Heart injury signs are associated with higher and earlier mortality in coronavirus disease 2019 (COVID-19)

  1. Chaomin Wu
  2. Xianglin Hu
  3. Jianxin Song
  4. Chunling Du
  5. Jie Xu
  6. Dong Yang
  7. Dechang Chen
  8. Ming Zhong
  9. Jinjun Jiang
  10. Weining Xiong
  11. Ke Lang
  12. Yuye Zhang
  13. Guohua Shi
  14. Lei Xu
  15. Yuanlin Song
  16. Xin Zhou
  17. Ming Wei
  18. Junhua Zheng
  19. The first batch of medical teams from Shanghai to support Hubei, China and study group

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Abstract

Importance

Heart injury can be easily induced by viral infection such as adenovirus and enterovirus. However, whether coronavirus disease 2019 (COVID-19) causes heart injury and hereby impacts mortality has not yet been fully evaluated.

Objective

To explore whether heart injury occurs in COVID-19 on admission and hereby aggravates mortality later.

Design, Setting, and Participants

A single-center retrospective cohort study including 188 COVID-19 patients admitted from December 25, 2019 to January 27, 2020 in Wuhan Jinyintan Hospital, China; follow up was completed on February 11, 2020.

Exposures

High levels of heart injury indicators on admission (hs-TNI; CK; CK-MB; LDH; α-HBDH).

Main Outcomes and Measures

Mortality in hospital and days from admission to mortality (survival days).

Results

Of 188 patients with COVID-19, the mean age was 51.9 years (standard deviation: 14.26; range: 21∼83 years) and 119 (63.3%) were male. Increased hs-TnI levels on admission tended to occur in older patients and patients with comorbidity (especially hypertension). High hs-TnI on admission (≥ 6.126 pg/mL), even within the clinical normal range (0∼28 pg/mL), already can be associated with higher mortality. High hs-TnI was associated with increased inflammatory levels (neutrophils, IL-6, CRP, and PCT) and decreased immune levels (lymphocytes, monocytes, and CD4 + and CD8 + T cells). CK was not associated with mortality. Increased CK-MB levels tended to occur in male patients and patients with current smoking. High CK-MB on admission was associated with higher mortality. High CK-MB was associated with increased inflammatory levels and decreased lymphocytes. Increased LDH and α-HBDH levels tended to occur in older patients and patients with hypertension. Both high LDH and α-HBDH on admission were associated with higher mortality. Both high LDH and α-HBDH were associated with increased inflammatory levels and decreased immune levels. hs-TNI level on admission was negatively correlated with survival days ( r = -0.42, 95% CI= -0.64∼-0.12, P=0.005). LDH level on admission was negatively correlated with survival days ( r = -0.35, 95% CI= -0.59∼-0.05, P=0.022).

Conclusions and Relevance

Heart injury signs arise in COVID-19, especially in older patients, patients with hypertension and male patients with current smoking. COVID-19 virus might attack heart via inducing inflammatory storm. High levels of heart injury indicators on admission are associated with higher mortality and shorter survival days. COVID-19 patients with signs of heart injury on admission must be early identified and carefully managed by cardiologists, because COVID-19 is never just confined to respiratory injury.

Key points

Question

Does coronavirus disease 2019 (COVID-19) cause heart injury and hereby impact mortality?

Findings

In this retrospective cohort study including 188 patients with COVID-19, patients with high levels of high-sensitivity cardiac troponin I (hs-TNI) on admission had significantly higher mortality (50.0%) than patients with moderate or low levels of hs-TNI (10.0% or 9.1%). hs-TNI level on admission was significantly negatively correlated with survival days ( r = -0.42, 95% CI= -0.64∼-0.12, P=0.005).

Meaning

COVID-19 patients with signs of heart injury on admission must be early identified and carefully managed by cardiologists, in order to maximally prevent or rescue heart injury-related mortality in COVID-19.

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  1. ScreenIT

    SciScore for 10.1101/2020.02.26.20028589: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementConsent: Written informed consent was waived because this research was retrospective observation and deindividuation.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Statistical analysis: SPSS for Windows (Version 24.0, IBM) and Graphpad prism 7.0 software were used for statistical analysis.
    SPSS
    suggested: (SPSS, RRID:SCR_002865)
    Graphpad
    suggested: (GraphPad, RRID:SCR_000306)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Some limitations existed in this study. First, we only assessed heart injury from the perspective of serum myocardial enzymes and protein. It would be better if echocardiography and electrocardiograph were also measured in this study. Secondly, it would be better if we could assess heart injury-specific mortality in the future study with a larger sample size. Thirdly, we have not been able to obtain myocardial tissues from COVID-19 patients. Thus we currently cannot directly observe myocardial injury from the golden standard of pathology. Although the first autopsy of COVID-19 patient was completed and pulmonary pathology was obtained on Feb 16, 2020 in Wuhan Jinyintan Hospital (China), it remains a long way to remind clinicians to focus on cardiac pathology for COVID-19 infection. Our present results also can remind pathologists to pay attention to cardiac pathology in the future, especially for those deceased COVID-19 patients who had high heart injury indicators on admission.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. Version published to 10.1101/2020.02.26.20028589v1 on medRxiv