Patterns of myocardial injury in recovered troponin-positive COVID-19 patients assessed by cardiovascular magnetic resonance

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Abstract

Background

Troponin elevation is common in hospitalized COVID-19 patients, but underlying aetiologies are ill-defined. We used multi-parametric cardiovascular magnetic resonance (CMR) to assess myocardial injury in recovered COVID-19 patients.

Methods and results

One hundred and forty-eight patients (64 ± 12 years, 70% male) with severe COVID-19 infection [all requiring hospital admission, 48 (32%) requiring ventilatory support] and troponin elevation discharged from six hospitals underwent convalescent CMR (including adenosine stress perfusion if indicated) at median 68 days. Left ventricular (LV) function was normal in 89% (ejection fraction 67% ± 11%). Late gadolinium enhancement and/or ischaemia was found in 54% (80/148). This comprised myocarditis-like scar in 26% (39/148), infarction and/or ischaemia in 22% (32/148) and dual pathology in 6% (9/148). Myocarditis-like injury was limited to three or less myocardial segments in 88% (35/40) of cases with no associated LV dysfunction; of these, 30% had active myocarditis. Myocardial infarction was found in 19% (28/148) and inducible ischaemia in 26% (20/76) of those undergoing stress perfusion (including 7 with both infarction and ischaemia). Of patients with ischaemic injury pattern, 66% (27/41) had no past history of coronary disease. There was no evidence of diffuse fibrosis or oedema in the remote myocardium (T1: COVID-19 patients 1033 ± 41 ms vs. matched controls 1028 ± 35 ms; T2: COVID-19 46 ± 3 ms vs. matched controls 47 ± 3 ms).

Conclusions

During convalescence after severe COVID-19 infection with troponin elevation, myocarditis-like injury can be encountered, with limited extent and minimal functional consequence. In a proportion of patients, there is evidence of possible ongoing localized inflammation. A quarter of patients had ischaemic heart disease, of which two-thirds had no previous history. Whether these observed findings represent pre-existing clinically silent disease or de novo COVID-19-related changes remain undetermined. Diffuse oedema or fibrosis was not detected.

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Most cited references 38

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Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Chaolin Huang, Yeming Wang, Xingwang Li … (2020)

Summary Background A recent cluster of pneumonia cases in Wuhan, China, was caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV). We report the epidemiological, clinical, laboratory, and radiological characteristics and treatment and clinical outcomes of these patients. Methods All patients with suspected 2019-nCoV were admitted to a designated hospital in Wuhan. We prospectively collected and analysed data on patients with laboratory-confirmed 2019-nCoV infection by real-time RT-PCR and next-generation sequencing. Data were obtained with standardised data collection forms shared by WHO and the International Severe Acute Respiratory and Emerging Infection Consortium from electronic medical records. Researchers also directly communicated with patients or their families to ascertain epidemiological and symptom data. Outcomes were also compared between patients who had been admitted to the intensive care unit (ICU) and those who had not. Findings By Jan 2, 2020, 41 admitted hospital patients had been identified as having laboratory-confirmed 2019-nCoV infection. Most of the infected patients were men (30 [73%] of 41); less than half had underlying diseases (13 [32%]), including diabetes (eight [20%]), hypertension (six [15%]), and cardiovascular disease (six [15%]). Median age was 49·0 years (IQR 41·0–58·0). 27 (66%) of 41 patients had been exposed to Huanan seafood market. One family cluster was found. Common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhoea (one [3%] of 38). Dyspnoea developed in 22 (55%) of 40 patients (median time from illness onset to dyspnoea 8·0 days [IQR 5·0–13·0]). 26 (63%) of 41 patients had lymphopenia. All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (12 [29%]), RNAaemia (six [15%]), acute cardiac injury (five [12%]) and secondary infection (four [10%]). 13 (32%) patients were admitted to an ICU and six (15%) died. Compared with non-ICU patients, ICU patients had higher plasma levels of IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, and TNFα. Interpretation The 2019-nCoV infection caused clusters of severe respiratory illness similar to severe acute respiratory syndrome coronavirus and was associated with ICU admission and high mortality. Major gaps in our knowledge of the origin, epidemiology, duration of human transmission, and clinical spectrum of disease need fulfilment by future studies. Funding Ministry of Science and Technology, Chinese Academy of Medical Sciences, National Natural Science Foundation of China, and Beijing Municipal Science and Technology Commission.

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Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Fei Zhou, Ting Yu, Ronghui Du … (2020)

Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

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Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China

Dawei Wang, Bo Hu, Fangfang Zhu … (2020)

In December 2019, novel coronavirus (2019-nCoV)-infected pneumonia (NCIP) occurred in Wuhan, China. The number of cases has increased rapidly but information on the clinical characteristics of affected patients is limited.

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Author and article information

Journal

Journal ID (nlm-ta): Eur Heart J

Journal ID (iso-abbrev): Eur Heart J

Journal ID (publisher-id): eurheartj

Title: European Heart Journal

Publisher: Oxford University Press

ISSN (Print): 0195-668X

ISSN (Electronic): 1522-9645

Publication date (Electronic): 18 February 2021

Electronic Location Identifier: ehab075

Affiliations

[1 ] Royal Free London NHS Foundation Trust , Pond Street, London NW3 2QG, UK

[2 ] Institute of Cardiovascular Science, University College London , UK

[3 ] Imperial College Healthcare NHS Trust , Du Cane Road, London W12 0HS, UK

[4 ] Barts Heart Centre, Barts Health NHS Trust , W Smithfield, London EC1A 7BE, UK

[5 ] National Heart and Lung Institute, Imperial College London , UK

[6 ] University College London Hospitals NHS Trust , London, UK

[7 ] Academic Department of Defence Medicine, Royal Centre for Defence Medicine , Edgbaston, Birmingham, UK

[8 ] National Heart, Lung, and Blood Institute, National Institute of Health , Bethesda, MD, USA

[9 ] National Amyloidosis Centre, Division of Medicine, University College London , UK

Author notes

Tushar Kotecha and Daniel S. Knight contributed equally to the article and should be considered joint lead authors.

Graham D. Cole and Marianna Fontana contributed equally to the article and should be considered joint last authors.

Corresponding author. Tel: (+44) 02074332764, Email: m.fontana@ 123456ucl.ac.uk

Author information

Tushar Kotecha https://orcid.org/0000-0003-0059-4817

Yousuf Razvi https://orcid.org/0000-0003-4766-3293

Kartik Kumar https://orcid.org/0000-0002-3142-5795

Kavitha Vimalesvaran https://orcid.org/0000-0003-2236-7279

George Thornton https://orcid.org/0000-0003-3289-2413

Rishi Patel https://orcid.org/0000-0002-3177-5680

Liza Chacko https://orcid.org/0000-0002-4524-1436

Clare Coyle https://orcid.org/0000-0001-9271-2491

Abhishek Shetye https://orcid.org/0000-0002-6918-2717

Robert Bell https://orcid.org/0000-0003-2199-2638

Meg Coleman https://orcid.org/0000-0002-1298-5156

Deepa Gopalan https://orcid.org/0000-0001-8079-205X

Melissa Heightman https://orcid.org/0000-0002-7507-2119

Toby Hillman https://orcid.org/0000-0002-3711-3960

Luke Howard https://orcid.org/0000-0003-2822-210X

Paramjit S Jeetley https://orcid.org/0000-0002-8181-4270

Onn Min Kon https://orcid.org/0000-0003-2647-4688

Jamil Mayet https://orcid.org/0000-0002-4665-6422

Rupert Negus https://orcid.org/0000-0003-1416-3321

Niket Patel https://orcid.org/0000-0001-8386-2260

Iain Pierce https://orcid.org/0000-0001-8546-5023

Anthony Wolff https://orcid.org/0000-0002-6780-4551

Hui Xue https://orcid.org/0000-0002-4561-5530

Peter Kellman https://orcid.org/0000-0002-9875-6070

Thomas A Treibel https://orcid.org/0000-0003-1560-7414

Marianna Fontana https://orcid.org/0000-0002-9233-9831

Article

Publisher ID: ehab075

DOI: 10.1093/eurheartj/ehab075

PMC ID: 7928984

PubMed ID: 33596594

SO-VID: 6a784e35-8120-4af8-9054-f2f39319ea2f

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

History

Date received : 10 November 2020

Date revision received : 14 December 2020

Date accepted : 03 February 2021

Date: 26 January 2021

Page count

Pages: 13

Funding

Funded by: National Institute for Health Research (NIHR) University College London Hospitals (UCLH) Biomedical Research Centre;

Funded by: (UCLH) and Barts NIHR Biomedical Research Centres and through a BHF Accelerator Award;

Award ID: AA/18/6/34223

Funded by: British Heart Foundation (BHF) Intermediate Fellowships;

Award ID: FS/18/21/33447

Award ID: FS/19/35/34374

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ScienceOpen disciplines: Cardiovascular Medicine

Keywords: covid-19,sars-cov-2,cardiovascular magnetic resonance,myocarditis,myocardial infarction,myocardial oedema

Data availability:

ScienceOpen disciplines: Cardiovascular Medicine

Keywords: covid-19, sars-cov-2, cardiovascular magnetic resonance, myocarditis, myocardial infarction, myocardial oedema

Patterns of myocardial injury in recovered troponin-positive COVID-19 patients assessed by cardiovascular magnetic resonance

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UCL: Covid-19 Research

Most cited references 38

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China

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