Cardiac Injury Patterns and Inpatient Outcomes Among Patients Admitted With COVID-19

Abstract

Although certain risk factors have been associated with increased morbidity and mortality in patients admitted with Coronavirus Disease 2019 (COVID-19), the impact of cardiac injury and high-sensitivity troponin-I (hs-cTnI) concentrations are not well described. In this large retrospective longitudinal cohort study, we analyzed the cases of 1,044 consecutively admitted patients with COVID-19 from March 9 until April 15. Cardiac injury was defined by hs-cTnI concentration >99th percentile. Patient characteristics, laboratory data, and outcomes were described in patients with cardiac injury and different hs-cTnI cut-offs. The primary outcome was mortality, and the secondary outcomes were length of stay, need for intensive care unit care or mechanical ventilation, and their different composites. The final analyzed cohort included 1,020 patients. The median age was 63 years, 511 (50% patients were female, and 403 (40% were white. 390 (38%) patients had cardiac injury on presentation. These patients were older (median age 70 years), had a higher cardiovascular disease burden, in addition to higher serum concentrations of inflammatory markers. They also exhibited an increased risk for our primary and secondary outcomes, with the risk increasing with higher hs-cTnI concentrations. Peak hs-cTnI concentrations continued to be significantly associated with mortality after a multivariate regression controlling for comorbid conditions, inflammatory markers, acute kidney injury, and acute respiratory distress syndrome. Within the same multivariate regression model, presenting hs-cTnI concentrations were not significantly associated with outcomes, and undetectable hs-cTnI concentrations on presentation did not completely rule out the risk for mechanical ventilation or death. In conclusion, cardiac injury was common in patients admitted with COVID-19. The extent of cardiac injury and peak hs-cTnI concentrations were associated with worse outcomes.

Figure 1

Survival probability of patients according to cardiac injury incidence categories. Kaplan Meier survival curves reveal the survival probability of patients according to cardiac injury incidence categories. Patients with injury on presentation (C), (red) have a lower survival probability than those who develop cardiac injury later in their stay (B), (purple) (adjusted log-rank p=0.012), and both have a lower survival probability than those who never develop cardiac injury (A), (green) (adjusted log-rank p <0.001 and p=0.003, respectively). Cardiac injury was defined by a hs-cTnI concentration >99th percentile.

Figure 2

Potential cardiac injury mechanisms in COVID-19. This figure illustrates the proposed mechanisms of cardiac injury in COVID-19. Systemic infection is likely mediated through angiotensin-converting enzyme 2 (ACE-2) receptors found on multiple cell lineages, including the alveolar and cardiac cells. The proposed mechanisms of injury include myopericarditis through direct viral infection or systemic inflammation, hypercoagulability leading to coronary bed microthrombi, vasculitis, stress cardiomyopathy, acute coronary syndrome, and type-II myocardial infarction from supply-demand mismatch.