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. 2022 Apr 25:9:809997.
doi: 10.3389/fcvm.2022.809997. eCollection 2022.

Biomarkers of Cardiac Injury, Renal Injury, and Inflammation Are Strong Mediators of Sex-Associated Death in COVID-19

Heidi S Lumish  1 , Eunyoung Kim  1 , Caitlin Selvaggi  2   3   4 , Tingyi Cao  2   3   4 , Aakriti Gupta  5 , Andrea S Foulkes  2   3   4 , Muredach P Reilly  1   6
Affiliations

Biomarkers of Cardiac Injury, Renal Injury, and Inflammation Are Strong Mediators of Sex-Associated Death in COVID-19

Heidi S Lumish et al. Front Cardiovasc Med. .

Abstract

Background: Studies examining outcomes among individuals with COronaVIrus Disease 2019 (COVID-19) have consistently demonstrated that men have worse outcomes than women, with a higher incidence of myocardial injury, respiratory failure, and death. However, mechanisms of higher morbidity and mortality among men remain poorly understood. We aimed to identify mediators of the relationship between sex and COVID-19-associated mortality.

Methods: Patients hospitalized at two quaternary care facilities, New York Presbyterian Hospital (CUIMC/NYPH) and Massachusetts General Hospital (MGH), for SARS-CoV-2 infection between February and May 2020 were included. Five independent biomarkers were identified as mediators of sex effects, including high-sensitivity cardiac troponin T (hs-cTNT), high sensitivity C-reactive protein (hs-CRP), ferritin, D-dimer, and creatinine.

Results: In the CUIMC/NYPH cohort (n = 2,626, 43% female), male sex was associated with significantly greater mortality (26 vs. 21%, p = 0.0146) and higher peak hs-cTNT, hs-CRP, ferritin, D-dimer, and creatinine (p < 0.001). The effect of male sex on the primary outcome of death was partially mediated by peak values of all five biomarkers, suggesting that each pathophysiological pathway may contribute to increased risk of death in men. Hs-cTnT, creatinine, and hs-CRP were the strongest mediators. Findings were highly consistent in the MGH cohort with the exception of D-dimer.

Conclusions: This study suggests that the effect of sex on COVID-19 outcomes is mediated by cardiac and kidney injury, as well as underlying differences in inflammation and iron metabolism. Exploration of these specific pathways may facilitate sex-directed diagnostic and therapeutic strategies for patients with COVID-19 and provides a framework for the study of sex differences in other complex diseases.

Keywords: SARS-CoV-2; biomarkers; inflammation; myocardial injury; sex differences.

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Conflict of interest statement

AF receives sponsored research support from Bristol Myers Squibb/Pfizer and Fitbit and has received expert witness testimonial fees from Round Table Group. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Causal mediation model. This study assessed the degree to which peak serum biomarkers mediated the association between male sex and death due to SARS-CoV-2 infection in hospitalized patients. Of the fifteen biomarkers tested, five were significant mediators of the association between male sex and 30-day mortality, with varying proportion mediated as represented by the arrow thickness. Potential confounders accounted for in the primary analysis included age, sex, race/ethnicity, and number of biomarker measurements. The proportion mediated is given by the Natural Indirect Effect (NIE) divided by the Total Effect [NIE + Natural Direct Effect (NDE)].
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