Myocardial Injury in Severe COVID-19 Compared With Non-COVID-19 Acute Respiratory Distress Syndrome
Thomas S Metkus1, Lori J Sokoll2, Andreas S Barth1
1Divisions of Cardiology (T.S.M., A.S.B., M.J.C., A.G.H., C.J.L., E.D.M., W.S.P., J.R.R., D.R.T., J.C.T., R.K.H.), Johns Hopkins University School of Medicine, Baltimore, MD.
Insights
Myocardial injury occurred in 51% of severe COVID-19 patients. While linked to comorbidities, its adverse prognosis in COVID-19 relates to critical illness and organ dysfunction, not just the heart injury itself.
Area of Science:
- Cardiology
- Infectious Diseases
- Critical Care Medicine
Background:
- Myocardial injury is a recognized complication of COVID-19, but its epidemiology and clinical impact, especially compared to other forms of acute respiratory distress syndrome (ARDS), require further elucidation.
- Significant knowledge gaps persist regarding the prevalence and prognostic implications of myocardial injury in patients with severe coronavirus disease 2019 (COVID-19).
Purpose of the Study:
- To determine the prevalence and outcomes of myocardial injury in severe COVID-19.
- To compare myocardial injury in COVID-19 patients with those experiencing ARDS unrelated to COVID-19.
Main Methods:
- Intubated COVID-19 patients from five hospitals (March-June 2020) with troponin levels assessed were included.
- Comparison was made with patients from a prior ARDS cohort study.
- Survival analysis focused on in-hospital death, and linear regression identified factors associated with myocardial injury in COVID-19.
Main Results:
- 51% of 243 intubated COVID-19 patients exhibited elevated troponin levels.
- Myocardial injury was associated with chronic kidney disease, lactate, ferritin, and fibrinogen.
- Mortality was significantly higher in COVID-19 patients with elevated troponin levels (>10x ULN: 61.5% vs.
- After adjustment, COVID-19 ARDS showed lower odds of myocardial injury compared to non-COVID-19 ARDS (OR, 0.55; P=0.005).
Conclusions:
- Myocardial injury in severe COVID-19 is influenced by baseline comorbidities, advanced age, and multisystem organ dysfunction, mirroring patterns seen in traditional ARDS.
- The poor prognosis associated with myocardial injury in COVID-19 is primarily attributed to extensive multisystem organ involvement and overall critical illness severity.
Background:
Knowledge gaps remain in the epidemiology and clinical implications of myocardial injury in coronavirus disease 2019 (COVID-19). We aimed to determine the prevalence and outcomes of myocardial injury in severe COVID-19 compared with acute respiratory distress syndrome (ARDS) unrelated to COVID-19.
Methods:
We included intubated patients with COVID-19 from 5 hospitals between March 15 and June 11, 2020, with troponin levels assessed. We compared them with patients from a cohort study of myocardial injury in ARDS and performed survival analysis with primary outcome of in-hospital death associated with myocardial injury. In addition, we performed linear regression to identify clinical factors associated with myocardial injury in COVID-19.
Results:
Of 243 intubated patients with COVID-19, 51% had troponin levels above the upper limit of normal. Chronic kidney disease, lactate, ferritin, and fibrinogen were associated with myocardial injury. Mortality was 22.7% among patients with COVID-19 with troponin under the upper limit of normal and 61.5% for those with troponin levels >10 times the upper limit of normal (P<0.001). The association of myocardial injury with mortality was not statistically significant after adjusting for age, sex, and multisystem organ dysfunction. Compared with patients with ARDS without COVID-19, patients with COVID-19 were older and had higher creatinine levels and less favorable vital signs. After adjustment, COVID-19-related ARDS was associated with lower odds of myocardial injury compared with non-COVID-19-related ARDS (odds ratio, 0.55 [95% CI, 0.36-0.84]; P=0.005).
Conclusions:
Myocardial injury in severe COVID-19 is a function of baseline comorbidities, advanced age, and multisystem organ dysfunction, similar to traditional ARDS. The adverse prognosis of myocardial injury in COVID-19 relates largely to multisystem organ involvement and critical illness.
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