Patterns of heart injury in COVID‐19 and relation to outcome

Saudi Medical Journal, 2020

Objectives: To evaluate acute cardiac injury in COVID-19 patients and its association with adverse outcomes including mortality in the United Arab Emirates (UAE) population. Methods: A retrospective study conducted between February and June 2020 in Dubai, UAE, for all laboratory-confirmed Coronavirus disease-19 patients. Demographic, clinical, laboratory, radiological, and clinical outcomes were compared between patients with and without acute cardiac injury. Results: During the study period, 203 patients were included, of which, 44 (21.7%) had evidence of Original Article acute cardiac injury. Compared with patients without acute cardiac injury, patients with acute cardiac injury were: older, had more shortness of breath, diabetes, hypertension, and more bilateral airspace shadowing on admission chest radiography. These patients also had a higher neutrophil count, C-reactive protein, procalcitonin, ferritin, D-dimers and lactate dehydrogenase but lower lymphocyte count. Regarding outcomes, these patients had higher intensive care admissions; a higher rate of complications including acute kidney and liver injury, acidosis, septic shock, acute respiratory distress syndrome, needed more mechanical ventilation, and had a significantly higher risk of death. Conclusion: Acute cardiac injury is common among Coronavirus disease-19 patients. These patients present with higher comorbidities, have high inflammatory markers and have greater risk for in-hospital multiorgan damage, need for mechanical ventilation, and death. Prompt full assessment and intervention are recommended.

Journal of Clinical Medicine, 2021

The exact mechanisms leading to myocardial injury in the coronavirus disease 2019 (COVID-19) are still unknown. In this retrospective observational study, we include all consecutive COVID-19 patients admitted to our center. They were divided into two groups according to the presence of myocardial injury. Clinical variables, Charlson Comorbidity Index (CCI), C-reactive protein (CRP), CAC (COVID-19-associated coagulopathy), defined according to the ISTH score, treatment and in-hospital events were collected. Between March and April 2020, 331 COVID-19 patients were enrolled, 72 of them (21.8%) with myocardial injury. Patients with myocardial injury showed a higher CCI score (median (interquartile range), 5 (4–7) vs. 2 (1–4), p = 0.001), higher CRP values (18.3 (9.6–25.9) mg/dL vs. 12.0 (5.4–19.4) mg/dL, p ˂ 0.001) and CAC score (1 (0–2) vs. 0 (0–1), p = 0.001), and had lower use of any anticoagulant (57 patients (82.6%) vs. 229 patients (90.9%), p = 0.078), than those without. In the a...

2020

Background: Myocardial injury is significantly and independently associated with mortality in COVID-19 patients. However, the pathogenesis of myocardial injury in COVID-19 is still not clear, and cardiac involvement by SARS-CoV-2 remains a major challenge worldwide.Aim: This histopathological and immunohistochemical study seeks to clarify the pathogenesis of myocardial injury in COVID-19.Methods: Postmortem minimally invasive autopsies were performed in two patients who died from COVID-19, and the myocardium samples were compared to a control patient. Immunohistochemistry (IHC) staining was performed using monoclonal antibodies against the following targets: caspase-1, ICAM-1, TNF-α, IL-4, IL-6, CD163, TGF-β, MMP-9, type 1 and type 3 collagen.Results: The histopathological analysis showed severe pericellular interstitial edema surrounding each of the cardiomyocytes. The IHC analysis showed increased expression of caspase-1, ICAM-1, IL-4, IL-6, CD163, MMP-9 and type 3 collagen in the...

Expert Review of Anti-infective Therapy, 2020

Introduction: Coronavirus disease 2019 (COVID-19) has the characteristics of high transmission, diverse clinical manifestations, and a long incubation period. In addition to infecting the respiratory system, COVID-19 also has adverse effects on the cardiovascular system. COVID-19 causes acute myocardial injuries, as well as chronic damage to the cardiovascular system. Areas covered: The present review is aimed at providing current information on COVID-19 and the cardiovascular system. PubMed, Scopus, Science direct, and Google Scholar were searched. Expert opinion: It is suggested that heart injury caused by COVID-19 infection might be an important cause of severe clinical phenotypes or adverse events in affected patients. Myocardial damage is closely related to the severity of the disease and even the prognosis in patients with COVID-19. In addition to disorders that are caused by COVID-19 on the cardiovascular system, more protection should be employed for patients with preexisting cardiovascular disease (CVD). Hence, it is very important that once relevant symptoms appear, patients with COVID-19 be rapidly treated to reduce mortality. Thus, early measurements of cardiac damage via biomarkers following hospitalization for COVID-19 infections in a patient with preexisting CVD are recommended, together with careful monitoring of any myocardial injury that might be caused by the infection.

Current Medical and Drug Research, 2021

The novel coronavirus which is also called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is responsible for COVID-19 (coronavirus disease 2019). SARS-CoV-2 is known to cause substantial pulmonary disease, including pneumonia and acute respiratory distress syndrome (ARDS), clinicians have observed many extra-pulmonary manifestations of COVID-19. SARS‐CoV‐2 infection is associated with a variety of pro‐inflammatory mediators that may play important roles in the pathophysiology of cardiac and arrhythmic complications. Systemic inflammatory response syndrome (cytokine storm) is another putative mechanism of myocardial injury. In addition to lung damage, there may be significant cardiac involvement in patients with COVID-19, which is responsible for worsening the clinical condition of the host. The main cardiac manifestations can be oedema, pericarditis, cardiac fibrosis, myocarditis, impairment of contractile function and cardiac electrophysiology. The cardiac status of patients with ongoing SARS-CoV-2 infection of surviving patients in convalescence period should be carefully monitored.

Life

The intricate relationship between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the cardiovascular system is an extensively studied pandemic topic, as there is an ever-increasing amount of evidence that reports a high prevalence of acute cardiac injury in the context of viral infection. In patients with Coronavirus disease 2019, COVID-19, a significant increase in serum levels of cardiac troponin or other various biomarkers was observed, suggesting acute cardiac injury, thus predicting both a severe course of the disease and a poor outcome. Pathogenesis of acute cardiac injury is not yet completely elucidated, though several mechanisms are allegedly involved, such as a direct cardiomyocyte injury, oxygen supply-demand inequity caused by hypoxia, several active myocardial depressant factors during sepsis, and endothelial dysfunction due to the hyperinflammatory status. Moreover, the increased levels of plasma cytokines and catecholamines and a significantly enhanc...

Ankara Eğitim ve Araştırma Hastanesi Tıp Dergisi, 2020

ACE2 receptors are reported to have an important role in myocardial injury in Covid-19. Direct myocardial toxic effect of virus, myocarditis, cytokine injury, microangiopathic injury related to virus infection may cause myocardial injury and eventually troponin levels increase. Those mechanisms are; unstable plaques in coronary arteries resulting in myocardial hypoxia, upregulation of ACE2 receptors in coronary arteries and cardiac tissue, direct toxic effect of virus towards myocytes, systemic inflammation, myocardial interstitial fibrosis, excessive immune response to interferon, increased cytokine release from helper T lymphocytes which lead to myocardial injury. In this reported case, clinical course was mild and outcome was good, patient was followed in ward and he did not need intensive care.

Saudi Medical Journal, 2020

Objectives: To evaluate acute cardiac injury in COVID-19 patients and its association with adverse outcomes including mortality in the United Arab Emirates (UAE) population. Methods: A retrospective study conducted between February and June 2020 in Dubai, UAE, for all laboratory-confirmed Coronavirus disease-19 patients. Demographic, clinical, laboratory, radiological, and clinical outcomes were compared between patients with and without acute cardiac injury. Results: During the study period, 203 patients were included, of which, 44 (21.7%) had evidence of Original Article acute cardiac injury. Compared with patients without acute cardiac injury, patients with acute cardiac injury were: older, had more shortness of breath, diabetes, hypertension, and more bilateral airspace shadowing on admission chest radiography. These patients also had a higher neutrophil count, C-reactive protein, procalcitonin, ferritin, D-dimers and lactate dehydrogenase but lower lymphocyte count. Regarding outcomes, these patients had higher intensive care admissions; a higher rate of complications including acute kidney and liver injury, acidosis, septic shock, acute respiratory distress syndrome, needed more mechanical ventilation, and had a significantly higher risk of death. Conclusion: Acute cardiac injury is common among Coronavirus disease-19 patients. These patients present with higher comorbidities, have high inflammatory markers and have greater risk for in-hospital multiorgan damage, need for mechanical ventilation, and death. Prompt full assessment and intervention are recommended.

The 2019 coronavirus pandemic (COVID-19), caused by SARS-CoV-2, has affected 5,701,337 individuals globally and accounted for 357,688 deaths as of May 2020. While much of the focus has been on systemic inflammation and pulmonary complications, including interstitial pneumonia and acute respiratory distress syndrome (ARDS), cardiovascular complications related to COVID-19 can also result in severe morbidity and mortality. Mortality for acute myocardial infarction in ARDS caused by SARS-CoV-2 accounts for 2.6%, with risk factors including older age, hypertension, diabetes mellitus and previous cardiovascular events. In approximately 5-25% of hospitalized COVID-19 cases, elevations in cardiac Troponin have been reported. This biomarker appears to correlate with disease severity and poorer prognosis. The pathophysiology behind acute myocardial injury is complex and includes variable degrees of type I and type II myocardial infarction, with a wide range of coronary artery appearances on angiography. This pandemic has disrupted several protocols of care for emergency cardiac conditions. This has led to clinicians relying on fibrinolysis to a much greater extent in the management of acute coronary syndrome, as opposed to primary Percutaneous Coronary Intervention (PCI).

Internal and Emergency Medicine

In this study, we aimed to assess the association between development of cardiac injury and short-term mortality as well as poor in-hospital outcomes in hospitalized patients with COVID-19. In this prospective, single-center study, we enrolled hospitalized patients with laboratory-confirmed COVID-19 and highly suspicious patients with compatible chest computed tomography features. Cardiac injury was defined as a rise of serum high sensitivity cardiac Troponin-I level above 99th percentile (men: > 26 ng/mL, women: > 11 ng/mL). A total of 386 hospitalized patients with COVID-19 were included. Cardiac injury was present among 115 (29.8%) of the study population. The development of cardiac injury was significantly associated with a higher in-hospital mortality rate compared to those with normal troponin levels (40.9% vs 11.1%, p value < 0.001). It was shown that patients with cardiac injury had a significantly lower survival rate after a median follow-up of 18 days from symptom onset (p log-rank < 0.001). It was further demonstrated in the multivariable analysis that cardiac injury could possibly increase the risk of short-term mortality in hospitalized patients with COVID-19 (HR = 1.811, p-value = 0.023). Additionally, preexisting cardiovascular disease, malignancy, blood oxygen saturation < 90%, leukocytosis, and lymphopenia at presentation were independently associated with a greater risk of developing cardiac injury. Development of cardiac injury in hospitalized patients with COVID-19 was significantly associated with higher rates of in-hospital mortality and poor in-hospital outcomes. Additionally, it was shown that development of cardiac injury was associated with a lower shortterm survival rate compared to patients without myocardial damage and could independently increase the risk of short-term mortality by nearly twofold .

Scientific Reports, 2021

Novel coronavirus disease (COVID-19) has led to a major public health crisis globally. Currently, myocardial damage is speculated to be associated with COVID-19, which can be seen as one of the main causes of death of patients with COVID-19. We therefore, aim to investigate the effects of COVID-19 disease on myocardial injury in hospitalized patients who have been tested positive for COVID-19 pneumonia in this study. A prospective study was conducted among 201 patients with COVID-19 in the Pakistan Military Hospital from April 1 to August 31, 2020, including non-critical cases and critical cases. COVID-19 patients were stratified as critical and non-critical according to the signs and symptoms severity; with those requiring intensive care and invasive mechanical ventilation as critical, and those did not requiring invasive mechanical ventilation as non-critical. A total of 201 COVID-19 patients with critical and non-critical categories presented with myocardial injury. All patients ...

JACC: Cardiovascular Imaging

Council, and Karolinska Institutet. Drs G. Reiter and Jin are employed by Siemens. Dr Ugander is a principal investigator for an institutional research and development agreement regarding CMR between Karolinska University Hospital and Siemens. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors' institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.

Diagnostics, 2021

can potentially affect all organs owing to the ubiquitous diffusion of the angiotensin-converting enzyme II (ACE2) receptor-binding protein. Indeed, the SARS-CoV-2 virus is capable of causing heart disease. This systematic review can offer a new perspective on the potential consequences of COVID-19 through an analysis of the current literature on cardiac involvement. This systematic review, conducted from March 2020 to July 2021, searched the current literature for postmortem findings in patients who were positive for SARS-CoV-2 by combining and meshing the terms "COVID-19", "postmortem", "autopsy", and "heart" in titles, abstracts, and keywords. The PubMed database was searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Sixteen papers met the inclusion criteria (case reports and series, original research, only English-written). A total of 209 patients were found (mean age (interquartile range (IQR)), 60.17 years (IQR, 54.75-70.75 years); 122 men (58.37%, ratio of men to women of 1:0.7%)). Each patient tested positive for SARS-CoV-2. Death was mainly the result of respiratory failure. The second most common cause of death was acute heart failure. Few patients specifically died of myocarditis. Variables such as pathological findings, immunohistochemical data, and previous clinical assessments were analyzed. Main cardiac pathological findings were cardiac dilatation, necrosis, lymphocytic infiltration of the myocardium, and small coronary vessel microthrombosis. Immunohistochemical analyses revealed an inflammatory state dominated by the constant presence of CD3+ and CD8+ cytotoxic lymphocytes and CD68+ macrophages. COVID-19 leads to a systemic inflammatory response and a constant prothrombotic state. The results of our systematic review suggest that SARS-CoV-2 was able to cause irreversible changes in several organs, including the heart; this is reflected by the increased cardiac risk in patients who survive COVID-19. Postmortem analysis (including autopsy, histologic, and immunohistochemical examination) is an indispensable tool to better understand pathological changes caused by emerging diseases such as COVID-19. Our results may provide more information on the involvement of the heart in COVID-19 patients.

2020

STRUCTURED ABSTRACTBackgroundThe degree of myocardial injury, reflected by troponin elevation, and associated outcomes among hospitalized patients with Coronavirus Disease (COVID-19) in the US are unknown.ObjectivesTo describe the degree of myocardial injury and associated outcomes in a large hospitalized cohort with laboratory-confirmed COVID-19.MethodsPatients with COVID-19 admitted to one of five Mount Sinai Health System hospitals in New York City between February 27th and April 12th, 2020 with troponin-I (normal value &lt;0.03ng/mL) measured within 24 hours of admission were included (n=2,736). Demographics, medical history, admission labs, and outcomes were captured from the hospitals’ EHR.ResultsThe median age was 66.4 years, with 59.6% men. Cardiovascular disease (CVD) including coronary artery disease, atrial fibrillation, and heart failure, was more prevalent in patients with higher troponin concentrations, as were hypertension and diabetes. A total of 506 (18.5%) patients...

Le Infezioni in Medicina, 2021

This is a systematic review of the literature specifically aimed to explore myocardial injury in coronavirus disease-19 (COVID-19) patients who were hospitalized with severe complicated infections. The medical literature was examined through the large medical databases, including Medline, Ovid, PubMed, and Embase, over the last year between January 2020 and May 2021. The search terms used were a combination of ''myocardial injury'' AND ''COVID-19'' AND "Hospitalization". Then we applied a step to filter the results to select original research articles only evaluating the myocardial injuries in severe COVID-19 hospitalized patients. Selected trials mentioned the type of myocardial injury detected with the infection. A total of 245 articles were extracted. Considering the exclusion of ineligible articles, 42 articles appeared. A total of 42 articles were eligible and were included SUMMARY in the review. These studies included a total of 4326 COVID-19 patients. The 30-day mortality was found to be associated with increased cardiac troponin and myocardial infarction could be a systemic reaction rather than the direct action of COVID-19. Patients with myocardial injury were significantly older and with co-morbid conditions. Studies also found a correlation of higher concentrations of cardiac enzymes with disease severity and increased in-hospital mortality. Myocardial injury was a significant predictor for severe COVID-19 infection and in-hospital mortality. Cardiac enzymes should be monitored in hospitalized patients with severe COVID-19 infections.