Admission Cardiac Diagnostic Testing with Electrocardiography and Troponin Measurement Prognosticates Increased 30-Day Mortality in COVID-19

Abstract

Background Cardiovascular involvement in coronavirus disease 2019 (COVID-19) is common and leads to worsened mortality. Diagnostic cardiovascular studies may be helpful for resource appropriation and identifying patients at increased risk for death. Methods and Results We analyzed 887 patients (aged 64±17 years) admitted with COVID-19 from March 1 to April 3, 2020 in New York City with 12 lead electrocardiography within 2 days of diagnosis. Demographics, comorbidities, and laboratory testing, including high sensitivity cardiac troponin T (hs-cTnT), were abstracted. At 30 days follow-up, 556 patients (63%) were living without requiring mechanical ventilation, 123 (14%) were living and required mechanical ventilation, and 203 (23%) had expired. Electrocardiography findings included atrial fibrillation or atrial flutter (AF/AFL) in 46 (5%) and ST-T wave changes in 306 (38%). 27 (59%) patients with AF/AFL expired as compared to 181 (21%) of 841 with other non-life-threatening rhythms (P<0.001). Multivariable analysis incorporating age, comorbidities, AF/AFL, QRS abnormalities, and ST-T wave changes, and initial hs-cTnT ≥20 ng/L showed that increased age (HR 1.04/year), elevated hs-cTnT (HR 4.57), AF/AFL (HR 2.07), and a history of coronary artery disease (HR 1.56) and active cancer (HR 1.87) were associated with increased mortality. Conclusions Myocardial injury with hs-cTnT ≥20 ng/L, in addition to cardiac conduction perturbations, especially AF/AFL, upon hospital admission for COVID-19 infection is associated with markedly increased risk for mortality than either diagnostic abnormality alone.

Keywords: COVID‐19; arrhythmia; atrial fibrillation; troponin.

Figure 1. Patient outcomes.

This diagram demonstrates patient outcomes. One thousand two hundred and fifty‐eight patients were diagnosed with COVID‐19 from March 1 to April 3, 2020 in the study with a minimum of 30 days of follow‐up. Of those patients, 887 had an ECG performed within 2 days of presentation, after the exclusion of 371 patients who did not have an ECG within 2 days. Of those 887 patients, 556 were living without requiring mechanical ventilation (of whom 501 had been discharged and 55 remained admitted). 123 patients were living and had required mechanical ventilation, of whom 94 remained intubated, 17 had been extubated but remained hospitalized, and 12 has been extubated and discharged from the hospital. A total of 208 patients had expired by 30 days of follow‐up. COVID‐19 indicates coronavirus disease 2019; and ED, emergency department.

Figure 2. Kaplan‐Meier estimates of survival by presence of absence of atrial fibrillation or atrial flutter (AF/AFL) on presenting ECG.

This figure demonstrates Kaplan‐Meier survival estimates at 30 days for patients stratified by presence (n=46) or absence (n=841) of AF/AFL on the presenting ECG. A total of 27 patients (59%) with AF/AFL on their presenting ECG expired, as compared to 181 (21%) of 841 patients without AF/AFL (P<0.001).