Acute myocardial injury (MI), defined by an increase in cardiac troponin (cTn), is common in patients hospitalized with COVID-19. MI has been associated with mortality in series mostly retrospective, including heterogeneous COVID-19 patients presenting with mild to critically ill conditions [1, 2]. Measurements of cardiac troponin (cTn) were often obtained only at baseline and requested based on clinical judgment. Thus, the prevalence of MI in the intensive care unit (ICU) patients evaluated by systematic serial cTn assessments is unknown. In addition, information for comprehension of the potential underlying mechanism leading to MI is still lacking. In this series of consecutive ICU COVID-19 patients, MI was assessed by a comprehensive workup including sequential cTn dosages, electrocardiography (ECG), and two-dimensional transthoracic echocardiography (TTE) to address the question of its prevalence, characterization, and prognostic value in the ICU setting.
All the consecutive patients with laboratory-confirmed SARS-CoV-2 infection admitted to our dedicated COVID-19 ICU between February 22 and April 31, 2020, were analysed. Laboratory confirmation of SARS-CoV-2 was defined as a positive result of real-time RT-PCR assay of nasal and pharyngeal swabs. The study was approved by the local Institutional Ethical Board (Sorbonne University, CER-2020-14). Cardiac investigations were systematically collected including daily dosage of High sensitivity cardiac troponin I (Hs-cTnI) during the first week of ICU stay, and B-type natriuretic peptide (BNP), ECG, and a TTE on ICU admission. The presence of MI was defined by the highest Hs-cTnI value above the 99th percentile upper reference limit and a change in values of ≥ 20% within the first 48 h (Hs-cTnI initial value) [3]. Studied outcomes were the overall mortality at day-28 and the incidence of cardiovascular events (a composite of death, cardiac-arrest, cardiogenic shock, and arterial thrombotic event) at day 28. The association between MI and outcomes was estimated by logistic regression.
Overall, 92 patients (78.3% men; age 62 [53–69] years) were analysed (Table 1). COVID-19 was diagnosed in ambulant setting, hospital (emergency department or conventional wards), and ICU in respectively 4 (4.3%), 70 (76.1%), and 18 (19.6%) patients. MI was diagnosed in 53 patients (57.6%; 95% confidence interval[CI], 46.8–67.9%) with a Hs-cTnI initial value of 112 (54–260) pg/ml. Among patient with MI, 13 (24.5%) presented ECG abnormalities including 1 (1.9%) ST-segment elevation, 2 (3.8%) ST-segment depression and 13 (24.5%) T wave inversion. Patients with MI had higher BNP levels (78 [20–188] vs. 20 [13–59], p < 0.001) and a lower left ventricular ejection fraction (55 [50–60] vs. 60 [55–60], p = 0.02) than patients without MI. A greater proportion of patients with MI required catecholamine, invasive mechanical ventilation, and renal replacement therapy. Cardiovascular events occurred in 23 (25%) patients, including cardiac arrest (n = 1, 1.1%), cardiogenic shock (n = 4, 4.3%), arterial thrombotic event (n = 4, 4.3%), and death (n = 18; 19.6%). Figure 1 illustrates the association of mortality with MI (Kaplan–Meier survival curves, log-rank test p = 0.05). At day 28, the Odds Ratio (OR) for death and cardiovascular events in patients with versus without MI were 3.14 (95% CI 1.02–11.89) and 4.22 (95%CI 1.43–12.40), respectively. When adjusting on sepsis-related organ failure assessment, these associations were not significant (OR 1.74, 95%CI 0.49–7.09 and OR 2.01, 95%CI 0.56–8.31, respectively). The magnitude of the Hs-cTnI initial values was associated with overall mortality (crude [OR] 2.42; 95%CI 1.25–4.94 per tenfold increase; Fig. 2). Median daily Hs-cTnI values during the first week of ICU admission remained higher in non-survivors, as compared with survivors (see Figure E1 in the online supplement data).
In this cohort of consecutive critically ill COVID-19 patients, the prevalence of MI was higher than that reported in non-ICU patients, suggesting that MI is related to an overall severity and a poor prognosis [1, 2]. Despite its association with an increased BNP level and a decreased left ventricular ejection fraction, MI rarely induced severe left ventricular systolic dysfunction. Severe right ventricular dilatation was also rarely diagnosed in our cohort, despite severe acute respiratory disease requiring mechanical ventilation. In line with our results, an international survey in COVID 19 patients reported left and right ventricular severe impairment in only 9% and 6% of cases [4]. As suggested by the absence of ECG abnormalities in most of our patients, MI may be mediated through non-ischemic mechanisms, such as cytokine storm or direct entry of SARS-CoV-2 into myocardial cells [5]. However, coronary mechanisms like microvascular damage, supply–demand inequity, or destabilization of atheroma cannot be excluded [2, 5].
To summarize, acute myocardial injury is very frequent in critically ill COVID-19 patients and is associated with severity.
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Abbreviations
- cTn:
-
Cardiac troponin
- BNP:
-
B-type natriuretic peptide
- COVID-19:
-
Coronavirus Disease 2019
- ECG:
-
Electrocardiography
- Hs-cTnI:
-
High sensitivity cardiac troponin I
- ICU:
-
Intensive care unit
- MI:
-
Myocardial injury
- TTE:
-
Two-dimensional transthoracic echocardiography
References
Santoso A, Pranata R, Wibowo A, Al-Farabi MJ, Huang I, Antariksa B. Cardiac injury is associated with mortality and critically ill pneumonia in COVID-19: a meta-analysis. Am J Emerg Med. 2020;S0735–6757:30280–1.
Lala A, Johnson KW, Januzzi JL, Russak AJ, Paranjpe I, Richter F, et al. Prevalence and impact of myocardial injury in patients hospitalized with COVID-19 infection. J Am Coll Cardiol. 2020;S0735–1097:35552–62.
Kozinski M, Krintus M, Kubica J, Sypniewska G. High-sensitivity cardiac troponin assays: from improved analytical performance to enhanced risk stratification. Crit Rev Clin Lab Sci. 2017;54:143–72.
Dweck MR, Bularga A, Hahn RT, Bing R, Lee KK, Chapman AR, et al. Global evaluation of echocardiography in patients with COVID-19. Eur Heart J Cardiovasc Imaging. 2020;1–10
Clerkin KJ, Fried JA, Raikhelkar J, Sayer G, Griffin JM, Masoumi A, et al. COVID-19 and cardiovascular disease. Circulation. 2020;141:1648–55.
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VL, SE, MF, and GV contributed to study conception and design. VL, SE, GV, AT participated in acquiring the data. VL, AC, GV, SE, NL, and MF analyzed and interpreted the study data. VL drafted the original manuscript. All authors revised the manuscript for important intellectual content. All authors read and approved the final manuscript.
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AC received a research grant from Resicard; and consultant/advisory board fees from Amgen, AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Novartis, and Pfizer, unrelated with the present study. GV received research grant from BioMérieux, SOS Oxygène, Janssen unrelated to the present study; and advisory board fees from BioMérieux unrelated to the present study. VL receives advisory board fees from Amomed unrelated with the present study. AT, JS, MF, NL, and SE declared no relevant conflict of interest.
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The study has been approved by the local institutional ethical board (Sorbonne University, CER-2020-14) as a component of standard care and patient consent was waived, as per French Law.
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15010_2020_1560_MOESM1_ESM.pdf
Supplementary file1 Figure E1. Daily High sensitivity cardiac troponin-I value (logarithmic scale) according to the vital status at day 28. Footnote Figure E1: Abbreviation: ICU, intensive care unit; Hs-cTnI, High sensitivity cardiac troponin-I. amissing data: day 1, 0; day 2, 2; day 3, 8; day 4, 20; day 5, 28; day 6, 34; day 7, 29. (PDF 30 KB)
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Labbé, V., Ederhy, S., Lapidus, N. et al. Characterization and outcomes of acute myocardial injury in COVID-19 intensive care patients. Infection 49, 563–566 (2021). https://doi.org/10.1007/s15010-020-01560-y
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DOI: https://doi.org/10.1007/s15010-020-01560-y