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Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China

Educational Objective
Review the incidence and significance of cardiac injury in patients with COVID-19
1 Credit CME
Key Points

Question  What is the incidence and significance of cardiac injury in patients with COVID-19?

Findings  In this cohort study of 416 consecutive patients with confirmed COVID-19, cardiac injury occurred in 19.7% of patients during hospitalization, and it was one independent risk factor for in-hospital mortality.

Meaning  Cardiac injury is a common condition among patients hospitalized with COVID-19, and it is associated with higher risk of in-hospital mortality.


Importance  Coronavirus disease 2019 (COVID-19) has resulted in considerable morbidity and mortality worldwide since December 2019. However, information on cardiac injury in patients affected by COVID-19 is limited.

Objective  To explore the association between cardiac injury and mortality in patients with COVID-19.

Design, Setting, and Participants  This cohort study was conducted from January 20, 2020, to February 10, 2020, in a single center at Renmin Hospital of Wuhan University, Wuhan, China; the final date of follow-up was February 15, 2020. All consecutive inpatients with laboratory-confirmed COVID-19 were included in this study.

Main Outcomes and Measures  Clinical laboratory, radiological, and treatment data were collected and analyzed. Outcomes of patients with and without cardiac injury were compared. The association between cardiac injury and mortality was analyzed.

Results  A total of 416 hospitalized patients with COVID-19 were included in the final analysis; the median age was 64 years (range, 21-95 years), and 211 (50.7%) were female. Common symptoms included fever (334 patients [80.3%]), cough (144 [34.6%]), and shortness of breath (117 [28.1%]). A total of 82 patients (19.7%) had cardiac injury, and compared with patients without cardiac injury, these patients were older (median [range] age, 74 [34-95] vs 60 [21-90] years; P < .001); had more comorbidities (eg, hypertension in 49 of 82 [59.8%] vs 78 of 334 [23.4%]; P < .001); had higher leukocyte counts (median [interquartile range (IQR)], 9400 [6900-13 800] vs 5500 [4200-7400] cells/μL) and levels of C-reactive protein (median [IQR], 10.2 [6.4-17.0] vs 3.7 [1.0-7.3] mg/dL), procalcitonin (median [IQR], 0.27 [0.10-1.22] vs 0.06 [0.03-0.10] ng/mL), creatinine kinase–myocardial band (median [IQR], 3.2 [1.8-6.2] vs 0.9 [0.6-1.3] ng/mL), myohemoglobin (median [IQR], 128 [68-305] vs 39 [27-65] μg/L), high-sensitivity troponin I (median [IQR], 0.19 [0.08-1.12] vs <0.006 [<0.006-0.009] μg/L), N-terminal pro-B-type natriuretic peptide (median [IQR], 1689 [698-3327] vs 139 [51-335] pg/mL), aspartate aminotransferase (median [IQR], 40 [27-60] vs 29 [21-40] U/L), and creatinine (median [IQR], 1.15 [0.72-1.92] vs 0.64 [0.54-0.78] mg/dL); and had a higher proportion of multiple mottling and ground-glass opacity in radiographic findings (53 of 82 patients [64.6%] vs 15 of 334 patients [4.5%]). Greater proportions of patients with cardiac injury required noninvasive mechanical ventilation (38 of 82 [46.3%] vs 13 of 334 [3.9%]; P < .001) or invasive mechanical ventilation (18 of 82 [22.0%] vs 14 of 334 [4.2%]; P < .001) than those without cardiac injury. Complications were more common in patients with cardiac injury than those without cardiac injury and included acute respiratory distress syndrome (48 of 82 [58.5%] vs 49 of 334 [14.7%]; P < .001), acute kidney injury (7 of 82 [8.5%] vs 1 of 334 [0.3%]; P < .001), electrolyte disturbances (13 of 82 [15.9%] vs 17 of 334 [5.1%]; P = .003), hypoproteinemia (11 of 82 [13.4%] vs 16 of 334 [4.8%]; P = .01), and coagulation disorders (6 of 82 [7.3%] vs 6 of 334 [1.8%]; P = .02). Patients with cardiac injury had higher mortality than those without cardiac injury (42 of 82 [51.2%] vs 15 of 334 [4.5%]; P < .001). In a Cox regression model, patients with vs those without cardiac injury were at a higher risk of death, both during the time from symptom onset (hazard ratio, 4.26 [95% CI, 1.92-9.49]) and from admission to end point (hazard ratio, 3.41 [95% CI, 1.62-7.16]).

Conclusions and Relevance  Cardiac injury is a common condition among hospitalized patients with COVID-19 in Wuhan, China, and it is associated with higher risk of in-hospital mortality.

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Article Information

Accepted for Publication: March 9, 2020.

Corresponding Author: Bo Yang, MD, PhD (yybb112@whu.edu.cn), and He Huang, MD, PhD (huanghe1977@whu.edu.cn), Cardiovascular Research Institute, Department of Cardiology, Renmin Hospital of Wuhan University, 238 Jiefang Rd, Wuchang District, Wuhan 430060, Hubei, China.

Published Online: March 25, 2020. doi:10.1001/jamacardio.2020.0950

Author Contributions: Drs B. Yang and H. Huang had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Shi, Qin, and Shen contributed to the work equally and should be regarded as co–first authors.

Concept and design: Shi, Qin, Shen, Cai, T. Liu, X. Liu, Liang, Zhao, H. Huang, B. Yang, C. Huang.

Acquisition, analysis, or interpretation of data: Shi, F. Yang, Gong, Liang, B. Yang.

Drafting of the manuscript: Shi, Qin, Shen, T. Liu, Zhao.

Critical revision of the manuscript for important intellectual content: Shi, Cai, F. Yang, Gong, X. Liu, Liang, H. Huang, B. Yang, C. Huang.

Statistical analysis: Shi, Qin, Shen, Cai, T. Liu, F. Yang, Gong.

Obtained funding: Shi.

Administrative, technical, or material support: Shi, Shen, F. Yang, Gong, Liang, Zhao, H. Huang, B. Yang, C. Huang.

Supervision: Shi, Qin, X. Liu, Liang, Zhao, B. Yang, C. Huang.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research was supported by grants from the Nature Science Foundation of China (grants 81800447 and 81770324), the Nature Science Foundation of Hubei province (grant 2017CFB204), and the Major Program of Technological Innovation of Hubei Province (grant 2016ACA153).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We acknowledge all medical staff involved in the diagnosis and treatment of patients with COVID-19 in Wuhan. We thank Xu Liu, MD, PhD, Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, for guidance in revision of manuscript and interpretation of results; we thank Min Chen, MAEng, Xuecheng Yu, MAEng, and and Zhongli Dai, BE, Wuhan Shinall Technology Co Ltd, for data collation and statistical analysis. They were not compensated for their contributions.

Huang  C , Wang  Y , Li  X ,  et al.  Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China.   Lancet. 2020;395(10223):497-506. doi:10.1016/S0140-6736(20)30183-5 PubMedGoogle ScholarCrossref
Wang  D , Hu  B , Hu  C ,  et al.  Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.   JAMA. Published online February 7, 2020. doi:10.1001/jama.2020.1585 PubMedGoogle Scholar
Madjid  M , Solomon  S , Vardeny  O . ACC clinical bulletin: cardiac implications of novel Wuhan coronavirus (2019-nCoV). Published February 13, 2020. Accessed February 13, 2020. https://www.acc.org/latest-in-cardiology/articles/2020/02/13/12/42/acc-clinical-bulletin-focuses-on-cardiac-implications-of-coronavirus-2019-ncov
World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected: interim guidance. Published January 28, 2020. Accessed January 31, 2020. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected
Ranieri  VM , Rubenfeld  GD , Thompson  BT ,  et al; ARDS Definition Task Force.  Acute respiratory distress syndrome: the Berlin Definition.   JAMA. 2012;307(23):2526-2533.PubMedGoogle Scholar
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group.  KDIGO clinical practice guideline for acute kidney injury.   Kidney Int Suppl. 2012;2:1.Google ScholarCrossref
Wang  M , Wu  Q , Xu  WZ ,  et al Clinical diagnosis of 8274 samples with 2019-novel coronavirus in Wuhan. Published 2020. Accessed March 12, 2020. https://www.medrxiv.org/content/10.1101/2020.03.02.20030189v1.full.pdf
Guan  WJ , Ni  ZY , Hu  Y ,  et al Clinical characteristics of 2019 novel coronavirus infection in China. Published 2020. Accessed March 12, 2020. https://www.medrxiv.org/content/10.1101/2020.02.06.20020974v1
Yu  CM , Wong  RS , Wu  EB ,  et al.  Cardiovascular complications of severe acute respiratory syndrome.   Postgrad Med J. 2006;82(964):140-144. doi:10.1136/pgmj.2005.037515 PubMedGoogle ScholarCrossref
Alhogbani  T .  Acute myocarditis associated with novel Middle east respiratory syndrome coronavirus.   Ann Saudi Med. 2016;36(1):78-80. doi:10.5144/0256-4947.2016.78 PubMedGoogle ScholarCrossref
Wrapp  D , Wang  N , Corbett  KS ,  et al.  Cryo-EM structure of the 2019-nCoV spike in the prefusion conformation.   Science. Published online February 19, 2020. doi:10.1126/science.abb2507 PubMedGoogle Scholar
Xin  Z , Ke  C , Zou  J ,  et al.  The single-cell RNA-seq data analysis on the receptor ACE2 expression reveals the potential risk of different human organs vulnerable to Wuhan 2019-nCoV infection.   Front Med. Published online February 8, 2020.Google Scholar
Xu  Z , Shi  L , Wang  Y ,  et al.  Pathological findings of COVID-19 associated with acute respiratory distress syndrome.   Lancet Respir Med. Published online February 18, 2020. doi:10.1016/S2213-2600(20)30076-X PubMedGoogle Scholar
Li  SS , Cheng  CW , Fu  CL ,  et al.  Left ventricular performance in patients with severe acute respiratory syndrome: a 30-day echocardiographic follow-up study.   Circulation. 2003;108(15):1798-1803. doi:10.1161/01.CIR.0000094737.21775.32 PubMedGoogle ScholarCrossref
Sellers  SA , Hagan  RS , Hayden  FG , Fischer  WA  II .  The hidden burden of influenza: a review of the extra-pulmonary complications of influenza infection.   Influenza Other Respir Viruses. 2017;11(5):372-393. doi:10.1111/irv.12470 PubMedGoogle ScholarCrossref
de Jong  MD , Simmons  CP , Thanh  TT ,  et al.  Fatal outcome of human influenza A (H5N1) is associated with high viral load and hypercytokinemia.   Nat Med. 2006;12(10):1203-1207. doi:10.1038/nm1477 PubMedGoogle ScholarCrossref
National Health Commission of People’s Republic of China. Diagnosis and treatment of pneumonia caused by novel coronavirus (trial version 4). In Chinese. Published 2020. http://www.nhc.gov.cn/yzygj/s7653p/202001/4294563ed35b43209b31739bd0785e67/files/7a9309111267475a99d4306962c8bf78.pdf
Madjid  M , Vela  D , Khalili-Tabrizi  H , Casscells  SW , Litovsky  S .  Systemic infections cause exaggerated local inflammation in atherosclerotic coronary arteries: clues to the triggering effect of acute infections on acute coronary syndromes.   Tex Heart Inst J. 2007;34(1):11-18.PubMedGoogle Scholar
Corrales-Medina  VF , Musher  DM , Shachkina  S , Chirinos  JA .  Acute pneumonia and the cardiovascular system.   Lancet. 2013;381(9865):496-505. doi:10.1016/S0140-6736(12)61266-5 PubMedGoogle ScholarCrossref
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