Myocardial injury in hospitalized COVID-19 patients: a retrospective study, systematic review, and meta-analysis

Impact on clinical guideline adherence of Orient-COVID, a clinical decision support system based on dynamic decision trees for COVID19 management: A randomized simulation trial with medical trainees

BACKGROUND

The adherence of clinicians to clinical practice guidelines is known to be low, including for the management of COVID-19, due to their difficult use at the point of care and their complexity. Clinical decision support systems have been proposed to implement guidelines and improve adherence. One approach is to permit the navigation inside the recommendations, presented as a decision tree, but the size of the tree often limits this approach and may cause erroneous navigation, especially when it does not fit in a single screen.

METHODS

We proposed an innovative visual interface to allow clinicians easily navigating inside decision trees for the management of COVID-19 patients. It associates a multi-path tree model with the use of the fisheye visual technique, allowing the visualization of large decision trees in a single screen. To evaluate the impact of this tool on guideline adherence, we conducted a randomized controlled trial in a near-real simulation setting, comparing the decisions taken by medical trainees using Orient-COVID with those taken with paper guidelines or without guidance, when performing on six realistic clinical cases.

RESULTS

The results show that paper guidelines had no impact (p=0.97), while Orient-COVID significantly improved the guideline adherence compared to both other groups (p<0.0003). A significant impact of Orient-COVID was identified on several key points during the management of COVID-19: ordering troponin lab tests, prescribing anticoagulant and oxygen therapy. A multifactor analysis showed no difference between male and female participants.

CONCLUSIONS

The use of an interactive decision tree for the management of COVID-19 significantly improved the clinician adherence to guidelines. Future works will focus on the integration of the system to electronic health records and on the adaptation of the system to other clinical conditions.

Impact of myocardial injury on cardiovascular complications in hospitalized patients with COVID-19: insights from Latin America

Introduction

Viral infection by SARS-CoV2 is a pandemic affecting over 600 million people worldwide. One of five hospitalized patients may present myocardial injury, strongly associated with disease severity and mortality.

Methodology

Retrospective cross-sectional study of hospitalized COVID-19 patients diagnosed between May 01, 2020, and June 30, 2021, from the database of the Registro Latinoamericano de Enfermedad Cardiovascular y COVID-19 (CARDIO COVID 19-20) with a troponin value recorded during hospitalization. A descriptive analysis of sociodemographic and clinical characteristics was performed. Bivariate analysis was conducted according to the presence or absence of myocardial injury. Survival analysis was made using Kaplan-Meier curves, by the presence of myocardial injury. A multivariate Poisson regression model was performed to determine factors associated with mortality. Statistical analyses were performed using the RStudio V.1.4.1717 package.

Results

A total of 2,134 patients were included, 64.2% were male, and 911 patients had myocardial injury. The median age of the total population was 61 years. Individuals with myocardial injury had a higher prevalence of hypertension, diabetes, and dyslipidemia. Survival probability was lower in this subgroup. Patients with myocardial injury had a 1.95 times higher risk of death. Age, male sex, chronic kidney disease, arrhythmias, decompensated heart failure, requirement of inotropic/vasopressor, and invasive mechanical ventilation were related to higher mortality risk in patients with myocardial injury.

Conclusion

Patients with COVID-19 and myocardial injury exhibit a broad spectrum of cardiac abnormalities. Myocardial injury is associated with a higher disease severity and risk of in-hospital mortality. This multicenter study uniquely represents data from 13 Latin American countries, offering regional insights into the impact of myocardial injury during the COVID-19 pandemic.

Statins for the prevention of cardiovascular events associated with avian influenza: the COVID-19 pandemic as a reference

There is growing concern that the severe respiratory disease in birds (avian influenza or 'bird flu') caused by the H5N1 influenza virus, might potentially spread more widely to humans and cause a pandemic. Here we discuss clinical issues related to human infections by the highly pathogenic H5N1 subtype of the avian influenza A virus and make a clinical comparison with recent information obtained from studies of SARS-CoV-2 infection. Firstly, we consider the potential increase in cardiovascular events in humans infected with the H5N1 virus. Like SARS-CoV-2 infection, H5N1 infection may result in endothelial dysfunction and the associated procoagulant and prothrombotic state, and via this mechanism, the infection can potentially increase cardiovascular morbidity, especially in vulnerable individuals with pre-existing cardiovascular disease. Secondly, we discuss the potential beneficial role of statin use, both in the prophylaxis and the treatment of individuals with influenza A(H5N1), as was found favorable for the treatment of COVID-19 caused by SARS-CoV-2 infection.

Clinical and electrocardiographic correlates of myocardial dysfunction after COVID-19 in nonhospitalised patients in long-term follow-up. Data from the polish long-covid cardiovascular study

Clinical evidence indicates that COVID-19 is a multiorgan disease that significantly impacts the cardiovascular system. However, little is known about the predictors of myocardial dysfunction after SARS-CoV-2 infection. Therefore, this research aimed to evaluate the clinical and electrocardiographic correlates of myocardial dysfunction after SARS-CoV-2 infection in nonhospitalised patients without previously diagnosed cardiovascular disease. This observational study included 448 patients selected from the database of 4142 patients in the Polish Long-Covid Cardiovascular study. All patients underwent a 12-lead electrocardiogram (ECG); 24-h Holter ECG monitoring, 24/7 ambulatory blood pressure monitoring, echocardiography, and cardiac magnetic resonance imaging. According to the results of diagnostic tests, patients were divided into two groups depending on the occurrence of myocardial dysfunction after COVID-19. Group 1-without myocardial dysfunction after COVID-19-consisted of 419 patients, with a mean age of 48.82 (SD ± 11.91), and Group 2 (29 patients)-with myocardial dysfunction after COVID-19, with a mean age of 51.45 (SD ± 12.92). When comparing the analysed groups, there were significantly more men in Group 2 (p = 0.006). QRS (corresponds to the time of ventricular contraction in an electrocardiographic examination) fragmentation (p = 0.031), arrhythmias (atrial fibrillation, supraventricular extrasystole, ventricular extrasystole) (p = 0.008), and male gender (p = 0.007) were independently associated with myocardial dysfunction after COVID-19. The study showed that myocardial damage after COVID-19 affects men more often and is independent of typical clinical factors and the severity of the disease course. The QRS fragmentation and arrhythmias observed in the ECG indicate the possibility of myocardial dysfunction in patients after COVID-19, which may be a valuable marker for physicians.

Comparison of Incidence and Prognosis of Myocardial Injury in Patients with COVID-19-Related Respiratory Failure and Other Pulmonary Infections: A Contemporary Cohort Study

Myocardial injury (MI) is frequent in critically ill patients with COVID-19, but its pathogenesis remains unclear. We hypothesized that MI is not solely due to viral infection by SARS-CoV-2 but rather due to the common pathophysiological mechanisms associated with severe pulmonary infections and respiratory failure. This contemporary cohort study was designed to compare the incidence of MI in patients with acute respiratory failure caused by COVID-19 to patients with other pulmonary infections. In addition, we aimed to investigate whether MI was a distinct risk factor for in-hospital mortality in patients with COVID-19 compared to those with non-COVID-19 infections. This study included 1444 patients with COVID-19 (55.5% men; age 58 (46;68) years) and 182 patients with other pulmonary infections (46.9% men; age 62 (44;73) years). The incidence of MI at ICU admission was lower in COVID-19 patients (36.4%) compared to non-COVID-19 patients (56%), and this difference persisted after adjusting for age, sex, coronary artery disease, heart failure, SOFA score, lactate, and C-reactive protein (RR 0.84 (95% CI, 0.71-0.99)). MI at ICU admission was associated with a 59% increase in mortality (RR 1.59 (1.36-1.86); p < 0.001), and there was no significant difference in the mortality between patients with COVID-19 and those with other pulmonary infections (p = 0.271). We concluded that MI is less frequent in patients with critical COVID-19 pneumonia and respiratory failure compared to those with other types of pneumonia. The occurrence of MI is a significant risk factor for in-hospital mortality, regardless of the etiology of the pulmonary infection.

Facing the pandemic with a smile: the case of Memedical and its impact on cardiovascular professionals

Since its outbreak, the Coronavirus disease 2019 (COVID-19) has profoundly changed the world we were acquainted with. After the first known contact with humankind in Wuhan, China, in December 2019, the reckless spread of such pathogen put the healthcare system to the test, leading to harmful consequences affecting human lives in every aspect. As of February 2022, the death toll amounts to almost 6 million deaths, but the pathogenic profile of SARS-CoV-2 goes way beyond the mere biological interaction between the viral particle and our organism. People had to deal with the severe psychological impact caused by the only available weapon to fight this infection, i.e., social distancing. The human psychological profile has been strained with repercussions we still are unaware of nowadays. Healthcare professionals were among the most hit categories, not only because of the quarantine but above all for the situations they had to bear every day, constantly facing desperation, death, isolation, and rage. In such circumstances, social media represented a powerful shelter, giving people the ability to keep in contact and to feel connected even if miles apart. In our country, the power of communication was strongly emphasized by launching an Italian Facebook group called "Memedical," where members can share ironic memes to feel closer and give a glimmer of happiness in such a challenging moment. Our review highlights the severity of this pandemic's impact, deteriorating the global population's physical and mental health, and shows how wise use of social media can benefit the quality of life.

Short- and long-term effects of the COVID-19 pandemic on patients with cardiovascular diseases: A mini-review

The COVID-19 pandemic had profound implications for patients with cardiovascular diseases (CVDs), both in the short- and long-term. In this article, we provide an overview of the effects of the pandemic on individuals with preexisting cardiovascular conditions. In the short term, the severe acute respiratory syndrome coronavirus 2 infection increased the risk of many cardiovascular events. Furthermore, the pandemic has disrupted health-care systems worldwide, leading to constraints in routine care, and limited access to specialized cardiovascular services and procedure. This has resulted in increased morbidity and mortality rates among patients with CVD (coronary artery disease, hypertrophic cardiomyopathy, heart failure (HF), heart transplant recipients, atrial fibrillation, atrial flutter, previous stroke, or previous peripheral artery disease). In the long term, the COVID-19 impact on patients with CVD extends beyond the acute phase of the disease. Studies have highlighted the development of long-term cardiovascular complications in COVID-19 survivors, such as acute coronary syndrome myocarditis, HF, stroke, venous thromboembolism, and arrhythmias, which may lead to a surge of new cases associated with CVD in the postpandemic era. Health-care systems must prioritize cardiovascular care, developing strategies to identify the patients at higher risk and provide the care to minimize the impact of the pandemic on patients with CVD.

Remdesivir, dexamethasone and angiotensin-converting enzyme inhibitors use and mortality outcomes in COVID-19 patients with concomitant troponin elevation

BACKGROUND

There are indications that viral myocarditis, demand ischemia, and renin-angiotensin-aldosterone system pathway activation play essential roles in troponin elevation in coronavirus disease 2019 (COVID-19) patients. Antiviral medications and steroids are used to treat viral myocarditis, but their effect in patients with elevated troponin, possibly from myocarditis, has not been studied.

AIM

To evaluate the effect of dexamethasone, remdesivir, and angiotensin-converting enzyme (ACE) inhibitors (ACEI) on mortality in COVID-19 patients with elevated troponin.

METHODS

Our retrospective observational study involved 1788 COVID-19 patients at seven hospitals in Southern California, United States. We did a backward selection Cox multivariate regression analysis to determine predictors of mortality in our study population. Additionally, we did a Kaplan Meier survival analysis in the subset of patients with elevated troponin, comparing survival in patients that received dexamethasone, remdesivir, and ACEI with those that did not.

RESULTS

The mean age was 66 years (range 20-110), troponin elevation was noted in 11.5% of the patients, and 29.9% expired. The patients' age [hazard ratio (HR) = 1.02, P < 0.001], intensive care unit admission (HR = 5.07, P < 0.001), and ventilator use (HR = 0.68, P = 0.02) were significantly associated with mortality. In the subset of patients with elevated troponin, there was no statistically significant difference in survival in those that received remdesivir (0.07), dexamethasone (P = 0.63), or ACEI (P = 0.8) and those that did not.

CONCLUSION

Although elevated troponin in COVID-19 patients has been associated with viral myocarditis and ACE II receptors, conventional viral myocarditis treatment, including antiviral and steroids, and ACEI did not show any effect on mortality in these patients.

The COVID-19 Pandemic and Coronary Heart Disease: the Next Surge

PURPOSE OF REVIEW

In this narrative review, we highlight different ways in which the COVID-19 pandemic has impacted coronary heart disease (CHD) burden and how a surge in morbidity and mortality may be expected in the near future. We also discuss potential solutions, and the direction subsequent research and corrective actions should take.

RECENT FINDINGS

COVID-19 has been implicated in the development and worsening of CHD via acute and chronic mechanisms in the form of plaque rupture, destabilization, and sustenance of a chronic inflammatory state leading to long COVID syndrome and increased rates of myocardial infarction. However, indirectly the pandemic is likely to further escalate the CHD burden through poor health behaviors such as tobacco consumption, reduced physical activity, economic devastation and its associated sequelae, and regular cardiac care interruptions and delays. COVID-19 has increased the total CHD burden and will require extensive resource allocation and multifaceted strategies to curb future rise.

Coronavirus disease-2019 and heart: assessment of troponin and cardiovascular comorbidities as prognostic markers in patients hospitalized with coronavirus disease-2019 in a tertiary center in Brazil

OBJECTIVE

Our study aimed to evaluate the correlation of cardiac troponin T levels with comorbidities and in-hospital outcomes in patients with coronavirus disease-2019 in Brazil.

METHODS

Data from a cohort of 3,596 patients who were admitted with suspected coronavirus disease-2019 in a Brazilian tertiary center, between March and August 2020, were reviewed. A total of 2,441 (68%) patients had cardiac troponin T determined in the first 72 h of admission and were stratified into two groups: elevated cardiac troponin T (cardiac troponin T >0.014 ng/mL) and normal cardiac troponin T. Associations between troponin, comorbidities, biomarkers, and outcomes were assessed. Regression models were built to assess the association of several variables with in-hospital mortality.

RESULTS

A total of 2,441 patients were embraced, of which 924 (38%) had normal cardiac troponin T and 1,517 (62%) had elevated cardiac troponin T. Patients with elevated cardiac troponin T were older and had more comorbidities, such as cardiovascular disease, hypertension, diabetes, arrhythmia, renal dysfunction, liver disease, stroke, cancer, and dementia. Patients with abnormal cardiac troponin T also had more altered laboratory parameters on admission (i.e., leukocytes, C-reactive protein, D-dimer, and B-type natriuretic peptide), as well as more need for intensive care unit, vasoactive drugs, mechanical ventilation, dialysis, and blood transfusion. All-cause mortality was markedly higher among patients with increased cardiac troponin T (42 vs. 16%, P<0.001). Multiple regression analysis demonstrated that in-hospital mortality was not independently associated with troponin elevation.

CONCLUSION

This study showed that cardiac troponin T elevation at admission was common and associated with several comorbidities, biomarkers, and clinical outcomes in patients hospitalized with coronavirus disease-2019, but it was not an independent marker of in-hospital mortality.

Imaging for Cardiovascular Complications of COVID-19: Cardiac Manifestations in Context

After the first confirmed case in 2019, COVID-19 rapidly spread worldwide and overwhelmed the medical community. In the intervening time, we have learned about COVID-19's clinical manifestations and have developed effective therapies and preventative vaccines. Severe COVID-19 infection is associated with many cardiovascular disorders in the acute phase, and patients recovered from illness can also manifest long-term sequelae, including long COVID syndrome. Furthermore, severe acute respiratory syndrome-related coronavirus-2 messenger RNA (mRNA) vaccination can trigger rare cases of myopericarditis. We have gained significant knowledge of the acute and long-term cardiovascular complications of COVID-19- and mRNA vaccine-associated myocarditis through clinical and investigative studies using cardiac imaging. In this review, we describe how cardiovascular imaging can be used to understand the cardiovascular complications and cardiac injury associated with acute COVID-19 infection, review the imaging findings in patients recovered from illness, and discuss the role and limitations of cardiac imaging in COVID-19 mRNA vaccine-associated myocarditis.

The effect of SARS-CoV-2 infection on cardiac function in post-COVID-19 survivors: A systematic review and meta-analysis

The longitudinal trajectories of cardiac structure and function following SARS-CoV-2 infection are unclear. Therefore, this meta-analysis aims to elucidate the effect of SARS-CoV-2 infection on cardiac function in coronavirus disease 2019 (COVID-19) survivors after recovery. PubMed/MEDLINE, CENTRAL, and EMBASE were systematically searched for articles published up to 1st August 2022. A systematic review and meta-analysis were performed to calculate the pooled effects size and 95% confidence interval of each outcome. A total of 21 studies including 2394 individuals (1436 post-COVID-19 cases and 958 controls) were included in the present meta-analysis. The pooled analyses compared with control groups showed a significant association between post-COVID-19 and reduced left ventricular ejection fraction (LV EF), LV end-diastolic volume (LV EDV), LV stroke volume (LV SV), mitral annular plane systolic excursion (MAPSE), global longitudinal strain, right ventricular EF (RV EF), RV EDV, RV ESV, RV SV, tricuspid annular plane systolic excursion, and increased LV mass. Subgroup analysis based on the severity of COVID-19 in the acute phase and subsequent chronic outcomes revealed that LV EF, MAPSE, RV EF, and RV ESV only decreased in studies including patients with a history of intensive care unit admission. Cardiac impairment after SARS-CoV-2 infection persisted in recovered COVID-19 patients even after 1 year. Future studies are warranted to determine the biological mechanisms underlying the long-term cardiovascular consequences of COVID-19.

Cardiac Injury in COVID-19: A Systematic Review of Relevant Meta-Analyses

Background

Cardiac injury (CI) is not a rare condition among hospitalized patients with coronavirus disease 2019 (COVID-19). Its prognostic value has been extensively reported through the literature, mainly in the context of observational studies. An impressive number of relevant meta-analyses has been conducted. These meta-analyses present similar and consistent results; yet interesting methodological issues emerge.

Methods

A systematic literature search was conducted aiming to identify all relevant meta-analyses on (i) the incidence, and (ii) the prognostic value of CI among hospitalized patients with COVID-19.

Results

Among 118 articles initially retrieved, 73 fulfilled the inclusion criteria and were included in the systematic review. Various criteria were used for CI definition mainly based on elevated cardiac biomarkers levels. The most frequently used biomarker was troponin. 30 meta-analyses reported the pooled incidence of CI in hospitalized patients with COVID-19 that varies from 5% to 37%. 32 meta-analyses reported on the association of CI with COVID-19 infection severity, with only 6 of them failing to show a statistically significant association. Finally, 46 meta-analyses investigated the association of CI with mortality and showed that patients with COVID-19 with CI had increased risk for worse prognosis. Four meta-analyses reported pooled adjusted hazard ratios for death in patients with COVID-19 and CI vs those without CI ranging from 1.5 to 3.

Conclusions

The impact of CI on the prognosis of hospitalized patients with COVID-19 has gained great interest during the pandemic. Methodological issues such as the inclusion of not peer-reviewed studies, the inclusion of potentially overlapping populations or the inclusion of studies with unadjusted analyses for confounders should be taken into consideration. Despite these limitations, the adverse prognosis of patients with COVID-19 and CI has been consistently demonstrated.

COVID-19 in Older Adults at the Time of the Omicron Variant

Since its outbreak, COVID-19 has had a significant impact on older adults worldwide [...].

Incidence of acute myocardial injury and its association with left and right ventricular systolic dysfunction in critically ill COVID-19 patients

Background

Previous studies have found an increase in cardiac troponins (cTns) and echocardiographic abnormalities in patients with COVID-19 and reported their association with poor clinical outcomes. Whether acute injury occurs during the course of critical care and if it is associated with cardiac function is unknown.

The purpose of this study was to document the incidence of acute myocardial injury (AMInj) and echocardiographically defined left ventricular (LV) and right ventricular (RV) systolic dysfunction in consecutive patients admitted to an intensive care unit (ICU) for COVID-19. The relationship between AMInj and echocardiographic abnormalities during the first 14 days of ICU admission was studied. Finally, the association between echocardiographic findings, AMInj and clinical outcome was evaluated.

Methods

Seventy-four consecutive patients (≥18 years) admitted to the ICU at Linköping University Hospital between 19 Mar 2020 and 31 Dec 2020 for COVID-19 were included. High-sensitivity troponin-T (hsTnT) was measured daily for up to 14 days. Transthoracic echocardiography was conducted within 72 h of ICU admission. Acute myocardial injury was defined as an increased hsTnT > 14ng/l and a > 20% absolute change with or without ischaemic symptoms. LV and RV systolic dysfunction was defined as at least 2 abnormal indicators of systolic function specified by consensus guidelines.

Results

Increased hsTnT was observed in 59% of patients at ICU admission, and 82% developed AMInj with peak levels at 8 (3–13) days after ICU admission. AMInj was not statistically significantly associated with 30-day mortality but was associated with an increased duration of invasive mechanical ventilation (10 (3–13) vs. 5 days (0–9), p=0.001) as well as ICU length of stay (LOS) (19.5 (11–28) vs. 7 days (5–13), p=0.015). After adjustment for SAPS-3 and admission SOFA score, the effect of AMInj was significant only for the duration of mechanical ventilation (p=0.030).

The incidence of LV and RV dysfunction was 28% and 22%, respectively. Only indices of LV and RV longitudinal contractility (mitral and tricuspid annular plane systolic excursion) were associated with AMInj. Echocardiographic parameters were not associated with clinical outcome.

Conclusions

Myocardial injury is common in critically ill patients with COVID-19, with AMInj developing in more than 80% after ICU admission. In contrast, LV and RV dysfunction occurred in approximately one-quarter of patients. AMInj was associated with an increased need for mechanical ventilation and ICU LOS but neither AMInj nor ventricular dysfunction was significantly associated with mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01030-8.