Carlo Mario Lombardi1, Valentina Carubelli1, Annamaria Iorio2, Riccardo M Inciardi1, Antonio Bellasi3, Claudia Canale4, Rita Camporotondo5, Francesco Catagnano6, Laura A Dalla Vecchia7, Stefano Giovinazzo4, Gloria Maccagni1,8, Massimo Mapelli9,10, Davide Margonato6,11, Luca Monzo12,13, Vincenzo Nuzzi14, Chiara Oriecuia15,16, Giulia Peveri10,15, Andrea Pozzi2, Giovanni Provenzale17, Filippo Sarullo18, Daniela Tomasoni1, Pietro Ameri4, Massimiliano Gnecchi5,19, Sergio Leonardi5,19, Marco Merlo14, Piergiuseppe Agostoni9,10, Stefano Carugo17, Gian Battista Danzi8, Marco Guazzi20,21, Maria Teresa La Rovere22, Andrea Mortara6, Massimo Piepoli23,24, Italo Porto4, Gianfranco Sinagra14, Maurizio Volterrani25, Claudia Specchia15, Marco Metra1, Michele Senni2. 1. Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy. 2. Cardiology Unit, Cardiovascular Department, Papa Giovanni XXIII Hospital-Bergamo, Bergamo, Italy. 3. Innovation and Brand Reputation Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy. 4. IRCCS Ospedale Policlinico San Martino-IRCCS Italian Cardiovascular Network, Department of Internal Medicine, University of Genova, Genova, Italy. 5. Intensive Cardiac Care Unit, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy. 6. Cardiology Department, Policlinico di Monza, Monza, Italy. 7. Istituti Clinici Scientifici Maugeri, IRCCS, Dipartimento di Cardiologia, Istituto Scientifico di Milano, Milan, Italy. 8. Division of Cardiology, Ospedale di Cremona, Cremona, Italy. 9. Centro Cardiologico Monzino, IRCCS, Milan, Italy. 10. Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy. 11. Department of Cardiology, University of Pavia, Pavia, Italy. 12. Istituto Clinico Casal Palocco, Rome, Italy. 13. Policlinico Casilino, Rome, Italy. 14. Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), and Department of Medical Surgical and Health Sciences, University of Trieste, Trieste, Italy. 15. Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy. 16. Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy. 17. Division of Cardiology, Ospedale San Paolo, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy. 18. Cardiovascular Rehabilitation Unit, Buccheri La Ferla Fatebenefratelli Hospital, Palermo, Italy. 19. Department of Molecular Medicine, Cardiology Unit, University of Pavia, Pavia, Italy. 20. Heart Failure Unit, Cardiology Department, University of Milan, Milan, Italy. 21. IRCCS Policlinico San Donato, Milan, Italy. 22. Istituti Clinici Scientifici Maugeri, IRCCS, Dipartimento di Cardiologia, Istituto Scientifico di Montescano, Pavia, Italy. 23. Heart Failure Unit, Guglielmo da Saliceto Hospital, AUSL Piacenza, Piacenza, Italy. 24. Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy. 25. Department of Cardiovascular and Respiratory Sciences, IRCCS, San Raffaele Pisana Rome, Rome, Italy.
Abstract
IMPORTANCE: Myocardial injury, detected by elevated plasma troponin levels, has been associated with mortality in patients hospitalized with coronavirus disease 2019 (COVID-19). However, the initial data were reported from single-center or 2-center studies in Chinese populations. Compared with these patients, European and US patients are older, with more comorbidities and higher mortality rates. OBJECTIVE: To evaluate the prevalence and prognostic value of myocardial injury, detected by elevated plasma troponin levels, in a large population of White Italian patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS: This is a multicenter, cross-sectional study enrolling consecutive patients with laboratory-confirmed COVID-19 who were hospitalized in 13 Italian cardiology units from March 1 to April 9, 2020. Patients admitted for acute coronary syndrome were excluded. Elevated troponin levels were defined as values greater than the 99th percentile of normal values. MAIN OUTCOMES AND MEASURES: Clinical characteristics and outcomes stratified as elevated or normal cardiac troponin levels at admission, defined as troponin T or troponin I at a level greater than the 99th percentile of normal values. RESULTS: A total of 614 patients with COVID-19 were included in this study (mean age [SD], 67 [13] years; 70.8% male), of whom 148 patients (24.1%) died during the hospitalization. Elevated troponin levels were found in 278 patients (45.3%). These patients were older (mean [SD] age, 64.0 [13.6] years vs 71.3 [12.0] years; P < .001) and had higher prevalence of hypertension (168 patients [50.5%] vs 182 patients [65.9%]; P < .001), heart failure (24 [7.2%]; 63 [22.8%]; P < .001), coronary artery disease (50 [15.0%] vs 87 [31.5%]; P < .001), and atrial fibrillation (33 [9.9%] vs 67 [24.3%]; P < .001). Elevated troponin levels were associated with an increased in-hospital mortality (37% vs 13%; HR, 1.71 [95% CI, 1.13-2.59]; P = .01 via multivariable Cox regression analysis), and this was independent from concomitant cardiac disease. Elevated troponin levels were also associated with a higher risk of in-hospital complications: heart failure (44 patients [19.2%] vs 7 patients [2.9%]; P < .001), sepsis (31 [11.7%] vs 21 [6.4%]; P = .03), acute kidney failure (41 [20.8%] vs 13 [6.2%]; P < .001), multiorgan failure (21 [10.9%] vs 6 [2.9%]; P = .003), pulmonary embolism (27 [9.9%] vs 17 [5.2%]; P = .04), delirium (13 [6.8%] vs 3 [1.5%]; P = .02), and major bleeding (16 [7.0%] vs 4 [1.6%]; P = .008). CONCLUSIONS AND RELEVANCE: In this multicenter, cross-sectional study of Italian patients with COVID-19, elevated troponin was an independent variable associated with in-hospital mortality and a greater risk of cardiovascular and noncardiovascular complications during a hospitalization for COVID-19.
IMPORTANCE: Myocardial injury, detected by elevated plasma troponin levels, has been associated with mortality in patients hospitalized with coronavirus disease 2019 (COVID-19). However, the initial data were reported from single-center or 2-center studies in Chinese populations. Compared with these patients, European and US patients are older, with more comorbidities and higher mortality rates. OBJECTIVE: To evaluate the prevalence and prognostic value of myocardial injury, detected by elevated plasma troponin levels, in a large population of White Italian patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS: This is a multicenter, cross-sectional study enrolling consecutive patients with laboratory-confirmed COVID-19 who were hospitalized in 13 Italian cardiology units from March 1 to April 9, 2020. Patients admitted for acute coronary syndrome were excluded. Elevated troponin levels were defined as values greater than the 99th percentile of normal values. MAIN OUTCOMES AND MEASURES: Clinical characteristics and outcomes stratified as elevated or normal cardiac troponin levels at admission, defined as troponin T or troponin I at a level greater than the 99th percentile of normal values. RESULTS: A total of 614 patients with COVID-19 were included in this study (mean age [SD], 67 [13] years; 70.8% male), of whom 148 patients (24.1%) died during the hospitalization. Elevated troponin levels were found in 278 patients (45.3%). These patients were older (mean [SD] age, 64.0 [13.6] years vs 71.3 [12.0] years; P < .001) and had higher prevalence of hypertension (168 patients [50.5%] vs 182 patients [65.9%]; P < .001), heart failure (24 [7.2%]; 63 [22.8%]; P < .001), coronary artery disease (50 [15.0%] vs 87 [31.5%]; P < .001), and atrial fibrillation (33 [9.9%] vs 67 [24.3%]; P < .001). Elevated troponin levels were associated with an increased in-hospital mortality (37% vs 13%; HR, 1.71 [95% CI, 1.13-2.59]; P = .01 via multivariable Cox regression analysis), and this was independent from concomitant cardiac disease. Elevated troponin levels were also associated with a higher risk of in-hospital complications: heart failure (44 patients [19.2%] vs 7 patients [2.9%]; P < .001), sepsis (31 [11.7%] vs 21 [6.4%]; P = .03), acute kidney failure (41 [20.8%] vs 13 [6.2%]; P < .001), multiorgan failure (21 [10.9%] vs 6 [2.9%]; P = .003), pulmonary embolism (27 [9.9%] vs 17 [5.2%]; P = .04), delirium (13 [6.8%] vs 3 [1.5%]; P = .02), and major bleeding (16 [7.0%] vs 4 [1.6%]; P = .008). CONCLUSIONS AND RELEVANCE: In this multicenter, cross-sectional study of Italian patients with COVID-19, elevated troponin was an independent variable associated with in-hospital mortality and a greater risk of cardiovascular and noncardiovascular complications during a hospitalization for COVID-19.
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