Higher COVID Death Risk Spelled Out by Troponins, ECG

Hospitalized patients with COVID-19 and myocardial injury had a broad range of echocardiographic abnormalities that put them at higher risk of in-hospital mortality, according to registry data from spring 2020.

Among 305 patients with lab-confirmed SARS-CoV-2 infection who underwent transthoracic echocardiography (TTE) and ECG evaluation, 62.6% had troponin elevations suggestive of myocardial injury (either at hospital admission or later during the hospitalization), according to Gennaro Giustino, MD, of Icahn School of Medicine at Mount Sinai in New York City, and colleagues.

Those with myocardial injury had more ECG abnormalities and higher levels of inflammatory and coagulation biomarkers. Additionally, they were more likely to have any major echocardiographic abnormalities (63.2% vs 21.7% in people without myocardial injury, OR 6.17, 95% CI 3.62-10.51).

“The echocardiographic abnormalities were diverse and included global LV [left ventricular] dysfunction, regional wall motion abnormalities, diastolic dysfunction, RV [right ventricular] dysfunction, and pericardial effusions, among others,” Giustino’s group wrote in the Journal of the American College of Cardiology.

Patients with myocardial injury also had greater LV volumes, wall thickness, and left atrial volumes. The majority had preserved LV function.

Rates of in-hospital mortality varied according to the presence of myocardial injury and echocardiographic abnormalities:

• 5.2% in patients without myocardial injury with or without TTE abnormalities
• 21.0% with myocardial injury without TTE abnormalities
• 31.2% with myocardial injury and TTE abnormalities

Myocardial injury with TTE abnormalities was associated with higher risk of death following multivariable adjustment for other complications of COVID (adjusted OR 3.87, 95% CI 1.27-11.80), Giustino and colleagues showed.

In contrast, myocardial injury without TTE abnormalities had no such relationship with mortality after adjustment (adjusted OR 1.00, 95% CI 0.27-3.71).

“Thus, TTE in patients with troponin-positive COVID-19 syndromes provides useful prognostic information. The association between myocardial injury and mortality (especially in those with echocardiographic abnormalities) is likely multifactorial and possibly both correlative and causative in nature,” the authors concluded.

In an accompanying editorial, Carl Lavie, MD, of John Ochsner Heart and Vascular Institute in New Orleans, and colleagues endorsed routine serial measurement of cardiac troponins in patients hospitalized for COVID-19 and TTE evaluation for those with high troponin levels.

The American College of Cardiology (ACC) currently recommends that COVID-19 patients with suspected acute MI have troponin measured, which “seems somehow inadequate” in light of Giustino and colleagues’ report that troponin-positive patients in general may benefit from routine TTE, they said.

Thus, the ACC criteria for troponin measurement should be expanded to all patients infected with SARS-CoV-2, not just those with a clinical suspicion of cardiac ischemia, Lavie’s group argued.

Data for the retrospective study came from the Cardiac Injury Research in COVID-19 registry, which included seven hospitals in New York City and Milan.

Patients included were those who had an index COVID-19 hospitalization from March 5-May 2, 2020. Mean age was 63, with men accounting for two-thirds of the 305-person cohort. Median BMI was 28.

Myocardial injury was more likely in older patients and those with hypertension or chronic kidney disease. People with higher BMI trended toward more myocardial injury without reaching statistical significance.

This latter point is important because “obese patients tend to experience worse outcomes and more critical illness in COVID-19 and are known to have more cardiac structural and functional abnormalities on TTE or other cardiac imaging, as well as more comorbidities associated with worse outcomes,” according to Lavie’s group.

In the study, it took a median 4 days from hospital admission to TTE evaluation for each person. The most commonly cited reasons for TTE were cardiac symptoms and troponin elevations.

People required ICU admission in 43.9% of cases and mechanical ventilation in 34.5%.

Giustino and colleagues reported that cardiac catheterization was performed in only 3.6% of patients, most of whom had confirmed acute coronary syndrome (ACS). The ACS cohort was notable for all patients having regional wall motion abnormalities on TTE (compared with 20% of troponin-positive peers without confirmed ACS).

“Therefore, in the appropriate clinical scenario, TTE (or a point-of-care ultrasound) may be considered among patients with COVID-19 infection and biomarker evidence of myocardial injury to potentially identify those who might benefit from expedited invasive management,” they suggested.

The study was limited by a modest sample size and lack of cardiac MRI data. In addition, data collection relied on manual electronic health record extraction.

“TTE evaluation should be considered in patients with COVID-19 and biomarker evidence of myocardial injury to characterize the underlying cardiac substrate, for risk stratification, and to potentially guide management strategies,” Giustino’s group maintained.