Prevalence and Impact of Myocardial Injury in Patients Hospitalized With COVID-19 Infection

Abstract

Background: The degree of myocardial injury, as reflected by troponin elevation, and associated outcomes among U.S. hospitalized patients with coronavirus disease-2019 (COVID-19) are unknown.

Objectives: The purpose of this study was to describe the degree of myocardial injury and associated outcomes in a large hospitalized cohort with laboratory-confirmed COVID-19.

Methods: Patients with COVID-19 admitted to 1 of 5 Mount Sinai Health System hospitals in New York City between February 27, 2020, and April 12, 2020, with troponin-I (normal value <0.03 ng/ml) measured within 24 h of admission were included (n = 2,736). Demographics, medical histories, admission laboratory results, and outcomes were captured from the hospitals' electronic health records.

Results: The median age was 66.4 years, with 59.6% men. Cardiovascular disease (CVD), including coronary artery disease, atrial fibrillation, and heart failure, was more prevalent in patients with higher troponin concentrations, as were hypertension and diabetes. A total of 506 (18.5%) patients died during hospitalization. In all, 985 (36%) patients had elevated troponin concentrations. After adjusting for disease severity and relevant clinical factors, even small amounts of myocardial injury (e.g., troponin I >0.03 to 0.09 ng/ml; n = 455; 16.6%) were significantly associated with death (adjusted hazard ratio: 1.75; 95% CI: 1.37 to 2.24; p < 0.001) while greater amounts (e.g., troponin I >0.09 ng/dl; n = 530; 19.4%) were significantly associated with higher risk (adjusted HR: 3.03; 95% CI: 2.42 to 3.80; p < 0.001).

Conclusions: Myocardial injury is prevalent among patients hospitalized with COVID-19; however, troponin concentrations were generally present at low levels. Patients with CVD are more likely to have myocardial injury than patients without CVD. Troponin elevation among patients hospitalized with COVID-19 is associated with higher risk of mortality.

Keywords: COVID-19; coronavirus; myocardial injury; troponin.

Graphical abstract

Figure 1

Distribution of Maximum In-Hospital Troponin Values for All Patients With Maximum Troponin Values <1.0 ng/ml Patients with troponin concentrations >1.0 ng/ml are not shown. COVID-19 = coronavirus disease-2019.

Figure 2

Plot of Longitudinal Troponin Values Over Time, Stratified By History of Cardiovascular Disease or No History of Cardiovascular Disease Cardiovascular disease includes coronary artery disease, heart failure, and atrial fibrillation. Smoothing lines fit via LOESS regression with shaded areas indicating 95% confidence intervals.

Figure 3

Cumulative Incidence Plots Displaying Probability for 3 Possible Outcomes (Mortality, Discharge From Hospital, or Continued Hospitalization) Over Time Cumulative incidence plots displaying probability for 3 possible outcomes (mortality, discharge from hospital, or continued hospitalization) over time.

Figure 4

Survival Past Hospital Admission, Stratified by Troponin Grouping (A) Patients were considered to be right-censored if they were discharged alive from the hospital or were still hospitalized at the time of data freeze (April 12, 2020). Survival times were significantly different between groups (p < 0.001). (B) Hazard ratios and 95% confidence intervals calculated by Cox proportional hazards regression models for mortality stratified by comorbidities. Patients with cardiovascular disease had comorbidities of coronary artery disease, heart failure, or atrial fibrillation. Patients with cardiovascular risk factors had comorbidities of diabetes mellitus or hypertension, but not cardiovascular disease.

Figure 4

Survival Past Hospital Admission, Stratified by Troponin Grouping (A) Patients were considered to be right-censored if they were discharged alive from the hospital or were still hospitalized at the time of data freeze (April 12, 2020). Survival times were significantly different between groups (p < 0.001). (B) Hazard ratios and 95% confidence intervals calculated by Cox proportional hazards regression models for mortality stratified by comorbidities. Patients with cardiovascular disease had comorbidities of coronary artery disease, heart failure, or atrial fibrillation. Patients with cardiovascular risk factors had comorbidities of diabetes mellitus or hypertension, but not cardiovascular disease.

Central Illustration

Prevalence, Potential Mechanisms, and Impact of Myocardial Injury in Coronavirus Disease-2019 Myocardial injury reflected by troponin concentrations above the upper reference limit (URL) of 0.03 ng/ml was present in 36% of patients hospitalized with coronavirus disease-2019 (COVID-19). Troponin levels among patients hospitalized with COVID-19 were generally <1.0 ng/ml. Even small amounts of myocardial injury (e.g., troponin I >0.03 to 0.09 ng/ml, n = 455 [16.6%]) were associated with death (adjusted HR: 1.75; 95% confidence interval: 1.37 to 2.24) while greater amounts (e.g., troponin I >0.09 ng/dl, n = 530 [19.4%]) were associated with more pronounced risk for death (adjusted HR: 1.77; 95% confidence interval: 1.39 to 2.26; p < 0.001). Troponin elevation in the setting of acute COVID-19 may primarily reflect nonischemic or secondary myocardial injury, but the true mechanism remains unknown. SARS-CoV-2 = severe acute respiratory syndrome-coronavirus-2.