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      Impaired cardiac function is associated with mortality in patients with acute COVID-19 infection

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          Abstract

          Background

          COVID-19 infection may cause severe respiratory distress and is associated with increased morbidity and mortality. Impaired cardiac function and/or pre-existing cardiovascular disease may be associated with poor prognosis. In the present study, we report a comprehensive cardiovascular characterization in the first consecutive collective of patients that was admitted and treated at the University Hospital of Tübingen, Germany.

          Methods

          123 consecutive patients with COVID-19 were included. Routine blood sampling, transthoracic echocardiography and electrocardiography were performed at hospital admission.

          Results

          We found that impaired left-ventricular and right-ventricular function as well as tricuspid regurgitation > grade 1 were significantly associated with higher mortality. Furthermore, elevated levels of myocardial distress markers (troponin-I and NT pro-BNP) were associated with poor prognosis in this patient collective.

          Conclusion

          Impaired cardiac function is associated with poor prognosis in COVID-19 positive patients. Consequently, treatment of these patients should include careful guideline-conform cardiovascular evaluation and treatment. Thus, formation of a competent Cardio-COVID-19 team may represent a major clinical measure to optimize therapy of cardiovascular patients during this pandemic.

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          Most cited references18

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          Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China

          Shaobo Shi, Mu Qin, Bo Shen … (2020)
          Coronavirus disease 2019 (COVID-19) has resulted in considerable morbidity and mortality worldwide since December 2019. However, information on cardiac injury in patients affected by COVID-19 is limited.
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            Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19)

            Riccardo Inciardi, Laura Lupi, Gregorio Zaccone … (2020)
            What are the cardiac complications associated with the emerging outbreak of coronavirus disease 2019 (COVID-19)? In this case report, an otherwise healthy 53-year-old patient developed acute myopericarditis with systolic dysfunction confirmed on cardiac magnetic resonance imaging a week after onset of fever and dry cough due to COVID-19. The patient was treated with inotropic support, antiviral drugs, corticosteroids, and chloroquine, with progressive stabilization of the clinical course. The emerging outbreak of COVID-19 can be associated with cardiac involvement, even after the resolution of the upper respiratory tract infection. This case report describes the presentation of acute myocardial inflammation in a patient with coronavirus disease 2019 (COVID-19) who recovered from influenzalike syndrome and developed fatigue and signs and symptoms of heart failure a week after upper respiratory tract symptoms. Virus infection has been widely described as one of the most common causes of myocarditis. However, less is known about the cardiac involvement as a complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. To describe the presentation of acute myocardial inflammation in a patient with coronavirus disease 2019 (COVID-19) who recovered from the influenzalike syndrome and developed fatigue and signs and symptoms of heart failure a week after upper respiratory tract symptoms. This case report describes an otherwise healthy 53-year-old woman who tested positive for COVID-19 and was admitted to the cardiac care unit in March 2020 for acute myopericarditis with systolic dysfunction, confirmed on cardiac magnetic resonance imaging, the week after onset of fever and dry cough due to COVID-19. The patient did not show any respiratory involvement during the clinical course. Cardiac involvement with COVID-19. Detection of cardiac involvement with an increase in levels of N-terminal pro–brain natriuretic peptide (NT-proBNP) and high-sensitivity troponin T, echocardiography changes, and diffuse biventricular myocardial edema and late gadolinium enhancement on cardiac magnetic resonance imaging. An otherwise healthy 53-year-old white woman presented to the emergency department with severe fatigue. She described fever and dry cough the week before. She was afebrile but hypotensive; electrocardiography showed diffuse ST elevation, and elevated high-sensitivity troponin T and NT-proBNP levels were detected. Findings on chest radiography were normal. There was no evidence of obstructive coronary disease on coronary angiography. Based on the COVID-19 outbreak, a nasopharyngeal swab was performed, with a positive result for SARS-CoV-2 on real-time reverse transcriptase–polymerase chain reaction assay. Cardiac magnetic resonance imaging showed increased wall thickness with diffuse biventricular hypokinesis, especially in the apical segments, and severe left ventricular dysfunction (left ventricular ejection fraction of 35%). Short tau inversion recovery and T2-mapping sequences showed marked biventricular myocardial interstitial edema, and there was also diffuse late gadolinium enhancement involving the entire biventricular wall. There was a circumferential pericardial effusion that was most notable around the right cardiac chambers. These findings were all consistent with acute myopericarditis. She was treated with dobutamine, antiviral drugs (lopinavir/ritonavir), steroids, chloroquine, and medical treatment for heart failure, with progressive clinical and instrumental stabilization. This case highlights cardiac involvement as a complication associated with COVID-19, even without symptoms and signs of interstitial pneumonia.
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              Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of Two-Dimensional Echocardiograms.

              N B Schiller, P Shah, M. Crawford … (1989)
              We have presented recommendations for the optimum acquisition of quantitative two-dimensional data in the current echocardiographic environment. It is likely that advances in imaging may enhance or supplement these approaches. For example, three-dimensional reconstruction methods may greatly augment the accuracy of volume determination if they become more efficient. The development of three-dimensional methods will depend in turn on vastly improved transthoracic resolution similar to that now obtainable by transesophageal echocardiography. Better resolution will also make the use of more direct methods of measuring myocardial mass practical. For example, if the epicardium were well resolved in the long-axis apical views, the myocardial shell volume could be measured directly by the biplane method of discs rather than extrapolating myocardial thickness from a single short-axis view. At present, it is our opinion that current technology justifies the clinical use of the quantitative two-dimensional methods described in this article. When technically feasible, and if resources permit, we recommend the routine reporting of left ventricular ejection fraction, diastolic volume, mass, and wall motion score.
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                Author and article information

                Contributors
                Meinrad Paul Gawaz:
                ORCID: http://orcid.org/0000-0003-1124-9592
                meinrad.gawaz@med.uni-tuebingen.de
                Journal
                Journal ID (nlm-ta): Clin Res Cardiol
                Journal ID (iso-abbrev): Clin Res Cardiol
                Title: Clinical Research in Cardiology
                Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )
                ISSN (Print): 1861-0684
                ISSN (Electronic): 1861-0692
                Publication date (Electronic): 14 June 2020
                Publication date PMC-release: 14 June 2020
                Pages: 1-9
                Affiliations
                Department of Cardiology and Angiology, University Hospital Tübingen, Eberhard Karls Universität Tübingen, Otfried-Müller Str.10, 72076 Tübingen, Germany
                Author information
                http://orcid.org/0000-0003-1124-9592
                Article
                Publisher ID: 1683
                DOI: 10.1007/s00392-020-01683-0
                PMC ID: 7293880
                PubMed ID: 32537662
                SO-VID: bd8649bd-497a-47b9-b0a2-0cb0be475a54
                Copyright © © The Author(s) 2020
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 7 May 2020
                Date accepted : 28 May 2020
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100001659, Deutsche Forschungsgemeinschaft;
                Award ID: 374031971
                Award Recipient :
                Categories
                Subject: Original Paper

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: covid-19,cardiac function,prognosis,cardiovascular disease,heart failure
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: covid-19, cardiac function, prognosis, cardiovascular disease, heart failure

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