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

      research-article
      1 , 2 , 1 , 2 , 1 , 3 , 3 , 2 , 4 , 1 , 4 , 1 , 4 , 1 , 2 , 3 , 5 , 2 , 4 , 2 , 4 , 6 , 3 , 2 , 6 , 1 , 2 , 3 , 1 , 3 , 6 , 6 , 3 , 5 , 1 , 1 , 3 , 5 , 3 , 5 , 1 , 7 , 2 , 4 , 6 , 3 , 5 , 1 , 1 , 2 , 4 , 3 , 5 , 1 , 8 , 8 , 2 , 4 , 2 , 4 , 3 , 5 , 1 , 9
      European Heart Journal
      Oxford University Press
      COVID-19, SARS-CoV-2, Cardiovascular magnetic resonance, Myocarditis, Myocardial infarction, Myocardial oedema

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

          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

            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

              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
                Eur Heart J
                Eur Heart J
                eurheartj
                European Heart Journal
                Oxford University Press
                0195-668X
                1522-9645
                18 February 2021
                : 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
                https://orcid.org/0000-0003-0059-4817
                https://orcid.org/0000-0003-4766-3293
                https://orcid.org/0000-0002-3142-5795
                https://orcid.org/0000-0003-2236-7279
                https://orcid.org/0000-0003-3289-2413
                https://orcid.org/0000-0002-3177-5680
                https://orcid.org/0000-0002-4524-1436
                https://orcid.org/0000-0001-9271-2491
                https://orcid.org/0000-0002-6918-2717
                https://orcid.org/0000-0003-2199-2638
                https://orcid.org/0000-0002-1298-5156
                https://orcid.org/0000-0001-8079-205X
                https://orcid.org/0000-0002-7507-2119
                https://orcid.org/0000-0002-3711-3960
                https://orcid.org/0000-0003-2822-210X
                https://orcid.org/0000-0002-8181-4270
                https://orcid.org/0000-0003-2647-4688
                https://orcid.org/0000-0002-4665-6422
                https://orcid.org/0000-0003-1416-3321
                https://orcid.org/0000-0001-8386-2260
                https://orcid.org/0000-0001-8546-5023
                https://orcid.org/0000-0002-6780-4551
                https://orcid.org/0000-0002-4561-5530
                https://orcid.org/0000-0002-9875-6070
                https://orcid.org/0000-0003-1560-7414
                https://orcid.org/0000-0002-9233-9831
                Article
                ehab075
                10.1093/eurheartj/ehab075
                7928984
                33596594
                6a784e35-8120-4af8-9054-f2f39319ea2f
                © The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

                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
                : 10 November 2020
                : 14 December 2020
                : 03 February 2021
                : 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
                Categories
                Fasttrack Congress
                AcademicSubjects/MED00200
                Custom metadata
                PAP

                Cardiovascular Medicine
                covid-19,sars-cov-2,cardiovascular magnetic resonance,myocarditis,myocardial infarction,myocardial oedema

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