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What is the impact of underlying cardiovascular disease (CVD) and myocardial injury on fatal outcomes in patients with coronavirus disease 2019 (COVID-19)?
In this case series study of 187 patients with COVID-19, 27.8% of patients had myocardial injury, which resulted in cardiac dysfunction and arrhythmias. Myocardial injury has a significant association with fatal outcome of COVID-19, while the prognosis of patients with underlying CVD but without myocardial injury were relatively favorable.
It is reasonable to triage patients with COVID-19 according to the presence of underlying CVD and evidence of myocardial injury for prioritized treatment and even more aggressive strategies.
Increasing numbers of confirmed cases and mortality rates of coronavirus disease 2019 (COVID-19) are occurring in several countries and continents. Information regarding the impact of cardiovascular complication on fatal outcome is scarce.
To evaluate the association of underlying cardiovascular disease (CVD) and myocardial injury with fatal outcomes in patients with COVID-19.
Design, Setting, and Participants
This retrospective single-center case series analyzed patients with COVID-19 at the Seventh Hospital of Wuhan City, China, from January 23, 2020, to February 23, 2020. Analysis began February 25, 2020.
Main Outcomes and Measures
Demographic data, laboratory findings, comorbidities, and treatments were collected and analyzed in patients with and without elevation of troponin T (TnT) levels.
Among 187 patients with confirmed COVID-19, 144 patients (77%) were discharged and 43 patients (23%) died. The mean (SD) age was 58.50 (14.66) years. Overall, 66 (35.3%) had underlying CVD including hypertension, coronary heart disease, and cardiomyopathy, and 52 (27.8%) exhibited myocardial injury as indicated by elevated TnT levels. The mortality during hospitalization was 7.62% (8 of 105) for patients without underlying CVD and normal TnT levels, 13.33% (4 of 30) for those with underlying CVD and normal TnT levels, 37.50% (6 of 16) for those without underlying CVD but elevated TnT levels, and 69.44% (25 of 36) for those with underlying CVD and elevated TnTs. Patients with underlying CVD were more likely to exhibit elevation of TnT levels compared with the patients without CVD (36 [54.5%] vs 16 [13.2%]). Plasma TnT levels demonstrated a high and significantly positive linear correlation with plasma high-sensitivity C-reactive protein levels (β = 0.530, P < .001) and N-terminal pro–brain natriuretic peptide (NT-proBNP) levels (β = 0.613, P < .001). Plasma TnT and NT-proBNP levels during hospitalization (median [interquartile range (IQR)], 0.307 [0.094-0.600]; 1902.00 [728.35-8100.00]) and impending death (median [IQR], 0.141 [0.058-0.860]; 5375 [1179.50-25695.25]) increased significantly compared with admission values (median [IQR], 0.0355 [0.015-0.102]; 796.90 [401.93-1742.25]) in patients who died (P = .001; P < .001), while no significant dynamic changes of TnT (median [IQR], 0.010 [0.007-0.019]; 0.013 [0.007-0.022]; 0.011 [0.007-0.016]) and NT-proBNP (median [IQR], 352.20 [174.70-636.70]; 433.80 [155.80-1272.60]; 145.40 [63.4-526.50]) was observed in survivors (P = .96; P = .16). During hospitalization, patients with elevated TnT levels had more frequent malignant arrhythmias, and the use of glucocorticoid therapy (37 [71.2%] vs 69 [51.1%]) and mechanical ventilation (31 [59.6%] vs 14 [10.4%]) were higher compared with patients with normal TnT levels. The mortality rates of patients with and without use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers was 36.8% (7 of 19) and 21.4% (36 of 168) (P = .13).
Conclusions and Relevance
Myocardial injury is significantly associated with fatal outcome of COVID-19, while the prognosis of patients with underlying CVD but without myocardial injury is relatively favorable. Myocardial injury is associated with cardiac dysfunction and arrhythmias. Inflammation may be a potential mechanism for myocardial injury. Aggressive treatment may be considered for patients at high risk of myocardial injury.
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Corresponding Author: Zhibing Lu, MD, Department of Cardiology (firstname.lastname@example.org), and Xinghuan Wang, MD, Department of Urology (email@example.com), Zhongnan Hospital of Wuhan University, 169 East Lake Rd, Wuhan 430071, Hubei, China.
Accepted for Publication: March 9, 2020.
Published Online: March 27, 2020. doi:10.1001/jamacardio.2020.1017
Correction: This article was corrected on May 20, 2020, to fix errors in the Abstract and Results section.
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Guo T et al. JAMA Cardiology.
Author Contributions: Drs Lu and X. Wang 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 Guo and Fan contributed equally to this work and are co–first authors.
Concept and design: Guo, Fan, Zhang, H. Wang, Wan, X. Wang, Lu.
Acquisition, analysis, or interpretation of data: Guo, Fan, Chen, Wu, He, H. Wang, Lu.
Drafting of the manuscript: Guo, Fan, Chen, Zhang, H. Wang, Lu.
Critical revision of the manuscript for important intellectual content: Fan, Wu, He, H. Wang, Wan, X. Wang, Lu.
Statistical analysis: Guo, Fan, Chen, Wu.
Obtained funding: Fan, Lu.
Administrative, technical, or material support: Fan, Wu, X. Wang, Lu.
Supervision: Fan, H. Wang, Wan, X. Wang, Lu.
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was supported by the Special Project for Significant New Drug Research and Development in the Major National Science and Technology Projects of China (project 2020ZX09201007).
Role of the Funder/Sponsor: The funder 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 Information: We acknowledge all health care workers involved in the diagnosis and treatment of patients at Seventh Hospital of Wuhan City; we appreciate Lei Liu, MD (Shenzhen Rosso Pharmaceutical Co Ltd Medical Center, Shenzhen, China), for the consultation for statistical analysis. Compensation was not received.
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