Admission High-Sensitive Cardiac Troponin T Level Increase Is Independently Associated with Higher Mortality in Critically Ill Patients with COVID-19: A Multicenter Study

Use and Prognostic Implications of Cardiac Troponin in COVID-19

Myocardial injury is common in patients with COVID-19 and is associated with an adverse prognosis. Cardiac troponin (cTn) is used to detect myocardial injury and assist with risk stratification in this population. SARS-CoV-2 infection can play a role in the pathogenesis of acute myocardial injury due to both direct and indirect damage to the cardiovascular system. Despite the initial concerns about an increased incidence of acute myocardial infarction (MI), most cTn increases are related to chronic myocardial injury due to comorbidities and/or acute nonischemic myocardial injury. This review will discuss the latest findings on this topic.

Prognostic value of the TyG index for in-hospital mortality in nondiabetic COVID-19 patients with myocardial injury

OBJECTIVE

The purpose of this study was to explore the efficacy of the triglyceride glucose (TyG) index on in-hospital mortality in nondiabetic coronavirus disease 2019 (COVID-19) patients with myocardial injury.

METHODS

This was a retrospective study, which included 218 nondiabetic COVID-19 patients who had myocardial injury. The TyG index was derived using the following equation: log [serum triglycerides (mg/dL) ×fasting blood glucose (mg/dL)/2].

RESULTS

Overall, 49 (22.4%) patients died during hospitalization. Patients who did not survive had a higher TyG index than survivors. In multivariate Cox regression analysis, it was found that the TyG index was independently associated with in-hospital death. A TyG index cutoff value greater than 4.97 was predicted in-hospital death in nondiabetic COVID-19 patients with myocardial damage, with 82% sensitivity and 66% specificity. A pairwise evaluation of receiver operating characteristic (ROC) curves demonstrated that the TyG index (AUC: 0.786) had higher discriminatory performance than both triglyceride (AUC: 0.738) and fasting blood glucose (AUC: 0.660) in predicting in-hospital mortality among these patients.

CONCLUSIONS

The TyG index might be used to identify high-risk nondiabetic COVID-19 patients with myocardial damage.

The Utility of Laboratory Parameters for Cardiac Inflammation in Heart Failure Patients Hospitalized with SARS-CoV-2 Infection

COVID-19 has been associated with cardiovascular consequences, including myocardial infarction, thromboembolic events, arrhythmia, and heart failure. Numerous overlapping mechanisms, such as the IL-6 dependent cytokine storm and unopposed angiotensin II stimulation, could be responsible for these consequences. Cardiac damage is hypothesized to be a consequence of the direct viral infection of cardiomyocytes, resulting in increased metabolic demand, immunological activation, and microvascular dysfunction. Patients with pre-existing chronic heart failure are therefore at increased risk of decompensation, further heart damage, and significant health deterioration. Based on the aforementioned assumptions, we developed a study aiming to provide a detailed description of changes in biological parameters and cardiac injury markers of patients with heart failure and SARS-CoV-2 infection by correlating them with the clinical presentation and COVID-19 vaccination status, to predict the probability of ICU admission based on their initial hospital presentation. A two-year retrospective study was performed on heart failure patients with a history of SARS-CoV-2 infection and detailed records of biological biomarkers; a total of 124 eligible patients with COVID-19 and 236 without COVID-19 were recruited. Patients with heart failure and SARS-CoV-2 infection had significantly elevated baseline biological parameters and cardiac markers compared to those without COVID-19. Several cardiac injury markers were identified as significant independent risk factors for ICU admission: CK-MB (HR = 4.1, CI[2.2–6.9]), myoglobin (HR = 5.0, CI[2.3–7.8]), troponin-I (HR = 7.1[4.4–9.6]) troponin-T (HR = 4.9, CI[1.7–7.4]). The elevation of a basic panel of acute inflammation markers (CRP, IL-6, fibrinogen), D-dimers, and BNP was also a significant risk factor. The follow-up of survivors at four weeks after viral clearance determined a worsened clinical picture by NYHA classification, worsened cardiac ultrasound findings, and a mild improvement in cardiac and inflammatory markers. Increased levels of myocardial damage parameters in association with cardiac ultrasound findings and basic inflammatory markers may enable early risk assessment and triage in hospitalized heart failure patients infected with SARS-CoV-2.

Biomarkers in the management of acute heart failure: state of the art and role in COVID-19 era

Acute heart failure (AHF) affects millions of people worldwide, and it is a potentially life‐threatening condition for which the cardiologist is more often brought into play. It is crucial to rapidly identify, among patients presenting with dyspnoea, those with AHF and to accurately stratify their risk, in order to define the appropriate setting of care, especially nowadays due to the coronavirus disease 2019 (COVID‐19) outbreak. Furthermore, with physical examination being limited by personal protective equipment, the use of new alternative diagnostic and prognostic tools could be of extreme importance. In this regard, usage of biomarkers, especially when combined (a multimarker approach) is beneficial for establishment of an accurate diagnosis, risk stratification and post‐discharge monitoring. This review highlights the use of both traditional biomarkers such as natriuretic peptides (NP) and troponin, and emerging biomarkers such as soluble suppression of tumourigenicity (sST2) and galectin‐3 (Gal‐3), from patients' emergency admission to discharge and follow‐up, to improve risk stratification and outcomes in terms of mortality and rehospitalization.

Cardiac biomarkers and COVID-19: A systematic review and meta-analysis

OBJECTIVE

To systematically investigate the relationship between cardiac biomarkers and COVID-19 severity and mortality.

METHODS

We performed a literature search using PubMed, Web of Science, and Google Scholar. The standardized mean difference (SMD) and 95% confidence interval (CI) were applied to estimate the combined results of 67 studies. A meta-analysis of cardiac biomarkers was used to evaluate disease mortality and severity in COVID-19 patients.

RESULTS

A meta-analysis of 7812 patients revealed that patients with high levels of cardiac troponin I (SMD = 0.81 U/L, 95% CI = 0.14-1.48, P = 0.017), cardiac troponin T (SMD = 0.78 U/L, 95% CI = 0.07-1.49, P = 0.032), high-sensitive cardiac troponin I (SMD = 0.66 pg/mL, 95% CI = 0.51-0.81, P < 0.001), high-sensitive cardiac troponin T (SMD = 0.93 U/L, 95% CI = 0.21-1.65, P = 0.012), creatine kinase-MB (SMD = 0.54 U/L, 95% CI = 0.39-0.69, P < 0.001), and myoglobin (SMD = 0.80 U/L, 95% CI = 0.57-1.03, P < 0.001) were associated with prominent disease severity in COVID-19 infection. Moreover, 9532 patients with a higher serum level of cardiac troponin I (SMD = 0.51 U/L, 95% CI = 0.37-0.64, P < 0.001), high-sensitive cardiac troponin (SMD = 0.51 ng/L, 95% CI = 0.29-0.73, P < 0.001), high-sensitive cardiac troponin I (SMD = 0.51 pg/mL, 95% CI = 0.38-0.63, P < 0.001), high-sensitive cardiac troponin T (SMD = 0.85 U/L, 95% CI = 0.63-1.07, P < 0.001), creatine kinase-MB (SMD = 0.48 U/L, 95% CI = 0.32-0.65, P < 0.001), and myoglobin (SMD = 0.55 U/L, 95% CI = 0.45-0.65, P < 0.001) exhibited a prominent level of mortality from COVID-19 infection.

CONCLUSION

Cardiac biomarkers (cardiac troponin I, cardiac troponin T, high-sensitive cardiac troponin, high-sensitive cardiac troponin I, high-sensitive cardiac troponin T, creatine kinase-MB, and myoglobin) should be more frequently applied in identifying high-risk COVID-19 patients so that timely treatment can be implemented to reduce severity and mortality in COVID-19 patients.

Mortality and Clinical Interventions in Critically ill Patient With Coronavirus Disease 2019: A Systematic Review and Meta-Analysis

Objective: The aims of this systematic review and meta-analysis were to summarize the current existing evidence on the outcome of critically ill patients with COVID-19 as well as to evaluate the effectiveness of clinical interventions.

Data Sources: We searched MEDLINE, the Cochrane library, Web of Science, the China Biology Medicine disc, China National Knowledge Infrastructure, and Wanfang Data from their inception to May 15, 2021. The search strings consisted of various search terms related to the concepts of mortality of critically ill patients and clinical interventions.

Study Selection: After eliminating duplicates, two reviewers independently screened all titles and abstracts first, and then the full texts of potentially relevant articles were reviewed to identify cohort studies and case series that focus on the mortality of critically ill patients and clinical interventions.

Main Outcomes and Measures: The primary outcome was the mortality of critically ill patients with COVID-19. The secondary outcomes included all sorts of supportive care.

Results: There were 27 cohort studies and six case series involving 42,219 participants that met our inclusion criteria. All-cause mortality in the intensive care unit (ICU) was 35% and mortality in hospital was 32% in critically ill patients with COVID-19 for the year 2020, with very high between-study heterogeneity (I² = 97%; p < 0.01). In a subgroup analysis, the mortality during ICU hospitalization in China was 39%, in Asia—except for China—it was 48%, in Europe it was 34%, in America it was 15%, and in the Middle East it was 39%. Non-surviving patients who had an older age [−8.10, 95% CI (−9.31 to −6.90)], a higher APACHE II score [−4.90, 95% CI (−6.54 to −3.27)], a higher SOFA score [−2.27, 95% CI (−2.95 to −1.59)], and a lower PaO₂/FiO₂ ratio [34.77, 95% CI (14.68 to 54.85)] than those who survived. Among clinical interventions, invasive mechanical ventilation [risk ratio (RR) 0.49, 95% CI (0.39–0.61)], kidney replacement therapy [RR 0.34, 95% CI (0.26–0.43)], and vasopressor [RR 0.54, 95% CI (0.34–0.88)] were used more in surviving patients.

Conclusions: Mortality was high in critically ill patients with COVID-19 based on low-quality evidence and regional difference that existed. The early identification of critical characteristics and the use of support care help to indicate the outcome of critically ill patients.