Multicenter Study

. 2020 Nov 3;76(18):2043-2055.

doi: 10.1016/j.jacc.2020.08.069.

Characterization of Myocardial Injury in Patients With COVID-19

Gennaro Giustino¹, Lori B Croft², Giulio G Stefanini³, Renato Bragato⁴, Jeffrey J Silbiger⁵, Marco Vicenzi⁶, Tatyana Danilov⁷, Nina Kukar⁸, Nada Shaban⁹, Annapoorna Kini², Anton Camaj², Solomon W Bienstock², Eman R Rashed¹⁰, Karishma Rahman², Connor P Oates², Samantha Buckley², Lindsay S Elbaum¹⁰, Derya Arkonac⁷, Ryan Fiter², Ranbir Singh², Emily Li², Victor Razuk², Sam E Robinson⁵, Michael Miller², Benjamin Bier², Valeria Donghi⁴, Marco Pisaniello¹¹, Riccardo Mantovani⁴, Giuseppe Pinto⁴, Irene Rota¹¹, Sara Baggio⁴, Mauro Chiarito⁴, Fabio Fazzari⁴, Ignazio Cusmano¹², Mirko Curzi⁴, Richard Ro², Waqas Malick², Mazullah Kamran⁵, Roopa Kohli-Seth¹³, Adel M Bassily-Marcus¹³, Eric Neibart², Gregory Serrao², Gila Perk², Donna Mancini², Vivek Y Reddy², Sean P Pinney², George Dangas², Francesco Blasi¹⁴, Samin K Sharma², Roxana Mehran², Gianluigi Condorelli⁴, Gregg W Stone², Valentin Fuster¹⁵, Stamatios Lerakis², Martin E Goldman¹⁶

Affiliations

¹ The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York. Electronic address: gennaro.giustino@mountsinai.org.
² The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York.
³ Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy. Electronic address: giulio.stefanini@gmail.com.
⁴ Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy.
⁵ Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, New York City, New York.
⁶ Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
⁷ Mount Sinai Beth Israel Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York.
⁸ Mount Sinai West Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York.
⁹ Mount Sinai Queens Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York.
¹⁰ The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York; Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, New York City, New York.
¹¹ Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.
¹² Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
¹³ Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York.
¹⁴ University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy.
¹⁵ The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
¹⁶ The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York. Electronic address: https://twitter.com/g_giustinoMD.

PMID: 33121710
PMCID: PMC7588179
DOI: 10.1016/j.jacc.2020.08.069

Multicenter Study

Characterization of Myocardial Injury in Patients With COVID-19

Gennaro Giustino et al. J Am Coll Cardiol. 2020.

. 2020 Nov 3;76(18):2043-2055.

doi: 10.1016/j.jacc.2020.08.069.

Authors

Affiliations

¹ The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York. Electronic address: gennaro.giustino@mountsinai.org.
² The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York.
³ Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy. Electronic address: giulio.stefanini@gmail.com.
⁴ Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy.
⁵ Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, New York City, New York.
⁶ Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy; Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
⁷ Mount Sinai Beth Israel Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York.
⁸ Mount Sinai West Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York.
⁹ Mount Sinai Queens Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York.
¹⁰ The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York; Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, New York City, New York.
¹¹ Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.
¹² Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.
¹³ Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York.
¹⁴ University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy.
¹⁵ The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
¹⁶ The Zena and Michael A. Wiener Cardiovascular Institute, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York. Electronic address: https://twitter.com/g_giustinoMD.

PMID: 33121710
PMCID: PMC7588179
DOI: 10.1016/j.jacc.2020.08.069

Abstract

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.

Keywords: COVID-19; echocardiography; myocardial infarction; myocardial injury.

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Figures

**Central Illustration**
Spectrum of Echocardiographic Abnormalities in Patients With Biomarker Evidence of Myocardial Injury and Coronavirus Disease-2019 Among patients with coronavirus disease-2019 (COVID-19) who underwent transthoracic echocardiography (TTE), cardiac structural abnormalities were present in nearly two-thirds of patients with myocardial injury. Cardiac structural abnormalities included right ventricular dysfunction, left ventricular (LV) wall motion abnormalities, global left ventricular dysfunction, diastolic dysfunction, and pericardial effusions.

**Figure 1**
In-Hospital Mortality in Patients With COVID-19, Myocardial Injury, and Echocardiographic Abnormalities Kaplan-Meier curves for all-cause mortality in patients with versus without myocardial injury **(A)** and in patients with versus without myocardial injury according to the presence or absence of major echocardiographic abnormalities **(B)**. Includes wall motion abnormalities, global left ventricular dysfunction, diastolic dysfunction, right ventricular dysfunction, and presence of pericardial effusion. Event rates are censored at 20 days from hospital admission. TTE = transthoracic echocardiography.

**Figure 2**
Independent Predictors of In-Hospital Death From Multivariable Logistic-Regression Analysis Results are reported as odds ratios (ORs) and 95% confidence intervals (CIs). The following variables were included in the final model: age, sex, race, history of heart failure, acute respiratory distress syndrome, acute kidney injury stage II or III, cardiocirculatory shock, myocardial injury (with or without major echocardiographic abnormalities), and center identifier. ∗Includes wall motion abnormalities, global left ventricular dysfunction, diastolic dysfunction, right ventricular dysfunction, or presence of mild or more severe pericardial effusion.

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Comment in

Cardiac Injury in COVID-19-Echoing Prognostication.
Lavie CJ, Sanchis-Gomar F, Lippi G. Lavie CJ, et al. J Am Coll Cardiol. 2020 Nov 3;76(18):2056-2059. doi: 10.1016/j.jacc.2020.08.068. J Am Coll Cardiol. 2020. PMID: 33121711 Free PMC article.

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Characterization of Myocardial Injury in Patients With COVID-19

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Characterization of Myocardial Injury in Patients With COVID-19

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