TY - JOUR
T1 - Myocardial involvement after hospitalization for COVID-19 complicated by troponin elevation: a prospective, multicenter, observational study
AU - Oxford Acute Myocardial Infarction OxAMI Study Investigators
AU - COVID-HEART investigators
AU - Artico, Jessica
AU - Shiwani, Hunain
AU - Moon, James C.
AU - Gorecka, Miroslawa
AU - McCann, Gerry P
AU - Singh, Trisha
AU - Dweck, Marc R
AU - Greenwood, John P
N1 - Funding Information:
Dr Berry acknowledges British Heart Foundation support (grant RE/18/6134217). Dr Artico received funding from the European Association of Cardiovascular Imaging (EACVI research grant App000073878). Dr McCann is funded by an NIHR research professorship (RP-2017-08-ST2-007). Dr Manisty is funded by an NIHR clinician scientist award (CS-2015-15-003). Drs Ferreira, Piechnik, and Neubauer thank the NIHR Oxford Biomedical Research Centre for support of this study. Dr Bucciarelli-Ducci is supported in part by the NIHR Biomedical Research Centre at University Hospitals Bristol National Health Service Foundation Trust and the University of Bristol. Additional support was provided by the NIHR Leicester Biomedical Research Centre and the NIHR Leeds Clinical Research Facility. Dr Dweck is supported by the British Heart Foundation (grant FS/SCRF/21/32010). The authors thank the patients and staff who supported this project.
Funding Information:
Supported by NIHR and UK Research and Innovation (COV0254). West Yorkshire and Humber Clinical Research Network (CV070) funded patient information leaflet translation.
Publisher Copyright:
© 2023 Lippincott Williams and Wilkins. All rights reserved.
PY - 2023/1/31
Y1 - 2023/1/31
N2 - BACKGROUND: Acute myocardial injury in hospitalized patients with coronavirus disease 2019 (COVID-19) has a poor prognosis. Its associations and pathogenesis are unclear. Our aim was to assess the presence, nature, and extent of myocardial damage in hospitalized patients with troponin elevation.METHODS: Across 25 hospitals in the United Kingdom, 342 patients with COVID-19 and an elevated troponin level (COVID+/troponin+) were enrolled between June 2020 and March 2021 and had a magnetic resonance imaging scan within 28 days of discharge. Two prospective control groups were recruited, comprising 64 patients with COVID-19 and normal troponin levels (COVID+/troponin-) and 113 patients without COVID-19 or elevated troponin level matched by age and cardiovascular comorbidities (COVID-/comorbidity+). Regression modeling was performed to identify predictors of major adverse cardiovascular events at 12 months.RESULTS: Of the 519 included patients, 356 (69%) were men, with a median (interquartile range) age of 61.0 years (53.8, 68.8). The frequency of any heart abnormality, defined as left or right ventricular impairment, scar, or pericardial disease, was 2-fold greater in cases (61% [207/342]) compared with controls (36% [COVID+/troponin-] versus 31% [COVID-/comorbidity+];
P<0.001 for both). More cases than controls had ventricular impairment (17.2% versus 3.1% and 7.1%) or scar (42% versus 7% and 23%;
P<0.001 for both). The myocardial injury pattern was different, with cases more likely than controls to have infarction (13% versus 2% and 7%;
P<0.01) or microinfarction (9% versus 0% and 1%;
P<0.001), but there was no difference in nonischemic scar (13% versus 5% and 14%;
P=0.10). Using the Lake Louise magnetic resonance imaging criteria, the prevalence of probable recent myocarditis was 6.7% (23/342) in cases compared with 1.7% (2/113) in controls without COVID-19 (
P=0.045). During follow-up, 4 patients died and 34 experienced a subsequent major adverse cardiovascular event (10.2%), which was similar to controls (6.1%;
P=0.70). Myocardial scar, but not previous COVID-19 infection or troponin, was an independent predictor of major adverse cardiovascular events (odds ratio, 2.25 [95% CI, 1.12-4.57];
P=0.02).
CONCLUSIONS: Compared with contemporary controls, patients with COVID-19 and elevated cardiac troponin level have more ventricular impairment and myocardial scar in early convalescence. However, the proportion with myocarditis was low and scar pathogenesis was diverse, including a newly described pattern of microinfarction.REGISTRATION: URL: https://www.isrctn.com; Unique identifier: 58667920.
AB - BACKGROUND: Acute myocardial injury in hospitalized patients with coronavirus disease 2019 (COVID-19) has a poor prognosis. Its associations and pathogenesis are unclear. Our aim was to assess the presence, nature, and extent of myocardial damage in hospitalized patients with troponin elevation.METHODS: Across 25 hospitals in the United Kingdom, 342 patients with COVID-19 and an elevated troponin level (COVID+/troponin+) were enrolled between June 2020 and March 2021 and had a magnetic resonance imaging scan within 28 days of discharge. Two prospective control groups were recruited, comprising 64 patients with COVID-19 and normal troponin levels (COVID+/troponin-) and 113 patients without COVID-19 or elevated troponin level matched by age and cardiovascular comorbidities (COVID-/comorbidity+). Regression modeling was performed to identify predictors of major adverse cardiovascular events at 12 months.RESULTS: Of the 519 included patients, 356 (69%) were men, with a median (interquartile range) age of 61.0 years (53.8, 68.8). The frequency of any heart abnormality, defined as left or right ventricular impairment, scar, or pericardial disease, was 2-fold greater in cases (61% [207/342]) compared with controls (36% [COVID+/troponin-] versus 31% [COVID-/comorbidity+];
P<0.001 for both). More cases than controls had ventricular impairment (17.2% versus 3.1% and 7.1%) or scar (42% versus 7% and 23%;
P<0.001 for both). The myocardial injury pattern was different, with cases more likely than controls to have infarction (13% versus 2% and 7%;
P<0.01) or microinfarction (9% versus 0% and 1%;
P<0.001), but there was no difference in nonischemic scar (13% versus 5% and 14%;
P=0.10). Using the Lake Louise magnetic resonance imaging criteria, the prevalence of probable recent myocarditis was 6.7% (23/342) in cases compared with 1.7% (2/113) in controls without COVID-19 (
P=0.045). During follow-up, 4 patients died and 34 experienced a subsequent major adverse cardiovascular event (10.2%), which was similar to controls (6.1%;
P=0.70). Myocardial scar, but not previous COVID-19 infection or troponin, was an independent predictor of major adverse cardiovascular events (odds ratio, 2.25 [95% CI, 1.12-4.57];
P=0.02).
CONCLUSIONS: Compared with contemporary controls, patients with COVID-19 and elevated cardiac troponin level have more ventricular impairment and myocardial scar in early convalescence. However, the proportion with myocarditis was low and scar pathogenesis was diverse, including a newly described pattern of microinfarction.REGISTRATION: URL: https://www.isrctn.com; Unique identifier: 58667920.
KW - COVID-19
KW - coronavirus
KW - troponin
KW - magnetic resonance imaging
KW - myocardial infarction
KW - myocardial injury
KW - cardiovascular disease
U2 - 10.1161/CIRCULATIONAHA.122.060632
DO - 10.1161/CIRCULATIONAHA.122.060632
M3 - Article
C2 - 36705028
SN - 0009-7322
VL - 147
SP - 364
EP - 374
JO - Circulation
JF - Circulation
IS - 5
ER -