Myocardial Involvement After Hospitalization for COVID-19 Complicated by Troponin Elevation: A Prospective, Multicenter, Observational Study
Authors: Artico Jessica , Shiwani Hunain , Moon James C. , Gorecka Miroslawa , McCann Gerry P. , Roditi Giles , Morrow Andrew , Mangion Kenneth , Lukaschuk Elena , Shanmuganathan Mayooran , Miller Christopher A. , Chiribiri Amedeo , Prasad Sanjay K. , Adam Robert D. , Singh Trisha , Bucciarelli-Ducci Chiara , Dawson Dana , Knight Daniel , Fontana Marianna , Manisty Charlotte , Treibel Thomas A. , Levelt Eylem , Arnold Ranjit , Macfarlane Peter W. , Young Robin , McConnachie Alex , Neubauer Stefan , Piechnik Stefan K. , Davies Rhodri H. , Ferreira Vanessa M. , Dweck Marc R. , Berry Colin ,   OxAMI (Oxford Acute Myocardial Infarction Study) Investigators; COVID-HEART Investigators†, Greenwood John P. 
Published: February 2023

Background:
Acute myocardial injury in hospitalized patients with coronavirus disease 2019 (COVID-19) has a poor prognosis. Its associations and pathogenesis are unclear. Our aim was to assess the presence, nature, and extent of myocardial damage in hospitalized patients with troponin elevation.

Methods:
Across 25 hospitals in the United Kingdom, 342 patients with COVID-19 and an elevated troponin level (COVID+/troponin+) were enrolled between June 2020 and March 2021 and had a magnetic resonance imaging scan within 28 days of discharge. Two prospective control groups were recruited, comprising 64 patients with COVID-19 and normal troponin levels (COVID+/troponin−) and 113 patients without COVID-19 or elevated troponin level matched by age and cardiovascular comorbidities (COVID−/comorbidity+). Regression modeling was performed to identify predictors of major adverse cardiovascular events at 12 months.

Results:

Of the 519 included patients, 356 (69%) were men, with a median (interquartile range) age of 61.0 years (53.8, 68.8). The frequency of any heart abnormality, defined as left or right ventricular impairment, scar, or pericardial disease, was 2-fold greater in cases (61% [207/342]) compared with controls (36% [COVID+/troponin−] versus 31% [COVID−/comorbidity+];
P
<0.001 for both). More cases than controls had ventricular impairment (17.2% versus 3.1% and 7.1%) or scar (42% versus 7% and 23%;
P
<0.001 for both). The myocardial injury pattern was different, with cases more likely than controls to have infarction (13% versus 2% and 7%;
P
<0.01) or microinfarction (9% versus 0% and 1%;
P
<0.001), but there was no difference in nonischemic scar (13% versus 5% and 14%;
P
=0.10). Using the Lake Louise magnetic resonance imaging criteria, the prevalence of probable recent myocarditis was 6.7% (23/342) in cases compared with 1.7% (2/113) in controls without COVID-19 (
P
=0.045). During follow-up, 4 patients died and 34 experienced a subsequent major adverse cardiovascular event (10.2%), which was similar to controls (6.1%;
P
=0.70). Myocardial scar, but not previous COVID-19 infection or troponin, was an independent predictor of major adverse cardiovascular events (odds ratio, 2.25 [95% CI, 1.12–4.57];
P
=0.02).

Conclusions:
Compared with contemporary controls, patients with COVID-19 and elevated cardiac troponin level have more ventricular impairment and myocardial scar in early convalescence. However, the proportion with myocarditis was low and scar pathogenesis was diverse, including a newly described pattern of microinfarction.

Registration:

URL:
https://www.isrctn.com
; Unique identifier: 58667920.