New research from an analysis of more than 400 patients from the Renmin Hospital of Wuhan University in Wuhan, China is shedding more light on the association of cardiac injury with mortality in patients with coronavirus disease 2019 (COVID-19).
Authored by Congxin Huang, MD, PhD, director of the Cardiovascular Research Institute at Wuhan University, and team of physicians from the hospital, the analysis revealed nearly 1 in 5 patients hospitalized with COVID-19 had a cardiac injury occur, and patients with cardiac injury had a three-fold increased risk of mortality.
To more clearly define the incidence and significance of cardiac injury in patients with COVID-19, investigators designed a retrospective cohort study of hospitalized patients with laboratory-confirmed COVID-19 between January 20 and February 10, 2020—with a follow-up period lasting until February 15.
Of note, the Renmin Hospital was assigned to treat severe cases in the Hubei Province by the Wuhan government and all cases were diagnosed according to World Health Organization (WHO) standards.
Initially, 1004 patients were identified from the medical record systems. After excluding cases that were not confirmed, those without available medical information and duplicated records, and patients missing values for high-sensitivity troponin I (hs-TNI) and creatinine kinase–myocardial band (CK-MB), the study cohort contained 416 cases. Investigators defined cardiac injury as blood levels of cardiac biomarkers above the 99th-percentile upper reference limit.
The mean age of patients was 64 (21-95) years, 211 were female, and 82 (19.7%) had cardiac injury. The most common symptom among the entire study cohort was fever (80.3%). Other common symptoms included cough (34.6%), shortness of breath (28.1%), fatigue (13.2%), and sputum production (5.5%).
In regard to common comorbidities, 30.5% of patients had hypertension and 14.4% had been previously diagnosed with diabetes. Additionally, 10.6% of patients had coronary heart disease (CHD), 5.3% had cerebrovascular disease, and 4.7% had chronic heart failure.
Analysis indicated patients with cardiac injury were more likely to require noninvasive (46.3% vs 3.9%; P
<.001) and invasive mechanical ventilation (22.0% vs 4.2%; P
<.001) during hospitalization. Patients with cardiac injury also had a greater risk for complications than those without, including acute respiratory distress syndrome (58.5% vs 14.7%; P
<.001), acute kidney injury (8.5% vs 0.3%; P
<.001), electrolyte disturbances (15.9% vs 5.1%; P
=.003), hypoproteinemia (13.4% vs 16 4.8%; P
= .01), and coagulation disorders (7.3% vs 1.8%; P
More than half of the patients (51.2%) who suffered cardiac injury died compared to just 4.5% of patients without cardiac injury (P
<.001). A Cox regression model indicated patients with cardiac injury were at a greater risk of mortality during the time from symptom onset (HR, 4.26 [95% CI, 1.92-9.49]) and from admission to endpoint (HR, 3.41 [95% CI, 1.62-7.16]).
Comparison of characteristics between patients with and without cardiac injury indicated patients with cardiac injury were older (74 [34- 95] years vs 60 [21-90] years; P
<.001) and more likely to have chest pain (13.4% vs 0.9%; P
<.001). Other differences included an increase in prevalence of hypertension (59.8% vs 23.4%), diabetes (24.4% vs 12.0%), CHD (29.3% vs 6.0%), cerebrovascular disease (15.9% vs 2.7%), chronic heart failure (14.6% vs 1.5%), chronic obstructive pulmonary disease (7.3% vs 1.8%), and cancer (8.5% vs 0.6%) in patients with cardiac injury (all P
Patients with cardiac injury had a higher proportion of multiple mottling and ground-glass opacity according to chest radiography results (64.6% vs 4.5%). Laboratory results indicated patients with cardiac had higher leukocyte counts (median interquartile range (IQR), 9400 [6900-13 800] vs 5500 [4200-7400] cells/μL) and levels of C-reactive protein (10.2 [6.4-17.0] vs 3.7 [1.0-7.3] mg/dL), procalcitonin (0.27 [0.10-1.22] vs 0.06 [0.03-0.10] ng/mL), CK-MB (3.2 [1.8-6.2] vs 0.9 [0.6-1.3] ng/mL), myohemoglobin (128 [68-305] vs 39 [27-65] μg/L), hs-TNI (0.19 [0.08-1.12] vs <.006 [<.006-.009] μg/L), N-terminal pro-B-type natriuretic peptide (1689 [698-3327] vs 139 [51-335] pg/mL), aspartate aminotransferase (40 [27-60] vs 29 [21-40] U/L), and creatinine (1.15 [0.72-1.92] vs 0.64 [0.54-0.78] mg/dL).
Investigators noted multiple limitations within their study. Limitations included logistic limitations such as inability to collect data ECG and other data, many with and without cardiac injury may not have reached clinical endpoints due to the ongoing nature of the study, and data from other centers and larger populations are necessary if the findings of the study are to be confirmed.
The study, “Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China
,” was published online in JAMA Cardiology.