Sex Differences in the Incidence and Risk Factors of Myocardial Injury in COVID-19 Patients: A Retrospective Cohort Study

Abstract

Male novel coronavirus disease (COVID-19) patients tend to have poorer clinical outcomes than female patients, while the myocardial injury is strongly associated with COVID-19-related adverse events. Owing to a lack of corresponding data, we aimed to investigate the sex differences in the incidence of myocardial injury in COVID-19 patients and to identify the potential underlying mechanisms, which may partly account for the sex bias in the incidence of adverse events. This retrospective study included 1,157 COVID-19 patients who were hospitalized in Huoshenshan Hospital from 12 March 2020 to 11 April 2020. Data on the patients’ demographic characteristics, initial symptoms, comorbidities and laboratory tests were collected. Totally, 571 (49.4%) female and 586 (50.6%) male COVID-19 patients were enrolled. The incidence of myocardial injury was higher among men than women (9.2 vs. 4.9%, p = 0.004). In the logistic regression analysis, age, and chronic kidney disease were associated with myocardial injury in both sexes. However, hypertension [odds ratio (OR) = 2.25, 95% confidence interval (CI) 1.20–4.22], coronary artery disease (OR = 2.46, 95% CI 1.14–5.34), leucocyte counts (OR = 3.13, 95% CI 1.24–7.86), hs-CRP (OR = 4.45, 95% CI 1.33–14.83), and D-dimer [OR = 3.93 (1.27–12.19), 95% CI 1.27–12.19] were independent risk factors only in the men. The correlations of hs-CRP and D-dimer with hs-cTnI and BNP were stronger in the men. The incidence of myocardial injury in COVID-19 patients is sex-dependent, predominantly in association with a greater degree of inflammation and coagulation disorders in men. Our findings can be used to improve the quality of clinical management in such settings.

Immunological aspects and gender bias during respiratory viral infections including novel Coronavirus disease‐19 (COVID‐19): A scoping review

“…Myocardial injury is another important COVID-19related adverse event and it is sex-dependent. 39 and humoral immunity (HI). 40 RLRs function as intracellular pattern recognition molecules that recognize the virus and facilitate the host immune response.…”

A close‐up view of dynamic biomarkers in the setting of COVID‐19: Striking focus on cardiovascular system

“…Moreover, WCC, hs‐CRP and d‐dimer were independent risk factors in male patients strongly correlated with hs‐cTnI and BNP changes 99 . It has also been proposed that the inflammatory biomarkers in males were significantly higher than in females in the course of disease progression, highlighting the stronger immune responses in women and robust inflammatory activation in males.…”

“… 98 Regarding the sex differences, Cheng et al declared that the incidence of myocardial injury among men was higher than women hospitalized due to the COVID‐19 (9.2 vs. 4.9%, p = 0.004). 99 Notably, it can be inferred that affecting ACE2 expression by sex hormones may underlie presumable sex differences in cardiotropic SARS‐CoV‐2 infection. 97 In line with this claim, a recent study reported that androgen signalling has a regulatory effect on ACE2 expression following the SARS‐CoV‐2 infection in human cardiac cells.…”

“…Based on logistic regression analysis, two factors of age and chronic kidney disease were directly associated with myocardial injury in male and female patients. 99 …”

“…Moreover, WCC, hs‐CRP and d‐dimer were independent risk factors in male patients strongly correlated with hs‐cTnI and BNP changes. 99 It has also been proposed that the inflammatory biomarkers in males were significantly higher than in females in the course of disease progression, highlighting the stronger immune responses in women and robust inflammatory activation in males. According to the results of a recent clinical study, early and peak levels of CRP IL‐6, PCT and ferritin changed in men remarkably more than women ( p < 0.05), leading to higher ICU admission and mortality rate in men.…”