Clinical significance of coronavirus disease 2019 in hospitalized patients with myocardial injury

Abstract

Background The clinical significance of Coronavirus disease 2019 (COVID‐19) as an associate of myocardial injury is controversial. Hypothesis Type 2 MI/Myocardial Injury are associated with worse outcomes if complicated by COVID‐19. Methods This longitudinal cohort study involved consecutive patients admitted to a large urban hospital. Myocardial injury was determined using laboratory records as ≥1 hs‐TnI result >99th percentile (male: >34 ng/L; female: >16 ng/L). Endotypes were defined according to the Fourth Universal Definition of Myocardial Infarction (MI) and COVID‐19 determined using PCR. Outcomes of patients with myocardial injury with and without COVID‐19 were assessed. Results Of 346 hospitalized patients with elevated hs‐TnI, 35 (10.1%) had laboratory‐confirmed COVID‐19 (median age [IQR]; 65 [59–74]; 64.8% male vs. COVID‐19 negative: 74 [63–83] years; 43.7% male). Cardiac endotypes by COVID‐19 status (yes vs. no) were: Type 1 MI (0 [0%] vs. 115 [100%]; p < .0005), Type 2 MI (13 [16.5%] vs. 66 [83.5%]; p = .045), and non‐ischemic myocardial injury (cardiac: 4 [5.8%] vs. 65 [94.2%]; p = .191, non‐cardiac:19 [22.9%] vs. 64 [77.%]; p < .0005). COVID‐19 patients had less comorbidity (median [IQR] Charlson Comorbidity Index: 3.0 [3.0] vs. 5.0 [4.0]; p = .001), similar hs‐TnI concentrations (median [IQR] initial: 46 [113] vs. 62 [138]; p = .199, peak: 122 [474] vs. 79 [220] ng/L; p = .564), longer admission (days) (median [IQR]: 14[19] vs. 6[12]; p = .001) and higher in‐hospital mortality (63.9% vs. 11.3%; OR = 13.2; 95%CI: 5.90, 29.7). Conclusions Cardiac sequelae of COVID‐19 typically manifest as Non‐cardiac myocardial injury/Type 2MI in younger patients with less co‐morbidity. Paradoxically, the admission duration and in‐hospital mortality are increased.

Cardiovascular System during SARS-CoV-2 Infection

“…A study on 346 patients with elevated hs-cTnT conducted in the UK has demonstrated that there were no COVID-19-positive patients in the group of 115 patients with Type 1 MI, and in the group of 231 patients with Type 2 MI/myocardial Injury there were 36 (16%) patients who were COVID-19-positive. Cardiac causes of MI were more common in patients without SARS-CoV-2 virus (positive: 11.1% vs. negative: 33.3%, p = 0.22), of which tachyarrhythmia and heart failure were the most likely mechanisms (15.7% and 15.1%) [34]. Next, a study on 313 patients of whom elevation was present in 85 patients (27.2%) and of those 85 patients, only 11.7% had criteria for MI: 7% had type 2 MI, and 4.7% had type 1 MI [9].…”

“…We used three articles in this section. Myocardial infarction in COVID-19-positive patients is not common [9,25,34]. A study on 346 patients with elevated hs-cTnT conducted in the UK has demonstrated that there were no COVID-19-positive patients in the group of 115 patients with Type 1 MI, and in the group of 231 patients with Type 2 MI/myocardial Injury there were 36 (16%) patients who were COVID-19-positive.…”

Cardiovascular and Renal Risk Factors and Complications Associated With COVID-19

“…Cardiovascular injury is associated with history of prior cardiovascular disease, and elevated cardiac enzymes in the context of COVID-19 are associated with poorer outcomes compared with other causes of non-acute coronary syndromes or myocardial injury (140). Direct effect on the heart secondary to viral infiltration has been reported but appears to be uncommon (141).…”

“…Systemic pathogenic infection may pre-dispose to acute type 1 MI due to increased levels of circulating inflammatory cytokines in COVID-19 and resultant macrophage activity within atherosclerotic plaques, leading to coronary plaque rupture and thrombosis. Acute SARS-CoV-2 infection is also associated with a pro-thrombotic and pro-coagulable state; when combined with risk factors such as diabetes which is associated with impaired fibrinolysis and increased platelet activation, coronary thrombosis may occur(140).…”

The Janus of COVID-19: from registry data to prospective studies

“…Troponin elevation in patients with COVID-19 not due to type 1 myocardial infarction is associated with greater mortality than non-COVID-19 causes of type 2 myocardial infarction or injury. 2 Given the prohibitive mortality in this higher-risk group, the data reflect a survival bias for patients surviving to discharge. Therefore, as Kotecha et al 1 point out, their study is focused to a small subgroup of patients with convalescent disease.…”