Myocardial Injury in Severe COVID-19 vs. ARDS

Quick Takes

  • Half of intubated COVID-19 patients manifest myocardial injury assessed by clinical troponin assays, which is associated with a graded increase in overall mortality.
  • However, the magnitude of mortality risk is attenuated after adjustment for degree of critical illness, suggesting that myocardial injury is reflective of baseline risk and comorbidities and underlying multisystem organ dysfunction.
  • Additional studies of myocardial injury in COVID-19 are indicated to investigate any novel mechanisms and identify targeted treatment of both primary cardiac involvement and the multisystem organ dysfunction.

Study Questions:

What are the prevalence and outcomes of myocardial injury in severe coronavirus disease 2019 (COVID-19) compared to acute respiratory distress syndrome (ARDS) unrelated to COVID-19?

Methods:

The investigators included intubated COVID-19 patients from five hospitals between March 15 and June 11, 2020, with troponin levels assessed. The authors compared them to patients from a cohort study of myocardial injury in ARDS. They performed survival analysis with primary outcome of in-hospital death associated with myocardial injury. They also performed linear regression to identify clinical factors associated with myocardial injury in COVID-19.

Results:

Of 243 patients intubated with COVID-19, 51% had troponin levels > upper limit of normal (ULN). Chronic kidney disease, lactate, ferritin, and fibrinogen were associated with myocardial injury. Mortality was 22.7% among COVID-19 patients with troponin < ULN and 61.5% for those with troponin levels >10x ULN (p < 0.001). The association of myocardial injury with mortality was not statistically significant after adjusting for age, sex, and multisystem organ dysfunction. Compared to non-COVID ARDS patients, patients with COVID-19 were older with higher creatinine and less favorable vital signs. After adjustment, COVID-19 was associated with lower odds of myocardial injury compared to non-COVID ARDS (odds ratio, 0.55; 95% confidence interval, 0.36-0.84; p = 0.005).

Conclusions:

The authors concluded that myocardial injury in severe COVID-19 is a function of baseline comorbidities, advanced age, and multisystem organ dysfunction similar to traditional ARDS.

Perspective:

This cohort study reports that half of intubated COVID-19 patients manifest myocardial injury assessed by clinical troponin assays, which is associated with a graded increase in overall mortality. However, the magnitude of mortality risk is attenuated after adjustment for degree of critical illness, suggesting that myocardial injury is reflective of baseline risk and comorbidities and underlying multisystem organ dysfunction. Of note, myocardial injury is actually less common in COVID-19 compared to conventional ARDS after adjusting for confounders of age, renal dysfunction, and degree of critical illness. Additional studies of myocardial injury in COVID-19 are indicated to investigate any novel mechanisms and identify targeted treatment of both primary cardiac involvement and the multisystem organ dysfunction.

Clinical Topics: Acute Coronary Syndromes, Dyslipidemia, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Lipid Metabolism, Acute Heart Failure

Keywords: Acute Coronary Syndrome, Coronavirus, COVID-19, Creatinine, Critical Illness, Ferritins, Fibrinogen, Geriatrics, Heart Failure, Hospital Mortality, Intubation, Renal Insufficiency, Chronic, Multiple Organ Failure, Primary Prevention, Respiratory Distress Syndrome, Adult, severe acute respiratory syndrome coronavirus 2, Troponin


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