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Myocardial Involvement After Hospitalization for COVID-19
Quick Takes
- Recent myocarditis is less frequent among people around 61 years of age, compared to previous reports.
- A new pattern of microinfarction was identified on cardiac MRI, which the authors attribute to the prothrombotic state caused by COVID.
- The presence of myocardial scar at 12 months is a poor prognostic factor.
Study Questions:
What are the characteristics of myocardial injury and its associations and sequelae in convalescent patients after hospitalization with coronavirus disease 2019 (COVID-19)?
Methods:
The study cohort was comprised of 342 COVID-19 patients with elevated troponin levels (COVID+/troponin+) from 25 UK hospitals, who had a magnetic resonance imaging (MRI) scan within 28 days of discharge between June 2020 and March 2021. Two control groups were also recruited: 64 COVID-19 patients with normal troponin levels (COVID+/troponin−) and 113 non-COVID patients with matched age and cardiovascular comorbidities (COVID−/comorbidity+). Predictors of major adverse cardiovascular events (MACE) at 12 months were determined utilizing regression modeling. The late gadolinium enhancement images were evaluated visually into six main categories: infarct (subendocardial or transmural scar consistent with a specific coronary territory), nonischemic (subepicardial or intramyocardial scar, which includes most scarring related to myocarditis), dual pathology (infarct and nonischemic), microinfarction (bright, subsegmental scarring that may appear in multiple territories), likely pre-existing scar or nonspecific scar, and no scar.
Results:
The final study cohort was comprised of 519 patients, of which 356 (69%) were men with a median age of 61.0 years. Heart abnormalities, defined as ventricular impairment, scar, or pericardial disease, were found to be twofold greater in cases (61%) compared to controls (36% COVID+/troponin− and 31% COVID−/comorbidity+; p < 0.001 for both). More cases had ventricular impairment (17.2%) or scar (42%) compared to controls (3.1% and 7.1% for ventricular impairment and 7% and 23% for scar; p < 0.001 for both). Cases had a higher occurrence of infarction (13%) or microinfarction (9%) than controls (2% and 0%, and 1% and 0%, respectively; p < 0.01 and p < 0.001), but no difference was found in nonischemic scar (13% vs. 5% and 14%; p = 0.10). The prevalence of probable recent myocarditis was 6.7% (23/342) in cases compared to 1.7% (2/113) in non-COVID controls (p = 0.045). During follow-up, 4 patients died and 34 experienced MACE (10.2%), which was similar to controls (6.1%; p = 0.70). Myocardial scar was an independent predictor of MACE (odds ratio, 2.25; 95% confidence interval, 1.12-4.57; p = 0.02), but previous COVID-19 infection and troponin were not.
Conclusions:
The authors conclude that patients with COVID-19 and high cardiac troponin levels show more ventricular impairment and heart scarring in the early stages of recovery compared to those without the virus. However, the number of cases of myocarditis is low and the cause of the scarring is varied, including a newly identified pattern of microinfarction.
Perspective:
In their discussion, the authors of this multicenter study point out that the clinical diagnosis for myocardial injury in the work setting was varied and often challenging to determine. Utilizing cardiac MRI, they were able to better delineate the clinic-pathologic features of myocardial involvement. They found that recent myocarditis is less frequent among people around 61 years old, compared to previous reports. They also identified a new pattern of microinfarction on cardiac MRI, which they attribute to the prothrombotic state caused by COVID. They also report that presence of myocardial scar at 12 months is a poor prognostic factor.
Clinical Topics: Acute Coronary Syndromes, COVID-19 Hub, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Pericardial Disease, Prevention, Acute Heart Failure, Magnetic Resonance Imaging
Keywords: Acute Coronary Syndrome, Comorbidity, COVID-19, Critical Care, Diagnostic Imaging, Gadolinium, Heart Failure, Heart Injuries, Infarction, Magnetic Resonance Imaging, Myocarditis, Patient Discharge, Pericarditis, Primary Prevention, Thrombosis, Troponin, Ventricular Dysfunction
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