sensitivity cardiac troponin (hs-cTn) elevation on admission or during hospitalization. The mortality rate in the CCS cohort was nearly three-fold higher. After adjusting for disease severity, myocardial injury resulted significantly associated with in-hospital mortality in the no-CCS group but not in CCS patients. Conclusions: Patients with CCS and COVID-19 showed high mortality rate. Myocardial injury may be a bystander in CCS patients and COVID-19, while in patients without known history of CCS, myocardial injury has a significant role in predicting poor outcomes.

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Focal ST-segment elevation without coronary occlusion: myocardial infarction with no obstructive coronary atherosclerosis associated with COVID-19—a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa532 ◽

2021 ◽

Vol 5 (2) ◽

Author(s):

Casey Meizinger ◽

Bruce Klugherz

Keyword(s):

Myocardial Infarction ◽

Coronary Artery Disease ◽

Respiratory Failure ◽

Coronary Atherosclerosis ◽

Myocardial Injury ◽

Cardiovascular Complications ◽

St Segment Elevation ◽

St Segment ◽

Hypoxic Respiratory Failure ◽

Artery Disease

Abstract Background While it is understood that coronavirus disease 2019 (COVID-19) is primarily complicated by respiratory failure, more data are emerging on the cardiovascular complications of this disease. A subset of COVID-19 patients present with ST-elevations on electrocardiogram (ECG) yet normal coronary angiography, a presentation that can fit criteria for myocardial infarction with no obstructive coronary atherosclerosis (MINOCA). There is little known about non-coronary myocardial injury observed in patients with COVID-19, and we present a case that should encourage further conversation and study of this clinical challenge. Case summary An 86-year-old man presented to our institution with acute hypoxic respiratory failure and an ECG showing anteroseptal ST-segment elevation concerning for myocardial infarction. Mechanic ventilation was initiated prior to presentation, and emergent transthoracic echocardiography reported an ejection fraction of 50–55%, with no significant regional wall motion abnormalities. Next, emergent coronary angiography was performed, and no significant coronary artery disease was detected. The patient tested positive for COVID-19. Despite supportive management in the intensive care unit, the patient passed away. Discussion We present a case of COVID-19 that is likely associated with MINOCA. It is crucial to understand that in COVID-19 patients with signs of myocardial infarction, not all myocardial injury is due to obstructive coronary artery disease. In the case of COVID-19 pathophysiology, it is important to consider the cardiovascular effects of hypoxic respiratory failure, potential myocarditis, and significant systemic inflammation. Continued surveillance and research on the cardiovascular complications of COVID-19 is essential to further elucidate management and prognosis.

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Cardiac complications during the active phase of COVID-19: review of the current evidence

Internal and Emergency Medicine ◽

10.1007/s11739-021-02763-3 ◽

2021 ◽

Author(s):

Mohammad Said Ramadan ◽

◽

Lorenzo Bertolino ◽

Tommaso Marrazzo ◽

Maria Teresa Florio ◽

...

Keyword(s):

Myocardial Injury ◽

Myocardial Damage ◽

Active Phase ◽

Mortality Rates ◽

Major Effect ◽

Current Evidence ◽

Cardiac Complications ◽

Published Data ◽

Improving Patient Care ◽

Overall Mortality

AbstractGrowing reports since the beginning of the pandemic and till date describe increased rates of cardiac complications (CC) in the active phase of coronavirus disease 2019 (COVID-19). CC commonly observed include myocarditis/myocardial injury, arrhythmias and heart failure, with an incidence reaching about a quarter of hospitalized patients in some reports. The increased incidence of CC raise questions about the possible heightened susceptibility of patients with cardiac disease to develop severe COVID-19, and whether the virus itself is involved in the pathogenesis of CC. The wide array of CC seems to stem from multiple mechanisms, including the ability of the virus to directly enter cardiomyocytes, and to indirectly damage the heart through systemic hyperinflammatory and hypercoagulable states, endothelial injury of the coronary arteries and hypoxemia. The induced CC seem to dramatically impact the prognosis of COVID-19, with some studies suggesting over 50% mortality rates with myocardial damage, up from ~ 5% overall mortality of COVID-19 alone. Thus, it is particularly important to investigate the relation between COVID-19 and heart disease, given the major effect on morbidity and mortality, aiming at early detection and improving patient care and outcomes. In this article, we review the growing body of published data on the topic to provide the reader with a comprehensive and robust description of the available evidence and its implication for clinical practice.

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