Death, discharge and arrhythmias among patients with COVID-19 and cardiac injury

Click to read the study in CMAJ

1. In patients positive for COVID-19 suffering cardiac injury, cardiac troponin (cTnI) levels were associated with poor survival, with peak cTnI levels shown to predict the need for invasive ventilation.

Evidence Rating Level: 2 (Good)

Reports show that patients with COVID-19-associated pneumonia and cardiac injury experience poor outcomes, but whether they were discharged or died remained uncharacterized as the pandemic was ongoing. Additionally, the arrhythmia burden in those admitted to the ICU was estimated at 44.4%, but the nature of these arrhythmias was also largely unknown. Studying data from the Wuhan outbreak, which had run its full course, could allow for identification of independent predictors of poor outcomes (ie need for invasive ventilation) and characterization of these arrhythmias.This retrospective cohort study included 1284 patients with severe COVID-19, defined as viral-positive patients who had CT-confirmed pneumonia, that were admitted to Tongji Hospital in Wuhan, China from Jan 29 to March 8, 2020. Of those, 1159 patients had their cTNI measured within 72 hours of admission and 170 patients with cardiac injury (cTNI >26.2pg/mL) were included (n=49 discharged alive, median 61.5yo, 16% male, onset of illness median 11 days; n=121 died, median 64yo, 77% male, onset of illness median 11 days) were included. Those patients with cardiac injury had a mortality rate over 10 times higher than those without elevated cTNI (71.2% vs 6.6%, p<0.001). Even after adjusting for age, sex, and usage of QT-prolonging medications, both initial (per 10-fold increase, HR 1.32, 95% CI 1.06-1.66) and peak cTNI levels (per 10-fold increase, HR 1.70, 95% CI 1.38-2.10) during hospital stay were associated with poor survival. Furthermore, peak cTNI levels were an independent predictor for needing invasive ventilatory support (OR 3.02, 95% CI 1.92-4.98). As well, 53 arrhythmia episodes were recorded on ECGs among 60 of the patients with cardiac injury (35 patients with atrial arrhythmias only, 2 ventricular only, 7 both), an association not previously seen with SARS or MERS. With 35 patients experiencing only atrial arrhythmias. Overall, patients who died in hospital had more dyspnea (51.2% vs 30.6%, p=0.02), a greater need for mechanical ventilation (66.9% vs 4.1%, p<0.001), and higher levels of cTNI (393.8 vs 48.5 pg/mL, p<0.001). Data on patients without cardiac injury, other than mortality, could not be accessed and whether patients developed cardiac injury past the first 72 hours after admission was not considered. Nonetheless, these findings support assessing cTNI levels in patients with COVID-19, undergoing therapy that prolongs repolarization.

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