Debra L. Beck and Eugene Braunwald, MD

There is little information on the impact of coronavirus disease 2019 (COVID-19) on individuals with underlying cardiovascular disease (CVD). Guo et al conducted a retrospective, single-center case series to evaluate the association of underlying CVD and myocardial injury with fatal outcomes in patients with COVID-19.

The researchers included 187 patients (mean age, 58.5 years; 48.7% male) with confirmed COVID-19 treated at the Seventh Hospital of Wuhan City, China, from January 23, 2020 to February 23, 2020. Analysis began February 25, 2020.

Overall, 144 patients (77%) were discharged and 43 patients (23%) died. Preexisting cardiovascular disease was present in 35.3% of patients.

Myocardial injury, defined as elevated serum troponin T (TnT) above the 99^th percentile upper reference limit, was seen in 27.8% of patients. Individuals with pre-existing CVD were more likely to exhibit elevated TnT levels on hospitalization than those without underlying CVD (54.5% vs. 13.2%). They were also more likely to required mechanical ventilation (59.6% vs. 10.4%).

For patients with no underlying CVD and normal TnT levels, in-hospital mortality was 7.62%. This rose to 13.33% for those with underlying CVD but normal TnT, and rose again to 37.50% for those without underlying CVD but elevated TnT. The highest mortality (69.44%) was seen in those with both underlying CVD and elevated serum TnT.

TnT levels were positively correlated with plasma high-sensitivity C-reactive protein levels (β = 0.530, P < .001) and N-terminal pro–brain natriuretic peptide (NT-proBNP) levels (β = 0.613, P < .001). Progressive serial increases in TnT and NT-proBNP were seen in patients who deteriorated toward death during hospitalization. Those with a more favorable outcomes with less severe illness, showed more stable low levels of these biomarkers.

Long-term outpatient medications prior to admission were not discontinued. Mortality in patients with and without use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers was 36.8% (7 of 19) and 25.6% (43 of 168).

Summary

The investigators concluded that myocardial injury is significantly associated with mortality in patients hospitalized with COVID-19, while the prognosis of patients with underlying CVD but without myocardial injury is relatively favorable.

Comments

In an editorial that accompanied this article, Drs. Bonow, Fonarow, O’Gara, and Yancy noted the link found by Guo et al between myocardial injury and both inflammation (hs-CRP) and ventricular dysfunction (NT-proBNP). They suggested that a consistent picture is emerging that older patients with pre-existing CVD and diabetes are prone to develop a higher acuity of illness, with a higher risk for myocardial injury, and markedly higher mortality.

Whether these reports are generalizable to non-Chinese cohorts is undetermined, but given the evidence to date, the one message that is clear is that prevention is paramount in these patients. “Until we know more, the populations described in these primary data reports should be most observant of strict hand hygiene, social distancing, and, where available, COVID-19 testing,” wrote the authors.

References

Guo T, Gan Y, Chen M, et al. Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020; Published online March 27.

Bonow RO, Fonarow GC, O’Gara PT, Yancy CW. Association of coronavirus disease (COVID-19) with myocardial injury and mortality. JAMA Cardiol. 2020; published online March 27.

Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine features a unique update program by Dr. Braunwald, creating a “living textbook” by featuring twice monthly updates including “Hot off the Press” and Late-Breaking Clinical Trials (links to authors’ presentation slides are also included).

Learn more about Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 11th Edition. Download a free chapter here.