Characterization of Myocardial Injury in Patients With COVID-19

Gennaro Giustino, MD; Lori B. Croft, MD; Giulio G. Stefanini, MD, PHD; Renato Bragato, MD; Jeffrey J. Silbiger, MD; Marco Vicenzi, MD; Tatyana Danilov, MD; Nina Kukar, MD; Nada Shaban, MD; Annapoorna Kini, MD; Anton Camaj, MD, MS; Solomon W. Bienstock, MD; Eman R. Rashed, MD; Karishma Rahman, MD, PHD; Connor P. Oates, MD; Samantha Buckley, BS; Lindsay S. Elbaum, MD; Derya Arkonac, MD; Ryan Fiter, MD; Ranbir Singh, MD; Emily Li, MD; Victor Razuk, MD; Sam E. Robinson, MD; Michael Miller, MS; Benjamin Bier, MD; Valeria Donghi, MD; Marco Pisaniello, MD; Riccardo Mantovani, MD; Giuseppe Pinto, MD; Irene Rota, MD; Sara Baggio, MD; Mauro Chiarito, MD; Fabio Fazzari, MD; Ignazio Cusmano, MD; Mirko Curzi, MD; Richard Ro, MD; Waqas Malick, MD; Mazullah Kamran, MD; Roopa Kohli-Seth, MD; Adel M. Bassily-Marcus, MD; Eric Neibart, MD; Gregory Serrao, MD; Gila Perk, MD; Donna Mancini, MD; Vivek Y. Reddy, MD; Sean P. Pinney, MD; George Dangas, MD, PHD; Francesco Blasi, MD, PHD; Samin K. Sharma, MD; Roxana Mehran, MD; Gianluigi Condorelli, MD; Gregg W. Stone, MD; Valentin Fuster, MD, PHD; Stamatios Lerakis, MD, PHD; Martin E. Goldman, MD


J Am Coll Cardiol. 2020;76(18):2043-2055. 

In This Article

Abstract and Introduction


Background: Myocardial injury is frequent among patients hospitalized with coronavirus disease-2019 (COVID-19) and is associated with a poor prognosis. However, the mechanisms of myocardial injury remain unclear and prior studies have not reported cardiovascular imaging data.

Objectives: This study sought to characterize the echocardiographic abnormalities associated with myocardial injury and their prognostic impact in patients with COVID-19.

Methods: We conducted an international, multicenter cohort study including 7 hospitals in New York City and Milan of hospitalized patients with laboratory-confirmed COVID-19 who had undergone transthoracic echocardiographic (TTE) and electrocardiographic evaluation during their index hospitalization. Myocardial injury was defined as any elevation in cardiac troponin at the time of clinical presentation or during the hospitalization.

Results: A total of 305 patients were included. Mean age was 63 years and 205 patients (67.2%) were male. Overall, myocardial injury was observed in 190 patients (62.3%). Compared with patients without myocardial injury, those with myocardial injury had more electrocardiographic abnormalities, higher inflammatory biomarkers and an increased prevalence of major echocardiographic abnormalities that included left ventricular wall motion abnormalities, global left ventricular dysfunction, left ventricular diastolic dysfunction grade II or III, right ventricular dysfunction and pericardial effusions. Rates of in-hospital mortality were 5.2%, 18.6%, and 31.7% in patients without myocardial injury, with myocardial injury without TTE abnormalities, and with myocardial injury and TTE abnormalities. Following multivariable adjustment, myocardial injury with TTE abnormalities was associated with higher risk of death but not myocardial injury without TTE abnormalities.

Conclusions: Among patients with COVID-19 who underwent TTE, cardiac structural abnormalities were present in nearly two-thirds of patients with myocardial injury. Myocardial injury was associated with increased in-hospital mortality particularly if echocardiographic abnormalities were present.


Coronavirus disease-2019 (COVID-19) is a global pandemic caused by the novel severe acute respiratory syndrome-coronavirus-2 that is resulting in substantial morbidity and mortality.[1] A significant proportion of patients presenting with COVID-19 infection requiring hospitalization have biomarker evidence of myocardial injury, which has been shown to be associated with increased risk of in-hospital morbidity and mortality.[2–11] The pathogenesis of myocardial injury in patients affected by COVID-19 remains unclear. Proposed mechanisms include cytokine-mediated damage, oxygen supply-demand imbalance, ischemic injury from microvascular thrombi formation and direct viral invasion of the myocardium.[9,11] In addition, the risk of coronary thrombotic events from atherosclerotic plaque rupture has previously been shown to be increased during viral infections,[12,13] although a reduction in the numbers of patients presenting to hospitals with acute coronary syndromes (ACSs) has thus far been described with COVID-19.[14,15]

Previous published series have defined myocardial injury only on the basis of myocardial necrosis biomarker elevations without imaging to characterize structural and functional cardiac abnormalities.[2,3,9] In this regard, performing an extensive cardiac work-up in patients with COVID-19 is logistically challenging due to their clinical status and the need to limit exposure of health care personnel. Therefore, the underlying cardiac abnormalities in patients with cardiac injury in the setting of COVID-19 infection remain unknown. To address this gap in current knowledge, in the present study, we comprehensively characterized patients with COVID-19 and evidence of myocardial injury using laboratory, electrocardiographic (ECG), and echocardiographic data.