Changes of Laboratory Cardiac Markers and Mechanisms of Cardiac Injury in Coronavirus Disease 2019

Evaluation of Biochemical Characteristics in a Retrospective Cohort of COVID-19 Patients

BACKGROUND

Coronavirus disease 2019 (COVID-19) has had a significant impact on global health and healthcare systems. This retrospective study aimed to assess the association between biochemical parameters and outcomes in COVID-19 patients in Jazan, Saudi Arabia.

METHODS

After establishing the inclusion criteria and obtaining ethical approval, data from 156 reverse transcriptase-polymerase chain reaction (RT-PCR)-confirmed COVID-19 patients were collected from electronic medical records from a general hospital in Samtah, Jazan, from April 2020 to October 2021. The collected data included patient demographics and liver, kidney, heart, and electrolyte function marker levels. Descriptive, inferential, and principal component analyses were conducted.

RESULTS

Survival rates varied according to age and body mass index (BMI). Statistical analysis demonstrated that the levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), sodium (Na), potassium (K), blood urea nitrogen (BUN), creatinine (Cr), creatine kinase (CK), CK myocardial band (MB), and lactate dehydrogenase (LDH) were significantly higher (P < 0.05) than the reference values, as assessed using the one-sample t-test. Principal component analysis (PCA) also revealed an underlying pattern in the variation of these biochemical markers. These findings suggest that certain biochemical parameters may serve as useful indicators for monitoring the condition of COVID-19 patients.

CONCLUSION

This retrospective study in Jazan, Saudi Arabia highlights the association between biochemical parameters and outcomes in COVID-19 patients. Elevated levels of markers of liver, kidney, heart, and electrolyte function suggest organ damage and dysregulation. The pattern identified through PCA provides insights into disease severity. Monitoring these parameters may serve as valuable indicators for assessing COVID-19 patients. Further research is needed to validate these findings, explore their potential for personalized treatment strategies, and improve patient outcomes during the ongoing pandemic.

Baseline Echocardiography and Laboratory Findings in MIS-C and Associations with Clinical Illness Severity

Children with COVID-associated multisystem inflammatory syndrome (MIS-C) may develop severe disease. We explored the association of admission echocardiographic and laboratory parameters with MIS-C disease severity. This retrospective, single center study of consecutive MIS-C patients (4/2020-12/2021) excluded those with preexisting cardiomyopathy, congenital heart disease, or prior cardiotoxic therapy. Our hypothesis was that worse admission echocardiographic and laboratory parameters were associated with more severe disease based on vasoactive medication use. Univariable and multivariable logistic regression models assessed the association between vasoactive medication use and baseline variables. Of 118 MIS-C patients, median age was 7.8 years (IQR 4.6, 11.8), 48% received vasoactive medication. Higher admission brain natriuretic peptide [OR 1.07 (95% CI 1.02,1.14), p = 0.019], C-reactive protein [OR 1.08 (1.03,1.14), p = 0.002], troponin [OR 1.05 (1.02,1.1), p = 0.015]; lower left ventricular ejection fraction [LVEF, OR 0.96 (0.92,1), p = 0.042], and worse left atrial reservoir strain [OR 0.96 (0.92,1), p = 0.04] were associated with vasoactive medication use. Only higher CRP [OR 1.07 (1.01, 1.11), p = 0.034] and lower LVEF [0.91 (0.84,0.98), p = 0.015] remained independently significant. Among those with normal admission LVEF (78%, 92/118), 43% received vasoactive medication and only higher BNP [OR 1.09 (1.02,1.19), p = 0.021 per 100 pg/mL] and higher CRP [OR 1.07 (1.02,1.14), p = 0.013] were associated with use of vasoactive medication. Nearly half of all children admitted for MIS-C subsequently received vasoactive medication, including those admitted with a normal LVEF. Similarly, admission strain parameters were not discriminatory. Laboratory markers of systemic inflammation and cardiac injury may better predict early MIS-C disease severity.

Biomarker based biosensors: An opportunity for diagnosis of COVID-19

Early diagnosis and treatment of diseases are crucial research areas of human health. For early diagnosis, one method that has proven efficient is the detection of biomarkers which can provide real-time and accurate biological information. Most biomarker detection is currently carried out at localised dedicated laboratories using large and automated analysers, increasing waiting time and costs. Smaller, faster, and cheaper devices could potentially replace these time-consuming laboratory analyses and make analytical results available as point-of-care diagnostics. Innovative biosensor-based strategies could allow biomarkers to be tested reliably in a decentralised setting. Early diagnosis of COVID-19 patients has a key role in order to use quarantine and treatment strategies in a timely manner. Raised levels of several biomarkers in COVID-19 patients are associated with respiratory infections or dysfunction of various organs. Through clinical studies of COVID-19 patient biomarkers such as ferritin, Interleukins, albumin and …are found to reveals significant differences in their excretion ranges from healthy patients and patients with SARS-CoV-2, in addition to the development of biomarkers based biosensor such as stated biomarkers can be used and to investigate more specific biomarkers further proteomic analysis can be performed. This review presents several biomarker alterations in COVID-19 patients such as salivary, circulatory, coagulation, cardiovascular, renal, liver, C-reactive protein (CRP), immunological and inflammatory biomarkers. Also, biomarker sensors based on electrochemical, optical, and lateral flow characteristics which have potential applications for SARS-COV-2 in the recent COVID-19 pandemic, will be discussed.

Correlations between Kidney and Heart Function Bioindicators and the Expressions of Toll-Like, ACE2, and NRP-1 Receptors in COVID-19

BACKGROUND

COVID-19 impacts the cardiovascular system resulting in myocardial damage, and also affects the kidneys leading to renal dysfunction. This effect is mostly through the binding with angiotensin-converting enzyme 2 (ACE2) and Neuropilin-1 (NRP-l) receptors. Toll-Like Receptors (TLRs) typically combine with microbial pathogens and provoke an inflammatory response.

AIM

This work aims to compare the changes in kidney and heart function bioindicators and expressions of TLRs (TLR2 and TLR2) as well as ACE2 and NRP-l receptors in moderate and severe COVID-19 patients. The correlations between kidney and heart function bioindicators and expressions of these receptors are also studied.

PATIENTS AND METHODS

In this study, 50 healthy control and 100 COVID-19 patients (55 males and 45 females) were enrolled. According to WHO guidelines, these participants were divided into severe (50 cases) and moderate (50 cases). Serum creatinine, blood urea, CK-MB, LDH, and Troponin I were estimated. We measured the gene expression for Toll-Like Receptors (TLR2 and TLR4), ACE2, and NRP-1 in the blood samples using quantitative real-time PCR (qRT-PCR).

RESULTS

In comparison with the healthy group, all patients exhibited a significant elevation in serum creatinine, urea, cardiac enzymes (CK-MB and LDH), and CRP. Serum Troponin I level was significantly increased in severe COVID-19 patients. Furthermore, all studied patients revealed a significant elevation in the expression levels of TLR2, TLR4, ACE2, and NRP-1 mRNA. In all patients, CK-MB, ACE2, and NRP-1 mRNA expression levels were positively correlated with both TLR2 and TLR4 expression levels. Moreover, serum creatinine and urea levels were positively correlated with both TLR2 and TLR 4 expression levels in the severe group only. In the moderate group, serum CK-MB activity and Troponin I level had a significant positive correlation with both NRP-1 and ACE2 expression levels, while serum urea level and LDH activity had a significant positive correlation with NRP-1 only. In severe patients, the increases in serum creatinine, urea, CK-MB, and LDH were significantly associated with the elevations in both ACE2 and NRP-1 expression levels, whereas serum Troponin I level had a positive direct relationship with NRP-1 only.

CONCLUSIONS

Our study concluded that expression levels for TLR2, TLR4, ACE2, and NRP-1 mRNA in both severe and moderate patients were positively correlated with renal biomarkers and cardiac enzymes. Innate immune markers can be important because they correlate with the severity of illness in COVID-19.

Cardiac biomarkers alterations in patients with SARS-CoV-2 infection

Reliable biomarkers are necessary for the risk stratification of patients infected with SARS-CoV-2. This novel coronavirus is now established to affect several organs in addition to the lungs, most prominently the heart. This is achieved through direct damage to the myocardium and indirect immune-associated effects during the cytokine storm. We performed a literature review aiming to identify the prognostic value of alterations of cardiac biomarkers in SARS-CoV-2 infection. Cardiac biomarkers are significantly elevated in patients with severe COVID-19 and are independent predictors of mortality. High-sensitivity troponin I and T are correlated with multiple inflammatory indexes and poor outcomes. Although cut-off values have been established for most of cardiac biomarkers, lower limits for troponins may have better prognostic values and longitudinal monitoring of cardiac biomarkers can help the clinician assess the patient's course. Additional measurements of NT-proBNP, can detect the subgroup of patients with poor prognosis.

Spectrum of hematological changes in COVID-19

Coronavirus disease 2019 (COVID-19) is caused by pathogenic and highly transmissible Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which is a single stranded RNA virus. It rapidly emerged from an epidemic to a global pandemic form spreading in alarming levels. The pathogenesis involving spike protein which is present on the viral surface, plays a key role in host attachment and penetration. SARS-CoV-2 infection significantly affects respiratory system, but may involve other systems including haematopoietic system and homeostasis. Aim of the review article is to discuss spectrum of haematological changes in the blood counts, coagulation, peripheral blood and bone marrow in COVID-19 for complete understanding the disease process, the knowledge of which is helpful in early diagnosis and management of these patients. An extensive immune profiling of B and T cell population with analysis of spectrum of immune changes during the period of infection were also discussed. In COVID-19, changes in laboratory parameters and hematologic abnormalities have been reported and its association with early diagnosis, disease prognosis and severity has been repeatedly discussed in the literature. Changes in laboratory investigations help in risk stratification and early intervention. The most common laboratory finding in COVID-19 is lymphopenia. COVID-19 patients presented with coagulopathy is at high risk of morbidity and mortality. In severe COVID-19 patients, bone marrow aspirate shows histiocytic proliferation with hemophagocytosis. To understand the correlations between immune responses and severity of COVID-19, immune profiling of B and T cell population was compared with extensive clinical data. A deep understanding of the laboratory findings and haematological abnormalities associated with SARS-CoV-2 infection would help to raise disease suspicion in absence of Real time polymerase chain reaction or antibody results. Also the blood counts along with the morphological changes in peripheral blood would be helpful in prompt screening, diagnosis, prognosis and management of COVID-19 patients.

Acute coronary syndrome in COVID-19 patients

Acute coronary syndrome (ACS) is caused by an acute mismatch between myocardial oxygen demand and its supply. This mechanism is largely associated with the progression of coronary atherosclerosis in combination with an inflammatory response, hypoxemia, and blood procoagulation. Patients with the coronavirus disease 2019 (COVID-19), aggravated by cardiovascular diseases and comorbidities, are at high risk of ACS.

Aim. To analyze the publications, which reflects the development of ACS in patients with COVID-19, its pathogenesis, and clinical course. Material and methods. Literature data were searched using Google Scholar, PubMed, ScienceDirect, and Cyberleninka services. The analysis included data from clinical guidelines on COVID-19, data from clinical studies, reports, and systematic reviews.

Results. This literature review summarizes and systematizes the data presented in modern publications, highlights the aspects of the clinical course and pathogenetic mechanisms underlying ACS in patients with COVID-19.

Conclusion. The pathogenesis of COVID-19 is inextricably associated with the widespread cytopathic effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), uncontrolled immune response that causes systemic inflammation, as well as the coagulation system activation. In patients with COVID-19, along with the atherosclerosis, these mechanisms significantly increase the risk of ACS and can worsen its in-hospital course.

Epidemiology, prognosis and management of potassium disorders in Covid-19

Coronavirus disease (Covid-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is currently the largest health crisis facing most countries. Several factors have been linked with a poor prognosis for this disease, including demographic factors, pre-existing comorbidities and laboratory parameters such as white blood cell count, D-dimer, C-reactive protein, albumin, lactate dehydrogenase, creatinine and electrolytes. Electrolyte abnormalities particularly potassium disorders are common among Covid-19 patients. Based on our pooled analysis, hypokalemia and hyperkalemia occur in 24.3% and 4.15% of Covid-19 patients, respectively. Potassium level deviation from the normal range may increase the chances of unfavorable outcomes and even death. Therefore, this article reviewed the epidemiology of potassium disorders and explained how hypokalemia and hyperkalemia are capable of deteriorating cardiac outcomes and the prognosis of Covid-19 for infected patients. The article finishes by highlighting some important considerations in the management of hypokalemia and hyperkalemia in these patients.

Biomarkers in COVID-19: An Up-To-Date Review

The ongoing pandemic of coronavirus disease 2019 (COVID-19) poses several challenges to clinicians. Timely diagnosis and hospitalization, risk stratification, effective utilization of intensive care services, selection of appropriate therapies, monitoring and timely discharge are essential to save the maximum number of lives. Clinical assessment is indispensable, but laboratory markers, or biomarkers, can provide additional, objective information which can significantly impact these components of patient care. COVID-19 is not a localized respiratory infection but a multisystem disease caused by a diffuse systemic process involving a complex interplay of the immunological, inflammatory and coagulative cascades. The understanding of what the virus does to the body and how the body reacts to it has uncovered a gamut of potential biomarkers. This review discusses the different classes of biomarkers - immunological, inflammatory, coagulation, hematological, cardiac, biochemical and miscellaneous - in terms of their pathophysiological basis followed by the current evidence. Differences between children and adults are highlighted. The role of biomarkers in the diagnosis and management of Multisystem Inflammatory Syndrome in Children (MIS-C) is reviewed. The correlation of biomarkers with clinical and radiological features and the viral load, temporal evolution and the effect of treatment remain to be studied in detail. Which biomarker needs to be evaluated when and in whom, and how best this information can contribute to patient care are questions which currently lack convincing answers. With the evidence currently available broad guidelines on the rational use of available biomarkers are presented. Integrating clinical and laboratory data, monitoring trends rather than a single value, correlating with the natural course of the disease and tailoring guidelines to the individual patient and healthcare setting are essential.

Meta-analysis of cardiac markers for predictive factors on severity and mortality of COVID-19

OBJECTIVES

Previous observational studies have suggested that increased cardiac markers are commonly found in COVID-19. This study aimed to determine the relationship between several cardiac markers and the severity/mortality of COVID-19 patients.

METHODS

Several cardiac markers were analysed in this meta-analysis. RevMan 5.4 was used to provide pooled estimates for standardised mean difference (SMD) with 95% confidence intervals.

RESULTS

Twenty-nine clinical studies were included in this meta-analysis. Significantly higher CK-MB (0.64, 95% CI = 0.19-1.09), PCT (0.47, 95% CI = 0.26-0.68), NT-proBNP (1.90, 95% CI = 1.63-2.17), BNP (1.86, 95% CI = 1.63-2.09), and d-dimer (1.30, 95% CI = 0.91-1.69) were found in severe compared with non-severe COVID-19. Significantly higher CK-MB (3.84, 95% CI = 0.62-7.05), PCT (1.49, 95% CI = 0.86-2.13), NT-proBNP (4.66, 95% CI = 2.42-6.91), BNP (1.96, 95% CI = 0.78-3.14), troponin (1.64 (95% CI = 0.83-2.45), and d-dimer (2.72, 95% CI = 2.14-3.29) were found in those who died from compared with survivors of COVID-19.

CONCLUSIONS

High CK-MB, PCT, NT-proBNP, BNP, and d-dimer could be predictive markers for severity of COVID-19, while high CK-MB, PCT, NT-proBNP, BNP, troponin, and d-dimer could be predictive markers for survival of COVID-19 patients.

COVID-19 and Toll-Like Receptor 4 (TLR4): SARS-CoV-2 May Bind and Activate TLR4 to Increase ACE2 Expression, Facilitating Entry and Causing Hyperinflammation

Causes of mortality from COVID-19 include respiratory failure, heart failure, and sepsis/multiorgan failure. TLR4 is an innate immune receptor on the cell surface that recognizes pathogen-associated molecular patterns (PAMPs) including viral proteins and triggers the production of type I interferons and proinflammatory cytokines to combat infection. It is expressed on both immune cells and tissue-resident cells. ACE2, the reported entry receptor for SARS-CoV-2, is only present on ~1-2% of the cells in the lungs or has a low pulmonary expression, and recently, the spike protein has been proposed to have the strongest protein-protein interaction with TLR4. Here, we review and connect evidence for SARS-CoV-1 and SARS-CoV-2 having direct and indirect binding to TLR4, together with other viral precedents, which when combined shed light on the COVID-19 pathophysiological puzzle. We propose a model in which the SARS-CoV-2 spike glycoprotein binds TLR4 and activates TLR4 signalling to increase cell surface expression of ACE2 facilitating entry. SARS-CoV-2 also destroys the type II alveolar cells that secrete pulmonary surfactants, which normally decrease the air/tissue surface tension and block TLR4 in the lungs thus promoting ARDS and inflammation. Furthermore, SARS-CoV-2-induced myocarditis and multiple-organ injury may be due to TLR4 activation, aberrant TLR4 signalling, and hyperinflammation in COVID-19 patients. Therefore, TLR4 contributes significantly to the pathogenesis of SARS-CoV-2, and its overactivation causes a prolonged or excessive innate immune response. TLR4 appears to be a promising therapeutic target in COVID-19, and since TLR4 antagonists have been previously trialled in sepsis and in other antiviral contexts, we propose the clinical trial testing of TLR4 antagonists in the treatment of severe COVID-19. Also, ongoing clinical trials of pulmonary surfactants in COVID-19 hold promise since they also block TLR4.