Risk factors for myocardial injury and death in patients with COVID-19: insights from a cohort study with chest computed tomography

Abstract

<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Aims</jats:title> <jats:p>Whether pulmonary artery (PA) dimension and coronary artery calcium (CAC) score, as assessed by chest computed tomography (CT), are associated with myocardial injury in patients with coronavirus disease 2019 (COVID-19) is not known. The aim of this study was to explore the risk factors for myocardial injury and death and to investigate whether myocardial injury has an independent association with all-cause mortality in patients with COVID-19.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods and Results</jats:title> <jats:p>This is a single-centre cohort study including consecutive patients with laboratory-confirmed COVID-19 undergoing chest CT on admission. Myocardial injury was defined as high-sensitivity troponin I &amp;gt; 20 ng/L on admission. A total of 332 patients with a median follow-up of 12 days were included. There were 68 (20.5%) deaths; 123 (37%) patients had myocardial injury. PA diameter was higher in patients with myocardial injury compared with patients without myocardial injury [29.0 (25th–75th percentile, 27–32) mm vs. 27.7 (25–30) mm, &amp;lt;iP &amp;gt; &amp;lt; 0.001). PA diameter was independently associated with an increased risk of myocardial injury [adjusted odds ratio 1.10, 95% confidence interval (CI) 1.02–1.19, P = 0.01] and death [adjusted hazard ratio (HR) 1.09, 95% CI 1.02–1.17, P = 0.01]. Compared with patients without myocardial injury, patients with myocardial injury had a lower prevalence of a CAC score of zero (25% vs. 55%, &amp;lt;iP &amp;gt; &amp;lt; 0.001); however, the CAC score did not emerge as a predictor of myocardial injury by multivariable logistic regression. Myocardial injury was independently associated with an increased risk of death by multivariable Cox regression (adjusted HR 2.25, 95% CI 1.27–3.96, P = 0.005). Older age, lower estimated glomerular filtration rate, and lower PaO&amp;lt;sub2&amp;gt;/FiO&amp;lt;sub2&amp;gt; ratio on admission were other independent predictors for both myocardial injury and death.</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>An increased PA diameter, as assessed by chest CT, is an independent risk factor for myocardial injury and mortality in patients with COVID-19. Myocardial injury is independently associated with an approximately two-fold increased risk of death.</jats:p> </jats:sec> <jats:sec> <jats:title>Translational perspective</jats:title> <jats:p>The present study identifies myocardial injury as a clinically relevant independent risk factor for death in the short term in a population of hospitalized patients with laboratory-confirmed COVID-19 outside of China undergoing chest computed tomography for suspected pneumonia on admission.</jats:p> <jats:p>The study also provides novel insights into the risk factors for myocardial injury, showing that an increased pulmonary artery diameter, assessed by chest computed tomography, is an independent predictor of myocardial injury as well as of mortality, suggesting that pulmonary circulation dysfunction is a pivotal pathological event with cardiac implications in COVID-19.</jats:p> </jats:sec>

Mortality and Disease Severity Among COVID-19 Patients Receiving Renin-Angiotensin System Inhibitors: A Systematic Review and Meta-analysis

“…The characteristics of the shortlisted studies are summarized in Table 1. Among shortlisted studies, 23 studies were from China , nine studies were from Italy [64][65][66][67][68][69][70][71][72], ten studies were from the United States [83][84][85][86][87][88][89][90][91][92], four studies were from South Korea [75][76][77][78], three studies were from France [60][61][62], two studies were from Spain [79,80], one study each was from Belgium [35], Denmark [59], Hong Kong [63], Kuwait [73], Singapore [74], Turkey [81], and the United Kingdom [82]; and one study included data from 38 countries [93]. There were 24 studies that included hypertensive patients exclusively (100%) [36, 38, 39, 43-45, 47, 48, 50-52, 54, 56, 58, 66, 71, 72, 75, 78, 81, 87-89, 91].…”

“…2; pooled OR = 0.73, 95% CI 0.56-0.95). In a separate pooled analysis of 11 studies that provided adjusted HRs, with 26,598 COVID-19 patients being analyzed [36,54,56,57,59,67,69,70,72,74,77], the use of an ACEI/ARB was significantly associated with lower risk of mortality compared to the non-use of an ACEI/ARB (Supplementary Figure S1; pooled HR = 0.75, 95% CI 0.60-0.95). The funnel plot was used to detect the publication bias and revealed some degree of asymmetry (Supplementary Figure S3 and S4).…”

Impact of myocardial injury on mortality in patients with COVID-19: a meta-analysis

“… 1 , 2 However, myocardial involvement has been observed in patients with COVID-19 and has been associated with worse clinical outcomes. 3 , 4 , 5 , 6 , 7 , 8 We aimed to provide a comprehensive and quantitative assessment of evidence about the impact of myocardial injury on mortality in patients with COVID-19.…”

“… 14 179 58 54 18 32 16 # 99 82 Ferrante et al. 8 332 67 71 21 54 15 – – Franks et al. 15 128 64 57 – – – – Guo et al.…”

“…This result was largely attenuated by the sensitivity analysis, using the adjusted HR from the multivariable analysis as effect estimates (HR 1.62; 95% CI 1.35–1.94; p = 0.016, and I 2 = 70.9%) that were available in four studies. 8 , 9 , 10 , 11

Fig. 1 Risk of all-cause mortality according to the occurrence of myocardial injury.

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