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Severe vs Milder COVID-19 Tied to
6-Fold Higher Risk of Acute Heart Injury
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Mark Mascolini
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Meta-analysis involving 4189 inpatients linked more severe COVID-19 infection to a 6-fold higher risk of acute cardiac injury [1]. COVID-19-related cardiac injury nearly quadrupled the risk of death.
SARS-CoV-2, the virus that causes COVID-19, uses angiotensin-converting enzyme 2 (ACE2) to enter cells. ACE2 is expressed not only on cells of alveoli (air sacs in lung), but also on cells in the heart, esophagus, kidney, bladder, and ileum (a portion of the small intestine). SARS-CoV-1, the cause of severe acute respiratory syndrome (SARS), may cause myocardial damage through its impact of ACE2.
Spurred by prior reports of myocarditis in people with COVID-19, researchers in China, Australia, the UK, and the USA conducted a systematic review and meta-analysis of observational studies that reported cardiac biomarkers in COVID-19 patients (troponin, creatine kinase-MB fraction, myoglobin, or NT-proBNP), acute cardiac injury according to severity of COVID-19, or mortality according to cardiac injury.
The researchers calculated standard mean difference (SMD) for all cardiac biomarkers and pooled them using random effects models. They carried out separate meta-analyses using SMD for troponin and weighted mean differences (WMD) for other biomarkers. The investigators estimated the association between acute cardiac injury and death as summary relative risks (RR). Meta-regression assessed whether patient characteristics modified differences in severity of cardiac injury biomarkers. Patient characteristics considered were age, sex, smoking, diabetes, hypertension, history of cardiovascular disease, coronary heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, chronic kidney disease, and COVID-19 severity.
The analysis focused on 4189 COVID-19 patients in 28 reports, 22 of which had data describing impact on myocardial injury. Among these 22 studies, 2 compared values between patients admitted to the intensive care unit or not, 10 compared values between survivors and nonsurvivors, and 10 compared severe versus nonsevere cases of COVID-19. Fourteen studies involved patients seen in Wuhan, where COVID-19 first emerged.
Cardiac injury biomarkers proved significantly higher overall in severe versus less severe COVID-19 (SMD 0.69, 95% confidence interval [CI] 0.48 to 0.89, P < 0.001). Average troponin was higher in severe than nonsevere cases (SMD 0.53, 95% CI 0.30 to 0.75, P < 0.001). The same held true for creatine kinase-MB (WMD 1.16, 95% CI 0.73 to 1.59, P < 0.001) and NT-proBNP (WMD 430.2, 95% CI 109.6 to 750.8, P = 0.009) but not myoglobin.
Defining acute cardiac injury as troponin above the upper limit, the researchers determined that acute injury was 6-fold more frequent with severe than nonsevere COVID-19 (summary RR 5.99, 95% CI 3.04 to 11.8, P < 0.001). One study found a higher incidence of arrhythmia in people with severe COVID-19 (44.4% versus 6.9%, P < 0.001). Meta-regression identified a positive association between hypertension prevalence and SMDs in cardiac injury biomarkers between more severe versus less severe COVID-19 (P = 0.030). There was no such association with age, male sex, smoking, or other comorbidities.
Death proved almost 4 times more frequent in people with than without acute cardiac injury (summary RR 3.85, 95% CI 2.13 to 6.96, P < 0.001) and almost 14-fold more frequent in people with severe versus less severe COVID-19 (summary RR 13.90, 95% CI 7.32 to 26.40, P < 0.001).
The researchers concluded that acute cardiac injury boosts risk of more severe COVID-19 and death, and that “patients with a history of hypertension seem to suffer more from cardiac damage.” Because of these findings, they support longitudinal measurement of cardiac damage biomarkers in inpatients with SARS-CoV-2 infection as a way to predict COVID-19 progression. The researchers call for studies to determine whether cardiac supportive measures and heart failure treatment benefit people with severe COVID-19.
Reference
1. Li JW, Han TW, Woodward M, et al. The impact of 2019 novel coronavirus on heart injury: A systemic review and meta-analysis. Prog Cardiovasc Dis. 2020 Apr 16. pii: S0033-0620(20)30080-3. doi: 10.1016/j.pcad.2020.04.008. https://www.sciencedirect.com/science/article/pii/S0033062020300803?via%3Dihub
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