A total of 2421 patients were hospitalized due to confirmed COVID-19 infection, of whom 501 (20.7%) had cardiac involvement. Of the 501 patients, 396 (79%) had evidence of ACI. Just more than half (n = 272, 54.3%) were male, the mean age was 67.5 (SD = 15.6) years. The median total duration of hospital stay was 13 days (interquartile range [IQR]: 7–26 days), and the median length of ICU stay was one day (IQR: 0–13) [Table 1].
There was no significant difference between the prevalence of ACI between males and females. The mean age of the group with ACI was significantly higher compared to the group without ACI (mean = 68.7 vs. 63.1; p = 0.003). The ACI group had a significantly longer total length of hospital stay (median = 15 vs. 9; p < 0.001) and length of ICU stay (median = 4 vs. 0; p < 0.001).
Table 1
| Total (n = 501) | Non-ACI (n = 105) | ACI (n = 396) | P - value |
Male, n (%) | 272 (54.3) | 63 (60) | 209 (52.8) | 0.185 |
Female, n (%) | 229 (45.71) | 42 (40) | 187 (47.2) | |
Age, mean (SD) | 67.5 (15.6) | 63.1 (19.2) | 68.7 (14.3) | 0.003 |
TLOHS, median days (IQR) | 13 (7–26) | 9 (5.5–17.5) | 15 (8–27) | < 0.001 |
LOICUS, median days (IQR) | 1 (0–13) | 0 (0–1) | 4 (0–15) | < 0.001 |
ACI, acute cardiac injury; TLOH, total length of hospital stay; LOICUS, length of intensive care unit stay; SD, standard deviation; IQR, interquartile range
Overall, compared to the group with no ACI, diabetes mellitus (75.3% vs. 60%; p = 0.003), known cardiovascular disease (48.2% vs. 37.1; p = 0.042), chronic kidney disease (32.3 vs. 16.2; p < 0.001), and chronic lung disease (22.2% vs. 12.4%; p = 0.02) were significantly more prevalent in the patients with ACI. No significant difference between the two groups was noted regarding smoking, hypertension, cerebrovascular disease, heart failure, malignancy, vaccination status, body mass index, HgbA1c, or dyslipidemia. The ACI group had a lower percentage of vaccination in the first and second doses, but it was not statistically significant [Table 2].
Table 2
| Total (n = 501) | Non-ACI (n = 105) | ACI (n = 396) | P - value |
BMI, mean (SD) | 29.9 (7.60) | 30 (7) | 29.9 (7.8) | 0.579 |
Diabetes mellitus | 361 (72.1) | 63 (60) | 298 (75.3) | 0.003 |
HgbA1c, median (IQR) | 7.2 (6.2–9.1) | 6.8 (5.9–8.8) | 7.3 (6.2–9.1) | 0.212 |
HTN | 364 (72.7) | 72 (68.6) | 292 (73.7) | 0.296 |
CVD | 230 (45.9) | 39 (37.1) | 191 (48.2) | 0.042 |
Cerebrovascular disease, | 99 (19.8) | 28 (26.7) | 71 (17.9) | 0.052 |
HF | 119 (23.8) | 21 (20) | 98 (24.8) | 0.303 |
Dyslipidemia | 125 (25.0) | 28 (26.7) | 97 (24.5) | 0.649 |
Smoking | 44 (8.8) | 14 (13.3) | 30 (7.6) | 0.077 |
Malignancy | 77 (15.4) | 19 (18.1) | 58 (14.7) | 0.392 |
CKD | 145 (29.0) | 17 (16.2) | 128 (32.3) | < 0.001 |
CLD | 101 (20.2) | 13 (12.4) | 88 (22.2) | 0.02 |
Not vaccinated | 468 (93.4) | 100 (95.2) | 368 (92.9) | 0.581 |
1 dose | 17 (3.4) | 2 (1.9) | 15 (3.8) | |
2 doses | 16 (3.2) | 3 (2.9) | 13 (3.3) | |
ACI, acute cardiac injury; BMI, body mass index; SD, standard deviation; IQR, interquartile range; HTN, hypertension; CVD, cardiovascular disease; HF, heart failure; CKD, chronic kidney disease; CLD, chronic lung disease. Variables are represented with numbers and frequencies unless otherwise stated.
The group without ACI presented more frequently with vomiting than patients who suffered from ACI (21.9% vs. 13.6%; p = 0.044). Other symptoms, including fever, cough, dyspnea, diarrhea, or muscle aches did not have an association with ACI. Patients with ACI had a higher incidence of bilateral lobe infiltrates on chest X-ray (77.8% vs. 60%; p < 0.001) and cardiomegaly (60.6% vs. 44.8%; p = 0.004). No difference was noted in the occurrence of pulmonary edema or pleural effusion. The major echocardiography findings were left ventricular dysfunction, mitral valve regurgitation, right ventricular dilation, and right ventricular dysfunction. No significant difference was noted between the two groups regarding the echocardiograph findings. The two major findings on computed tomography (CT) were ground glass opacity and consolidation. The ECG findings include bundle branch block, ST-elevation, QTc prolongation, atrial fibrillation, and T-wave inversion. These findings were more prevalent in the ACI patients than the patients without ACI, although the difference was not statistically significant [Table 3].
Table 3
Clinical presentation and imaging
| Total (n = 501) | Non-ACI (n = 105) | ACI (n = 396) | P - value |
Symptoms: Fever | 289 (57.7) | 64 (61) | 225 (56.8) | 0.445 |
Cough | 293 (58.5) | 58 (55.2) | 235 (59.3) | 0.449 |
Dyspnea | 312 (62.3) | 66 (62.9) | 246 (62.1) | 0.89 |
Diarrhea | 70 (14.0) | 13 (12.4) | 57 (14.4) | 0.592 |
Vomiting | 77 (15.4) | 23 (21.9) | 54 (13.6) | 0.044 |
Muscle ache | 64 (12.8) | 18 (17.1) | 46 (11.6) | 0.144 |
ECG findings: | | | | |
Bundle branch block | 29 (5.8) | 5 (4.8) | 24 (6.1) | 0.605 |
ST-elevation | 17 (6.4) | 1 (2) | 16 (7.9) | 0.098 |
QTc prolongation | 38 (14.9) | 9 (18) | 29 (14.2) | 0.501 |
Atrial fibrillation | 63 (23.8) | 8 (16) | 55 (25.6) | 0.138 |
T-wave inversion | 34 (6.8) | 7 (6.7) | 27 (6.8) | 0.956 |
X-ray findings: | | | | |
Bilateral infiltrates | 371 (74.1) | 63 (60) | 308 (77.8) | < 0.001 |
Pleural effusion | 227 (45.3) | 43 (41) | 184 (46.5) | 0.312 |
Cardiomegaly | 287 (57.3) | 47 (44.8) | 240 (60.6) | 0.004 |
Pulmonary edema | 89 (17.8) | 16 (15.2) | 73 (18.4) | 0.44 |
CT findings: | | | | |
Ground glass opacity | 75 (15.0) | 15 (14.3) | 60 (15.2) | 0.824 |
Consolidation | 47 (9.4) | 6 (5.7) | 41 (10.4) | 0.127 |
Echo findings: | | | | |
Right ventricular dilation | 14 (2.8) | 3 (2.9) | 11 (2.8) | 0.965 |
Right ventricular dysfunction | 37 (7.4) | 1 (1) | 15 (3.8) | 0.096 |
Left ventricular dysfunction | 16 (3.2) | 8 (7.6) | 29 (7.3) | 0.918 |
Mitral valve regurgitation | 31 (6.2) | 5 (4.8) | 26 (6.6) | 0.483 |
ACI, acute cardiac injury; CT, computed tomography; Echo, echocardiograph. All variables are represented as numbers and frequencies.
Patients with ACI had a higher respiratory rate (RR) (median = 23; IQR: 20–30 vs. median = 22, IQR: 20–27; p = 0.012) and a lower SpO2 (median = 95; IQR: 90–98 vs. median = 97; IQR: 93–99; p = 0.004).
High sensitivity cardiac troponin (median = 35.7; IQR: 16–40 vs. median = 8.2; IQR = 3.6–14.5; p < 0.001) was significantly higher in the patients with ACI. Patients with ACI had a higher white blood count (WBC) (median = 6.7 vs. 5.7; p = 0.023), higher procalcitonin (median = 0.22; IQR: 0.1–0.7 vs. median = 0.1; IQR: 0.1–0.2; p < 0.001), abnormal liver function test with aspartate aminotransferase (AST) (median = 36, IQR: 25–54 Vs. median = 27; IQR: 20–41; p < 0.001), lactate dehydrogenase (LDH) (median = 377; IQR: 274–513 vs. median = 315; IQR: 222–403; p < 0.001). and more prolonged partial thrombin time (PTT) (median = 34; IQR: 29.8–38 vs. median = 33; IQR: 28–36; p = 0.008 [Table 4].
Table 4
| Total (n = 501) | Non-ACI (n = 105) | ACI (n = 396) | P - value |
HR (bpm) | 90 (80–103) | 88 (76.5–102) | 91 (81.3–103) | 0.113 |
SBp (mmHg) | 128 (113–145.5) | 125 (109–145) | 130 (114.3–146) | 0.481 |
RR (bpm) | 23 (20–28) | 22 (20–27) | 23 (20–30) | 0.012 |
SpO2 (%) | 95 (91–98) | 97 (93–99) | 95 (90–98) | 0.004 |
WBC (x109/L) | 6.6 (4.6–9.4) | 5.7 (4.3–8.7) | 6.7 (4.8–9.6) | 0.023 |
lymphocyte count (x109/L) | 1.11 (0.76–1.64) | 1.105 (0.8–1.6) | 1.11 (0.7–1.6) | 0.989 |
Hgb (g/dL) | 12.1 (10.4–13.7) | 12.1 (9.8–13.7) | 12.1 (10.6–13.7) | 0.441 |
platelet count (x109/L) | 216 (157–286) | 229.5 (159.3–287.5) | 212 (157–286) | 0.256 |
Procalcitonin (µg/L) | 0.18 (0.08–0.62) | 0.1 (0.1–0.2) | 0.22 (0.1–0.7) | < 0.001 |
ESR (mm/h) | 79 (53–109) | 65 (42–106.5) | 80.5 (57–111) | 0.313 |
eGFR (mL/min/1.73m2) | 51 (23.75, 86.25) | 74 (48–95) | 48 (23–85) | 0.071 |
Albumin (g/L) | 35 (33–39) | 36 (33–39) | 35 (32–39) | 0.228 |
AST (IU/L) | 34 (24–52) | 27 (20–41) | 36 (25–54) | < 0.001 |
ALT (U/L) | 23 (15–39) | 21 (14–36) | 24 (16–40) | 0.102 |
LDH (U/L) | 350 (264–488.75) | 315 (222–403) | 377 (274–513) | < 0.001 |
Hs-cTnI (pg/mL) | 25.8 (10.8–71) | 8.2 (3.6–14.5) | 35.7 (15.5–90.3) | < 0.001 |
Highest recorded Hs-cTnI | 97 (34.8–381.95) | 9.8 (4.6–18.7) | 140.8 (56.9–617.6) | < 0.001 |
NT-proBNP (pg/mL) | 131.5 (56–376.25) | 132 (62–256) | 128 (56–515) | 0.365 |
Creatine kinase (IU/L) | 97 (47–215) | 76 (32–187) | 101 (51–221) | 0.043 |
D-dimer (mg/L) | 1.18 (0.6–2.57) | 0.97 (0.5–2.9) | 1.2 (0.6–2.5) | 0.158 |
PTT (s) | 33 (29–37) | 33 (28–36) | 34 (29.8–38) | 0.008 |
ACI, acute cardiac injury; SBp, systolic blood pressure; HR, heart rate; SpO2, peripheral oxygen saturation; WBC, white blood cell; ESR, erythrocyte sedimentation rate; Hgb, hemoglobin; eGFR, estimated glomerular filtration rate; ALT, alanine aminotransferase; Hs-cTnI; high sensitivity cardiac troponin I; AST, aspartate aminotransferase; PTT, partial prothrombin time; LDH, lactate dehydrogenase. All variables are represented as median and interquartile range; BNP, brain natriuretic peptide. |
Patients with ACI were significantly more likely to require mechanical ventilation (55.6% Vs. 21.9%; p < 0.001) and receive systemic steroids (75% vs. 64.8%; p = 0.004). The patients with evidence of ACI were more likely to suffer from complications such as pneumonia (80% vs. 65.7%; p = 0.003), ARDS (33.1% vs. 8.6%; p < 0.001), complete picture of sepsis (24.2% vs. 9.5%; p < 0.001), arrhythmias (42% vs. 30.5%; p = 0.22), and cardiogenic shock (5.3% vs. 0%; p = 0.001). In addition, the patients with ACI were more likely to be admitted to the ICU, more likely to suffer from cardiac arrest, and more likely to die (57.1% vs. 26.7%, 38.9% vs. 13.3%, and 38.1% vs. 11.4%, respectively; p < 0.001) compared to patients with no evidence of ACI. The median total length of hospital stay (15 days; IQR: 8–27 vs. 9 days; IQR: 5.5–17.5; P < 0.001) and median length of ICU stay (4 days; IQR: 0–15 vs. 0 days IQR: 0–1; P < 0.001) were significantly longer for the ACI patients [Table 5].
Table 5
Management and complications
| Total (n = 501) | Non-ACI (n = 105) | ACI (n = 396) | P - value |
Mechanical ventilation | 243 (48.5) | 23 (21.9) | 220 (55.6) | < 0.001 |
Systemic steroids | 365 (72.9) | 68 (64.8) | 297 (75) | 0.04 |
Immunoglobulin | 24 (4.8) | 7 (6.7) | 17 (4.3) | 0.33 |
Acute kidney injury | 153 (30.5) | 0 (0) | 21 (5.3) | < 0.001 |
Cardiogenic shock | 21 (4.2) | 0 (0) | 21 (5.3) | 0.001 |
Myocarditis | 8 (1.6) | 0 (0) | 8 (2) | 0.214 |
Thromboembolism | 52 (10.4) | 9 (8.6) | 43 (10.9) | 0.486 |
Arrhythmias | 201 (40.1) | 32 (30.5) | 169 (42.7) | 0.022 |
Pneumonia | 386 (77.0) | 69 (65.7) | 317 (80.1) | 0.003 |
Sepsis | 106 (21.2) | 10 (9.5) | 96 (24.2) | < 0.001 |
ARDS | 140 (28) | 9 (8.6) | 131 (33.1) | < 0.001 |
ADHF | 16 (3.2) | 6 (6.1) | 10 (2.6) | 0.105 |
ICU admission | 254 (50.7) | 28 (26.7) | 226 (57.1) | < 0.001 |
Cardiac arrest | 168 (33.5) | 14 (13.3) | 154 (38.9) | < 0.001 |
Death | 163 (32.5) | 12 (11.4) | 151 (38.1) | < 0.001 |
ACI, acute cardiac injury; ARDS, acute respiratory distress syndrome; ADHF, acute decompensated heart failure ICU, intensive care unit. All variables are represented as numbers and frequencies. |
The results of the multivariate analysis show that an elevated AST, creatine kinase, and D-dimer were associated with an increased risk of ACI (adjusted OR = 3.14, 1.05, and 1.51, respectively). In addition, cardiomegaly on X-ray was significantly associated with ACI (adjusted OR = 1.73; 95%CI: 1.11– 2.72) [Table 6].
Table 6
Univariate and multivariate regression analysis of the risk factors associated with cardiac injury
| Unadjusted OR (95% CI) | P - value | Adjusted OR1 (95% CI) | P - value |
Elevated BNP | 0.79 (0.51–1.22) | 0.291 | 0.66 (0.42–1.04) | 0.070 |
Elevated AST | 2.46 (1.56–3.87) | < 0.001 | 3.14 (1.94–5.10) | < 0.001 |
Elevated Creatine kinase | 1.35 (0.80–2.29) | 0.265 | 1.05 (0.66–1.67) | 0.823 |
Elevated D-dimer | 1.58 (1.02–2.46) | 0.042 | 1.51 (0.96–2.38) | 0.076 |
Cardiomegaly on X-ray | 1.90 (1.23–2.94) | 0.004 | 1.73 (1.11–2.72) | 0.016 |
OR, odds ratio; CVD, cardiovascular disease; CKD, chronic kidney disease; CL, chronic lung disease; AST, aspartate aminotransferase; BNP, brain natriuretic peptide. 1Adjusted for age, gender, diabetes, and chronic kidney disease. |
The second multivariate analysis model results show that elevated troponin, AST, D-dimer, and LDH were significantly associated with increased mortality risk (adjusted OR = 4.73, 2.72, 1.79, and 2.3, respectively) [Table 7].
Table 7
Univariate and multivariate regression analysis of the risk factors associated with in-hospital mortality
| Unadjusted OR (95% CI) | P - value | Adjusted OR1 (95% CI) | P - value |
Elevated Hs-cTnI | 4.77 (2.53–9.00) | < 0.001 | 4.73 (2.49–8.98) | < 0.001 |
Elevated BNP | 0.83 (0.57–1.21) | 0.340 | 0.79 (0.54–1.15) | 0.220 |
Elevated AST | 2.78 (1.88–4.10) | < 0.001 | 2.72 (1.83–4.04) | < 0.001 |
Elevated Creatine kinase | 1.38 (0.90–2.11) | 0.140 | 1.30 (0.84–2.01) | 0.245 |
Elevated D-dimer | 1.79 (1.18–2.72) | 0.006 | 1.79 (1.17–2.72) | 0.007 |
Elevated LDH | 2.34 (1.52–3.61) | < 0.001 | 2.30 (1.50–3.60) | < 0.001 |
OR, odds ratio; CVD, cardiovascular disease; CKD, chronic kidney disease; CLD, chronic lung disease; AST, aspartate aminotransferase; BNP, brain natriuretic peptide; LDH, lactate dehydrogenase; Hs-cTnI, high sensitivity cardiac troponin I. 1Adjusted for age and gender. |
The Kaplan-Meier method was used to estimate the cumulative mortality proportions for troponin [Figure 1]. The patients were divided into “normal” and “elevated” based on the levels of troponin. Patients with ACI had significantly shorter median survival duration than the patients without ACI (70 vs. 33 days; p = 0.001). Additionally, the hazard ratio for troponin adjusted for age and gender was 2.11 (p = 0.013).