[Skip to Content]
[Skip to Content Landing]

Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)

Educational Objective
To understand the affect of underlying cardiovascular disease (CVD) and myocardial injury on fatal outcomes in patients with coronavirus disease 2019 (COVID-19)
1 Credit CME
Key Points

Question  What is the impact of underlying cardiovascular disease (CVD) and myocardial injury on fatal outcomes in patients with coronavirus disease 2019 (COVID-19)?

Findings  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.

Meaning  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.

Abstract

Importance  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.

Objective  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.

Results  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.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Author: Zhibing Lu, MD, Department of Cardiology (luzhibing222@163.com), and Xinghuan Wang, MD, Department of Urology (wangxinghuan@whu.edu.cn), 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.

References
1.
Lu  H , Stratton  CW , Tang  YW .  Outbreak of pneumonia of unknown etiology in Wuhan, China: the mystery and the miracle.   J Med Virol. 2020;92(4):401-402. doi:10.1002/jmv.25678PubMedGoogle ScholarCrossref
2.
Hui  DS , I Azhar  E , Madani  TA ,  et al.  The continuing 2019-nCoV epidemic threat of novel coronaviruses to global health: the latest 2019 novel coronavirus outbreak in Wuhan, China.   Int J Infect Dis. 2020;91:264-266. doi:10.1016/j.ijid.2020.01.009PubMedGoogle ScholarCrossref
3.
Paules  CI , Marston  HD , Fauci  AS .  Coronavirus infections: more than just the common cold.   JAMA. Published online January 23, 2020. doi:10.1001/jama.2020.0757PubMedGoogle Scholar
4.
Wuhan Municipal Health Commission. Report of clustering pneumonia of unknown etiology in Wuhan City. Published December 31, 2019. Accessed January 31, 2020. http://wjw.wuhan.gov.cn/front/web/showDetail/2019123108989
5.
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)30183-5PubMedGoogle ScholarCrossref
6.
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 February 7, 2020. doi:10.1001/jama.2020.1585PubMedGoogle Scholar
7.
World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected. Published March 13, 2020. Accessed January 28, 2020. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected
8.
World Medical Association.  World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.   JAMA. 2013;310(20):2191-2194. doi:10.1001/jama.2013.281053Google ScholarCrossref
9.
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
10.
Wu  Z , McGoogan  JM .  Characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention.   JAMA. Published online February 24, 2020. doi:10.1001/jama.2020.2648PubMedGoogle Scholar
11.
Oudit  GY , Kassiri  Z , Jiang  C ,  et al.  SARS-coronavirus modulation of myocardial ACE2 expression and inflammation in patients with SARS.   Eur J Clin Invest. 2009;39(7):618-625. doi:10.1111/j.1365-2362.2009.02153.xPubMedGoogle ScholarCrossref
12.
Zhu  N , Zhang  D , Wang  W ,  et al; China Novel Coronavirus Investigating and Research Team.  A Novel coronavirus from patients with pneumonia in China, 2019.   N Engl J Med. 2020;382(8):727-733. doi:10.1056/NEJMoa2001017PubMedGoogle ScholarCrossref
13.
Xu  X , Chen  P , Wang  J ,  et al.  Evolution of the novel coronavirus from the ongoing Wuhan outbreak and modeling of its spike protein for risk of human transmission.   Sci China Life Sci. 2020;63(3):457-460. doi:10.1007/s11427-020-1637-5PubMedGoogle ScholarCrossref
14.
Henry  C , Zaizafoun  M , Stock  E , Ghamande  S , Arroliga  AC , White  HD .  Impact of angiotensin-converting enzyme inhibitors and statins on viral pneumonia.   Proc (Bayl Univ Med Cent). 2018;31(4):419-423. doi:10.1080/08998280.2018.1499293PubMedGoogle ScholarCrossref
15.
Kuba  K , Imai  Y , Rao  S ,  et al.  A crucial role of angiotensin converting enzyme 2 (ACE2) in SARS coronavirus-induced lung injury.   Nat Med. 2005;11(8):875-879. doi:10.1038/nm1267PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close