Myocardial Involvement After Hospitalization for COVID-19 Complicated by Troponin Elevation: A Prospective,
Jessica Artico1, Hunain Shiwani1, James C Moon1
1Institute of Cardiovascular Science (J.A., H.S., J.C.M., R.D.A., C.M., T.A.T., R.H.D.), University College London, UK.
Insights
Patients with COVID-19 and elevated troponin levels show increased heart abnormalities, including ventricular impairment and myocardial scar. Myocardial scar independently predicts major adverse cardiovascular events.
Area of Science:
- Cardiology
- Infectious Diseases
- Medical Imaging
Background:
- Acute myocardial injury in COVID-19 patients is linked to poor outcomes.
- The exact causes and associations of this injury remain unclear.
- This study investigates myocardial damage in hospitalized COVID-19 patients with elevated troponin.
Purpose of the Study:
- To assess the presence, nature, and extent of myocardial damage.
- To identify predictors of major adverse cardiovascular events in COVID-19 patients.
Main Methods:
- 342 COVID-19 patients with elevated troponin (COVID+/troponin+) underwent MRI.
- Two control groups were used: COVID-19 with normal troponin (COVID+/troponin-) and non-COVID-19 with comorbidities (COVID-/comorbidity+).
- Regression modeling identified predictors of 12-month major adverse cardiovascular events.
Main Results:
- COVID+/troponin+ patients had significantly higher rates of heart abnormalities (61%) versus controls (36% and 31%).
- Ventricular impairment and myocardial scar were more prevalent in COVID+/troponin+ patients.
- Myocardial scar, not prior COVID-19 or troponin levels, independently predicted major adverse cardiovascular events (OR 2.25).
Conclusions:
- COVID-19 patients with elevated troponin exhibit increased ventricular impairment and myocardial scar.
- The study identified a diverse scar pathogenesis, including microinfarction.
- Myocardial scar is a significant predictor of future cardiovascular events in these patients.
Background:
Acute myocardial injury in hospitalized patients with coronavirus disease 2019 (COVID-19) has a poor prognosis. Its associations and pathogenesis are unclear. Our aim was to assess the presence, nature, and extent of myocardial damage in hospitalized patients with troponin elevation.
Methods:
Across 25 hospitals in the United Kingdom, 342 patients with COVID-19 and an elevated troponin level (COVID+/troponin+) were enrolled between June 2020 and March 2021 and had a magnetic resonance imaging scan within 28 days of discharge. Two prospective control groups were recruited, comprising 64 patients with COVID-19 and normal troponin levels (COVID+/troponin-) and 113 patients without COVID-19 or elevated troponin level matched by age and cardiovascular comorbidities (COVID-/comorbidity+). Regression modeling was performed to identify predictors of major adverse cardiovascular events at 12 months.
Results:
Of the 519 included patients, 356 (69%) were men, with a median (interquartile range) age of 61.0 years (53.8, 68.8). The frequency of any heart abnormality, defined as left or right ventricular impairment, scar, or pericardial disease, was 2-fold greater in cases (61% [207/342]) compared with controls (36% [COVID+/troponin-] versus 31% [COVID-/comorbidity+]; P<0.001 for both). More cases than controls had ventricular impairment (17.2% versus 3.1% and 7.1%) or scar (42% versus 7% and 23%; P<0.001 for both). The myocardial injury pattern was different, with cases more likely than controls to have infarction (13% versus 2% and 7%; P<0.01) or microinfarction (9% versus 0% and 1%; P<0.001), but there was no difference in nonischemic scar (13% versus 5% and 14%; P=0.10). Using the Lake Louise magnetic resonance imaging criteria, the prevalence of probable recent myocarditis was 6.7% (23/342) in cases compared with 1.7% (2/113) in controls without COVID-19 (P=0.045). During follow-up, 4 patients died and 34 experienced a subsequent major adverse cardiovascular event (10.2%), which was similar to controls (6.1%; P=0.70). Myocardial scar, but not previous COVID-19 infection or troponin, was an independent predictor of major adverse cardiovascular events (odds ratio, 2.25 [95% CI, 1.12-4.57]; P=0.02).
Conclusions:
Compared with contemporary controls, patients with COVID-19 and elevated cardiac troponin level have more ventricular impairment and myocardial scar in early convalescence. However, the proportion with myocarditis was low and scar pathogenesis was diverse, including a newly described pattern of microinfarction.
Registration:
URL: https://www.isrctn.com; Unique identifier: 58667920.
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