A study published in the Journal of the American College of Cardiology (JACC) has identified different types of cardiac structural damage experienced by COVID-19 patients after cardiac injury that can be associated with deadly conditions including heart attack, pulmonary embolism, heart failure, and myocarditis.
“Early detection of structural abnormalities may dictate more appropriate treatments, including anticoagulation and other approaches for hospitalized and post-hospitalized patients,” said study author Valentin Fuster, director of Mount Sinai Heart and physician-in-chief of The Mount Sinai Hospital, New York, USA.
The international, retrospective study expands on previous research showing that myocardial injury is prevalent among patients hospitalized with COVID-19 and is associated with higher risk of mortality. That study focused on the patients’ levels of troponin—proteins that are released when the heart muscle becomes damaged—and their outcomes.
The study looked at the presence of cardiac troponin elevations in combination with the presence of echocardiographic abnormalities, and found that the combination was associated with worse prognosis and mortality than troponin elevations alone.
“This is one of the first studies to provide detailed echocardiographic and electrocardiographic data in hospitalised patients with COVID-19 and laboratory evidence of myocardial injury,” said first and corresponding author Gennaro Giustino, cardiology fellow at The Mount Sinai Hospital, New York, USA. “We found that among COVID-19 patients who underwent transthoracic echocardiography, these cardiac structural abnormalities were diverse and present in nearly two-thirds of patients.”
Researchers looked at transthoracic echocardiographic (TTE) and electrocardiographic (ECG) scans of 305 adult patients with confirmed positive COVID-19 admitted to four New York City hospitals within the Mount Sinai Health System, Elmhurst Hospital in Queens, and two hospitals in Milan, Italy, between March and May 2020.
Median age was 63 years and 67.2 percent were men. 190 patients (62.6%) had evidence of myocardial injury; 118 of them had heart damage at the time of hospitalisation admission and 72 developed myocardial injury during hospitalisation. Researchers found that patients with myocardial injury had more electrocardiographic abnormalities, higher inflammatory biomarkers, and an increased prevalence of TTE abnormalities when compared to patients without heart injury.
Abnormalities were diverse, with some patients exhibiting multiple abnormalities. The study suggests that 26.3% had right ventricular dysfunction, 23.7% had regional left ventricular wall motion abnormalities, 18.4% had diffuse left ventricular dysfunction, 13.2% had grade II or III diastolic dysfunction, and 7.2% had pericardial effusions.
The study went on to look at in-hospital mortality and troponin elevation. It shows that troponin elevation was 5.2% among patients who did not have heart injury, compared to 18.6% for patients with myocardial injury but without echocardiographic abnormalities, and 31.7% for patients with myocardial injury who also had echocardiographic abnormalities. Researchers adjusted for other major complications from COVID-19 including shock, acute respiratory distress syndrome, and renal failure.
“Our study shows that an echocardiogram performed with appropriate personal protection considerations is a useful and important tool in early identification of patients at greater risk for COVID-19-related cardiac injury, who may benefit from a more aggressive therapeutic approach earlier in their hospitalisation,” said corresponding author Martin Goldman (Icahn School of Medicine at Mount Sinai, New York, USA). “Additionally, because this is a new disease with lingering symptoms, we plan on following these patients closely using imaging to evaluate the evolution and hopefully resolution of these cardiac issues.”