Cardiac Injury Common in COVID-19, Predicts Mortality

Debra L Beck

March 25, 2020

In an observational study from Wuhan, China, cardiac injury was seen in 19.7% of patients with confirmed coronavirus disease 2019 (COVID-19) and was an independent predictor of in-hospital mortality.

Mortality among patients with cardiac injury was 51.2%, compared with 4.5% among those without cardiac injury (P < .001).

In a Cox regression model, patients with cardiac injury (vs without) had more than a fourfold increased risk for death during the time from symptom onset to death (hazard ratio, 4.26; 95% CI, 1.92 - 9.49).

Cardiac injury was defined as blood levels of high-sensitivity troponin I (hs-TnI) above the 99th-percentile upper reference limit, regardless of new abnormalities in electrocardiography and echocardiography.

Median hs-TnI was 0.19 μg/L in patients with cardiac injury and less than 0.006, the lowest measured value in that hospital, in those without cardiac injury (P < .001).

Shaobo Shi, MD, and colleagues from the Renmin Hospital of Wuhan University, China, published their findings online March 25 in JAMA Cardiology.

"On the basis of the present results of hs-TnI and ECG findings in a subset of patients, we can only estimate the severity of cardiac injury. Thus, because of the current limited evidence, the question of whether the SARS-CoV-2 virus can directly injure the heart requires further demonstration," Shi and colleagues conclude.

The study involved 416 consecutive patients hospitalized at Renmin Hospital with laboratory-confirmed COVID-19 from January 20 to February 10.

"If these findings are true, we should proactively examine for myocardial injury in all COVID-19 patients, as early detection and treatment may save more lives," said Ron Waksman, MD, in an email exchange.

"A few words of caution though: this study was done on patients who were admitted for hospitalization and may not apply to all patients who are tested as COVID-19-positive. Also, patients with myocardial injury had multiorgan failure, so involvement of the myocardium may not be specific but could be part of the diffuseness of the disease that also involved the heart," he added.

Commenting for | Medscape Cardiology, Mohammad Madjid, MD, UTHealth, Houston, said: "This paper provides a lot of important information on who dies of COVID and, as we completely expected, we see that cardiac injury increases the risk of death significantly."

Madjid was the first author on the ACC's Clinical Bulletin on the cardiovascular complications of COVID-19 and has studied the impact of influenza and cardiac health for more than 20 years.

"It looks like a combination of cardiovascular issues and pulmonary issues hand-in-hand lead to the demise of these patients," he added, which is consistent with previous reports out of Wuhan.

In early February, Wang et al reported that of 138 hospitalized COVID-19 patients in Wuhan, 7.2% experienced cardiac injury and 16.7% developed arrhythmia. Acute cardiac injury was found in five patients (14%) with COVID-19 from an even earlier study published in January.

Detailed Findings

Median age of the analyzed cohort was 64 years (range, 21 to 95 years), and 50.7% of the patients were female. Fever was the most common symptom (80.3%), followed by cough (34.6%) and shortness of breath (28.1%).

Compared with those without, the 82 patients (19.7%) found to have cardiac injury were older (median, 74 years vs 60 years; P < .001) and had more comorbidities, such as hypertension (59.8% vs 23.4%; P < .001) and coronary heart disease (29.3% vs 6.0%; P < .001).

Leukocyte counts (median, 9400 vs 5500 cells/μL) and C-reactive protein (10.2 vs 3.7 mg/dL) were both significantly higher (P < .001 for both).

Eighteen of 82 patients with cardiac injury (22.0%) required mechanical ventilation, compared with 14 of 334 without cardiac injury (4.2%; P < .001).

The incidence of acute respiratory distress syndrome was 58.5% and 14.7%, respectively (P < .001).

There were no conflicts of interest reported.

JAMA Card. Published online March 25, 2020. Full text, Comment


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