COVID-19-associated myocardial injury

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Main article: COVID-19

For COVID-19 frequently asked inpatient questions, click here

For COVID-19 frequently asked outpatient questions, click here

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; [[

Synonyms and Keywords: Novel coronavirus, COVID-19, Wuhan coronavirus, coronavirus disease-19, coronavirus disease 2019, SARS-CoV-2, COVID-19, COVID-19, 2019-nCoV, 2019 novel coronavirus, cardiovascular finding in COVID-19, myocardial injury in COVID-19, COVID-19-associated myocardial injury, SARS-CoV2-associated myocardial injury, COVID-19 myocardial injury.

Overview

Coronavirus disease 2019 (COVID-19) is a rapidly expanding global pandemic which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 has caused a lot of morbidity and mortality. Some hospitalized patients can develop an acute COVID-19 myocardial injury, which can manifest with a variety of clinical presentations but often presents as an acute cardiac injury with cardiomyopathy, ventricular arrhythmias, and hemodynamic instability, acute coronary syndrome, cardiogenic shock. Patients with preexisting cardiovascular disease have higher morbidity and mortality. Acute myocardial injury may be defined across studies as any of the following: Elevated troponin levels. The upper reference limit for the high-sensitivity troponin I (hs-TnI) test (0.04ng/mL), based on the 99th percentile of measurements reported in healthy population without the occlusion of coronary arteries. Elevated cardiac biomarker levels to > 99th percentile of upper reference limit. Electrocardiographic and echocardiographic abnormalities.

Historical Perspective

• One of the first reports of myocardial injury associated with SARS-CoV-2 was a study of 41 patients diagnosed with COVID-19 in Wuhan, China, wherein 5 patients (12%) had a high-sensitivity troponin I above the threshold of 28 pg/mL
• The novel coronavirus, SARS-CoV-2, is identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China in late December 2019. This novel coronavirus, SARS-CoV-2, was named the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) for it similarity severe acute respiratory syndrome related coronaviruses such as SARS-CoV, which caused acute respiratory distress syndrome (ARDS) in 2002–2003.
• On January 30, 2020,the World Health Organization(WHO) declared the outbreak as a Public Health Emergency of International Concern.
• On March 12, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic.

Classification

There is no established system for the classification of Acute myocardial injury in COVID-19.

Pathophysiology

• The pathophysiology of myocardial injury include,
  • Hyperinflammation and cytokine storm mediated through pathologic T-cells and monocytes leading to myocarditis
  • Respiratory failure and hypoxemia resulting in damage to cardiac myocytes
  • Down regulation of ACE2 expression and subsequent protective signaling pathways in cardiac myocytes
  • Hypercoagulability and development of coronary microvascular thrombosis
  • Diffuse endothelial injury and ‘endotheliitis’ in several organs, including the heart as a direct consequence of SARS-CoV-2 viral involvement and/or resulting from host inflammatory response.
  • Inflammation and/or stress causing coronary plaque rupture or supply-demand mismatch leading to myocardial ischemia/infarction.
  • Adverse medication effects may disproportionately challenge a diseased heart, with special consideration for the regimen of hydroxychloroquine and azithromycin treatment due to the potential for QTc prolongation
  • Direct invasion of the cardiac tissue by COVID-19.

Hyperinflammation and cytokine storm:

• Immune dysregulation, including T cell and immune signaling dysfunction, recognized as an important factor in the pathogenesis of vascular disease, may also adversely affect the body's response to SARS-CoV-2 infection
• The role of CD4(+)CD25(+)FOXP3(+) regulatory T (TREG) cells in the modulation of inflammation and immunity has received increasing attention. Given the important role of TREG cells { T regulatory cells}) in the induction and maintenance of immune homeostasis and tolerance, dysregulation in the generation or function of TREG cells{ Regulatory T cells}) can trigger abnormal immune responses and lead to pathology.
• Evidence from experimental and clinical studies has indicated that TREG cells { Regulatory T cells})might have an important role in protecting against cardiovascular disease, in particular atherosclerosis and abdominal aortic aneurysm.
• The role of TREG cells is evident in the pathogenesis of a number of cardiovascular diseases, including atherosclerosis, hypertension, ischaemic stroke, abdominal aortic aneurysm, Kawasaki disease, pulmonary arterial hypertension, myocardial infarction and remodelling, postischaemic neovascularization, myocarditis and dilated cardiomyopathy, and heart failure.

Role of ACE Receptor :

• ACE-2 is a membrane-bound aminopeptidate receptor expressed on the epithelial cells of the lungs, intestines, kidneys and blood vessels. It has important immune and cardiovascular roles. Angiotensin-converting enzyme (ACE) cleaves angiotensin I to generate angiotensin II (Ang II), which binds to and activates AT₁R, thus promoting vasoconstriction.
• ACE-2 cleaves angiotensin II and generates angiotensin 1–7, a powerful vasodilator acting through Mas receptors.
• SARS-CoV-2 has a spike protein receptor-binding domain, similar to SARS-CoV-1, which interacts with the ACE-2 receptor and acts as the primary functional receptor for pathogenicity and human-to-human transmission. Furthermore, SARS-CoV-2 binding to ACE-2 leads to its down regulation and increases angiotensin II,a pro-inflammatory factor in the lung.
• This subsequently leads to lower amount of angiotensin 1–7. Thus loss of protective signaling pathway in cardiac myocytes. The detrimental effect of ACE-2 downregulation would impede cardioprotective effects of angiotensin 1–7 leading to increased TNFα production, other cytokines release that can result in acute respiratory syndrome, acute cardiac injury and multiorgan dysfunction.

Causes

• Acute respiratory distress syndrome. (ARDS)
• Pneumonia
• Hypercoagulability and plaque rupture
• Hyperinflammation and cytokine storm
• Direct invasion of the cardiac tissue by COVID-19.
• Myocarditis and myocyte necrosis.

Epidemiology and Demographics

Incidence

• The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
• In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.

Prevalence

• The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.
• In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.
• The prevalence of [disease/malignancy] is estimated to be [number] cases annually.

Case-fatality rate/Mortality rate

• A summary of 44,672 COVID-19 cases documented by the Chinese Center for Disease Control and Prevention demonstrated a case fatality rate of 10.5% with comorbid CVD ( cardiovascular disease) compared to a 2.4% overall case fatality rate

Age

• Patients with this marker of myocardial injury were older and had more comorbidities (including chronic heart failure in 14.6 versus 1.5 percent), greater laboratory abnormalities (including higher levels of C-reactive protein, procalcitonin, and aspartate aminotransferase), more lung radiographic abnormalities, and more complications compared with those without myocardial injury.

Race

• As of June 12, 2020, age-adjusted hospitalization rates are highest among non-Hispanic American Indian or Alaska Native and non-Hispanic black persons, followed by Hispanic or Latino persons.[https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html
  • Non-Hispanic American Indian or Alaska Native persons have a rate approximately 5 times that of non-Hispanic white persons,
  • non-Hispanic black persons have a rate approximately 5 times that of non-Hispanic white persons,
  • Hispanic or Latino persons have a rate approximately 4 times that of non-Hispanic white persons

Gender

• .

Region

• The majority of [disease name] cases are reported in [geographical region].

• [Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].

• A summary of 44,672 COVID-19 cases documented by the Chinese Center for Disease Control and Prevention demonstrated a case fatality rate of 10.5% with comorbid CVD ( cardiovascular disease) compared to a 2.4% overall case fatality rate
• The frequency of myocardial injury (as reflected by elevation in cardiac troponin levels) is variable among hospitalized patients with COVID-19, with reported frequencies of 7 to 28 percent .
• Some studies have identified greater frequency and magnitude of troponin elevations in hospitalized patients with more severe disease and worse outcomes
• In a series of 416 patients with COVID-19 who were hospitalized in Wuhan, China, 19.7 percent had high-sensitivity troponin I (hs-TnI) above the 99th percentile upper reference limit on admission.
• Patients with this marker of myocardial injury were older and had more comorbidities (including chronic heart failure in 14.6 versus 1.5 percent), greater laboratory abnormalities (including higher levels of C-reactive protein, procalcitonin, and aspartate aminotransferase), more lung radiographic abnormalities, and more complications compared with those without myocardial injury.
• The mortality rate was also higher in those with myocardial injury (51.2 versus 4.5 percent).
• The risk of death starting from the time of symptom onset was more than four times higher in patients with evidence of myocardial injury on admission.

Risk Factors

• A meta-analysis of 6 studies inclusive of 1,527 patients with COVID-19 examined the prevalence of cardio vascular disease (CVD) and reported the prevalence of hypertension, cardiac and cerebrovascular disease, and diabetes to be 17.1%, 16.4%, and 9.7%, respectively

Screening

• There is insufficient evidence to recommend routine screening for acute myocardial injury in COVID-19 patients.

Natural History, Complications, and Prognosis

Complications

• The disease also contributes to cardiovascular complications, including
  • Acute coronary syndromes
  • Arrhythmias
  • Myocarditis
  • Pericarditis
  • Heart failure
  • Cardiogenic shock
  • Death

Prognosis

• Prognosis of COVID-19 myocardial injury patients is generally poor.
• A retrospective analysis of the cause of death in Chinese patients infected with COVID-19 revealed that 40% of patients died at least in part because of myocardial injury and circulatory collapse.
• In another study, patients hospitalized for COVID-19 infection developed cardiac injury in roughly 20% of cases; thus leading to greater than 50% mortality.
• Older patients with preexisting cardiovascular comorbidities and diabetes are prone to develop a higher acuity of illness after contracting SARS-CoV-2 associated with higher risk of myocardial injury and a markedly higher short-term mortality rate.

Diagnosis

Laboratory

• Cardiac Biomarkers:
  • The upper reference limit for the high-sensitivity troponin I (hs-TnI) test (0.04ng/mL), based on the 99th percentile of measurements reported in healthy population without the occlusion of coronary arteries.
  • In the recently published retrospective study of 191 COVID-19 patients from two separate hospitals in China, the incidence of elevation in high-sensitivity cardiac troponin I (cTnI) (>28 pg/ml) was 17%, and it was significantly higher among non-survivors (46% versus 1%, p<0.001).
  • Furthermore, elevation of this biomarker was noted to be a predictor of in-hospital death (univariable OR 80.07, 95% CI [10.34–620.36], p<0.0001). The most abrupt increase in cTnI in non-survivors was noted beyond day 16 after the onset of disease. In the same study, the incidence of acute cardiac injury was 17% among all-comers, but significantly higher among non-survivors (59% versus 1%, p<0.0001).
  • CK-MB >2.2 ng/mL
  • Guo et al¹¹ provide additional novel insights that TnT levels are significantly associated with levels of C-reactive protein and N-terminal pro-B-type natriuretic peptide (NT-proBNP), thus linking myocardial injury to severity of inflammation and ventricular dysfunction

Inflammatory biomarkers:

• Elevated levels of inflammatory markers including erythrocyte sedimentation rate, C reactive protein, and procalcitonin are usually seen in myocarditis but they are non-specific and do not confirm the diagnosis. Increases levels of Interleukin-6 (IL-6), d-dimer, serum ferritin, prothrombin time were seen in COVID-19 patients.

History and Symptoms

• Patients with COVID-19 can present with the typical symptoms and signs of SARS-CoV-2 nfection such as fever, cough, dyspnea, and bilateral infiltrates on chest imaging can present with chest pain, dyspnea, dysarrhythmia, and acute left ventricular dysfunction

Electrocardiogram

• The electrocardiogram (ECG) can demonstrate a range of findings
  • In some cases mimicking acute coronary syndrome (ACS).
  • The ECG abnormalities result from myocardial inflammation and include non-specific ST segment-T wave abnormalities.
  • T wave inversion.
  • PR segment and ST segment deviations (depression and elevation)

Treatment

There is so specific treatment , and treatment varies depending upon presentation (COVID-19-associated myocarditis, COVID-19-associated myocardial infarction,COVID-19-associated heart failure, COVID-19-associated arrhythmia and conduction system disease, COVID-19-associated cardiogenic shock, COVID-19-associated cardiac arrest, COVID-19-associated pericarditis, COVID-19-associated spontaneous coronary artery dissection.

References

COVID 19