Death, discharge and arrhythmias among patients with COVID-19 and cardiac injury

Abstract

Background: Cardiac injury is common in severe coronavirus disease 2019 (COVID-19) and is associated with poor outcomes. We aimed to study predictors of in-hospital death, characteristics of arrhythmias and the effects of QT-prolonging therapy in patients with cardiac injury.

Methods: We conducted a retrospective cohort study involving patients with severe COVID-19 who were admitted to Tongji Hospital in Wuhan, China, between Jan. 29 and Mar. 8, 2020. Among patients who had cardiac injury, which we defined as an elevated level of cardiac troponin I (cTnI), we identified demographic and clinical characteristics associated with mortality and need for invasive ventilation.

Results: Among 1284 patients with severe COVID-19, 1159 had a cTnI level measured on admission to hospital, of whom 170 (14.7%) had results that showed cardiac injury. We found that mortality was markedly higher in patients with cardiac injury (71.2% v. 6.6%, p < 0.001). We determined that initial cTnI (per 10-fold increase, hazard ratio [HR] 1.32, 95% confidence interval [CI] 1.06-1.66) and peak cTnI level during illness (per 10-fold increase, HR 1.70, 95% CI 1.38-2.10) were associated with poor survival. Peak cTnI was also associated with the need for invasive ventilation (odds ratio 3.02, 95% CI 1.92-4.98). We found arrhythmias in 44 of the 170 patients with cardiac injury (25.9%), including 6 patients with ventricular tachycardia or fibrillation, all of whom died. We determined that patients who received QT-prolonging drugs had longer QTc intervals than those who did not receive them (difference in medians, 45 ms, p = 0.01), but such treatment was not independently associated with mortality (HR 1.04, 95% CI 0.69-1.57).

Interpretation: We found that in patients with COVID-19 and cardiac injury, initial and peak cTnI levels were associated with poor survival, and peak cTnI was a predictor of need for invasive ventilation. Patients with COVID-19 warrant assessment for cardiac injury and monitoring, especially if therapy that can prolong repolarization is started.

Trial registration: Chinese Clinical Trial Registry, No. ChiCTR2000031301.

Figure 1:

Flow chart of the study population. Patients (n = 1284) with pneumonia associated with coronavirus disease 2019 (COVID-19) that was confirmed by computed tomography (CT) were transferred to Tongji Hospital, Wuhan, China, and included in our study. From this group, 1159 patients underwent testing for cardiac troponin I (cTnI) at admission to hospital, of which 170 had a positive result (elevated level of cTnI). Of these 170 patients, 44 had abnormalities in heart rhythm diagnosed, and 6 died of ventricular tachycardia/ventricular fibrillation (VT/VF). Note: ECG = electrocardiogram.

Figure 2:

Cardiac injury, death and discharge in coronavirus disease 2019 (COVID-19) patients. (A) Outcomes of death or discharge from hospital of patients based on level of cardiac troponin I (cTnI) at admission. (B) Distribution of cTnI concentrations for the 170 patients who tested positive with outcomes. The median and interquartile range for each outcome group is shown.

Figure 3:

Representative electrocardiograms of arrhythmias in patients with coronavirus disease 2019 (COVID-19) and cardiac injury. (A) Frequent premature atrial complexes. (B) Atrial tachycardia/atrial flutter. (C) Atrial fibrillation. (D) Frequent premature ventricular complexes.