Echo Abnormalities in COVID-Associated Myocardial Injury
- Among patients with COVID-19 and myocardial injury who underwent clinically indicated echocardiograms, approximately 2/3 had major abnormalities, including left or right ventricular dysfunction.
- In the setting of COVID-19 with myocardial injury, major echocardiographic abnormalities were independently associated with a ~4-fold increase in in-hospital mortality.
In patients with myocardial injury associated with coronavirus disease 2019 (COVID-19), what echocardiographic abnormalities are seen, and what are their prognostic implications?
This retrospective cohort study included COVID-19 patients who had transthoracic echocardiograms (TTEs) performed during their index hospitalizations at seven centers in New York City and Milan, Italy, from March to May 2020. Myocardial injury was defined as serum cardiac troponin (Tn) above the upper reference limit at each hospital. Major echocardiographic abnormalities included global left ventricular (LV) dysfunction, LV wall motion abnormalities, grade II or III LV diastolic dysfunction, right ventricular (RV) dysfunction, and small or larger pericardial effusion. The primary clinical endpoint was in-hospital all-cause mortality.
The cohort comprised 305 patients (median age 63 years, 67.2% male, 34.5% mechanically ventilated), of whom 190 patients (62.6%) had biomarker evidence of myocardial injury. The most common indications for TTE were cardiac symptoms, including chest pain and dyspnea, and elevated Tn. Major echocardiographic abnormalities were more common in the myocardial injury group than in the non-myocardial injury group (63.2% vs. 21.7%; odds ratio [OR], 6.17; 95% confidence interval [CI], 3.62-10.51; p < 0.0001). Among patients with myocardial injury, RV dysfunction was seen in 26.3%, global LV dysfunction in 18.4%, regional LV wall motion abnormalities in 23.7%, grade II or III diastolic dysfunction in 13.2%, and pericardial effusion in 7.2%. Patients with regional wall motion abnormalities more frequently had ST-segment changes in a coronary artery distribution than diffuse ST changes. Only 11/305 patients (3.6%) underwent cardiac catheterization, of whom eight had confirmed acute coronary syndrome (ACS); all patients with ACS had regional wall motion abnormalities on TTE.
In-hospital mortality occurred in 5.2% of patients without myocardial injury, 21.0% of patients with myocardial injury but no echocardiographic abnormalities, and 31.2% of patients with myocardial injury and echocardiographic abnormalities (trend adjusted OR, 2.27; 95% CI, 1.30-3.94; p = 0.004). In multivariable analysis, mortality was increased in patients with myocardial injury and echocardiographic abnormalities (adjusted OR, 3.87; 95% CI, 1.27-11.80) but not in patients without echocardiographic abnormalities (adjusted OR, 1.00; 95% CI, 0.27-3.71). Other independent predictors of in-hospital mortality included age, Hispanic ethnicity, history of heart failure, shock, acute respiratory distress syndrome, and acute kidney injury.
Major echocardiographic abnormalities are associated with increased risk of in-hospital mortality in patients with myocardial injury due to COVID-19.
Myocardial injury in COVID-19 may occur by a variety of mechanisms, including supply-demand mismatch, endothelial dysfunction, plaque rupture, myocyte necrosis due to elevated intracardiac filling pressures, cytokine-mediated myocardial damage, and viral invasion of myocytes. Therefore, patients with myocardial injury are a clinically heterogeneous group. TTE can help identify patients who are likely to benefit from coronary angiography and percutaneous coronary intervention, clarify etiology of shock, and inform decisions regarding therapy for patients with suspected pulmonary embolism. It is important to note that all patients in this study were clinically referred for TTE, and the findings should not be interpreted to suggest that all patients with COVID-19 should undergo cardiac imaging. Patients who underwent only point-of-care cardiac ultrasound were excluded from this study. Further research is needed to establish how well point-of-care cardiac ultrasound performs in comparison with TTE in real-world settings among patients with COVID-19.
Keywords: Acute Coronary Syndrome, Acute Kidney Injury, Chest Pain, Coronavirus, COVID-19, Dyspnea, Diagnostic Imaging, Echocardiography, Heart Failure, Hospital Mortality, Myocardium, Pericardial Effusion, Respiration, Artificial, Respiratory Distress Syndrome, severe acute respiratory syndrome coronavirus 2, Troponin, Ventricular Dysfunction
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