Correlations of Before and After Event Echocardiographic Parameters with Troponin and BNP in Hospitalized COVID-19 Patients With Cardiovascular Events.

To the Editor:

Right and left ventricular (RV and LV, respectively) dysfunction were found to be significantly related to adverse outcomes in COVID-19 patients. 1-7 There is no study to specifically evaluate echocardiography in the cohort of patients who suffered cardiovascular events. We examined echocardiographic parameters before or after cardiovascular events to predict myocardial injuries so that clinicians could be better prepared to manage pending cardiovascular events or their sequalae.

Forty-nine patients from a multicenter, retrospective database of 700 adult patients hospitalized with a diagnosis of COVID-19 from March 7, 2020, to July 1, 2020 who suffered at least one cardiovascular event and underwent echocardiography were selected. 8,9 Cardiovascular events included heart failure, cardiogenic shock, acute myocardial infarction, cardiomyopathy, myocarditis, cardiac arrhythmias, cerebrovascular events, pulmonary embolism, pulmonary edema, deep vein thrombosis, and cardiac arrest. Clinical diagnoses of cardiovascular events were made by individual physicians at each site. In this cohort, 30 patients (61%) had echocardiography performed before their cardiac event, and 19 (39%) had echocardiography performed after their cardiac event. Our end points of analysis were admission troponin, peak troponin and brain natriuretic peptide (BNP) concentrations. Echocardiographic parameters and laboratory values were stratified by timing of echocardiography. Correlations between before-event echocardiographic parameters and admission troponin are detailed in Table 1 . Significant correlations were found between LV ejection fraction (EF), LV volume, mitral valve E/E’ and admission troponin. Correlations between before-event echocardiographic parameters and BNP are also shown in Table 1 . No before-event echocardiographic parameters were found to have significant correlations with BNP. Correlations of after-event echocardiographic parameters with peak troponin and BNP are detailed in Table 2 . A significant correlation was found between RV diameter and peak troponin (r = 0.98; p = 0.019); however, no after-event echocardiographic parameters were found to be significantly correlated with BNP. Thus, LV systolic and diastolic dysfunction (indicated by increased mitral valve E/E’ ratio) before a cardiovascular event were correlated with initial myocardial injury levels as indicated by admission troponin. An increase in RV size on after-event echocardiography was correlated with the maximal myocardial injury as indicated by peak troponin in COVID-19 patients.

Table 1

Pearson correlations between before-event echocardiographic parameters and log admission troponin and log brain natriuretic peptide (BNP)

	log Troponin		log BNP
Variable	ra	P value	ra	P value
LV ejection fraction, %	-0.68	<.001	-0.14	.51
LV volume, mL	0.45	.039	0.04	.87
LA volume, mL	-0.34	.14	-0.04	.89
RV diameter, cm	0.25	.28	0.42	.08
RA volume, mL	0.24	.27	0.18	.45
Ascending aorta size, cm	0.04	.91	-0.46	.35
Peak E-wave, m/s	-0.07	.74	-0.35	.09
TV TAPSE	0.07	.75	-0.05	.84
Estimated RVSP, mmHg	-0.15	.59	0.16	.54
Estimated RAP, mmHg	0.14	.60	0.32	.21
MV E' Lateral Velocity, m/s	-0.11	.60	-0.08	.71
MV E/E' Lateral	0.43	.038	0.08	.72

Abbreviations: LV, left ventricle; LA, left atrium; RV, right ventricle; RA, right atrium; TV, tricuspid valve; TAPSE, tricuspid annular plane systolic excursion; RVSP, right ventricle systolic pressure; RAP, right atrial pressure; MV, mitral valve.

Pearson correlation coefficient

Table 2

Pearson correlations between after-event echocardiographic parameters and log peak troponin and log brain natriuretic peptide (BNP)

	log Troponin		log BNP
Variable	ra	P value	ra	P value
LV ejection fraction, %	-0.20	.61	-0.41	.11
LV volume, mL	-0.65	.11	0.29	.36
LA volume, mL	-0.62	.38	-0.08	.86
RV diameter, cm	0.98	.019	0.55	.10
RA volume, mL	0.32	.54	0.22	.51
Ascending aorta size, cm	-0.42	.31	-0.39	.13
Peak E-wave, m/s	-0.79	.42	0.10	.81
TV TAPSE	0.03	.96	-0.31	.39
Estimated RVSP, mmHg	-0.06	.89	-0.35	.24
Estimated RAP, mmHg	-0.29	.63	-0.31	.33
MV E' Lateral Velocity, m/s	0.80	.10	0.51	.13
MV E/E' Lateral	-0.20	.61	-0.41	.11

Abbreviations: LV, left ventricle; LA, left atrium; RV, right ventricle; RA, right atrium; TV, tricuspid valve; TAPSE, tricuspid annular plane systolic excursion; RVSP, right ventricle systolic pressure; RAP, right atrial pressure; MV, mitral valve.

Pearson correlation coefficient

The novelties of this current study include identification of before-event echocardiographic parameters which correlates with initial myocardial injury levels and discovery of after-event echocardiographic parameters which corelates with the maximal myocardial injury levels. Changes in these echocardiographic parameters should alert physicians to imminent hemodynamic instability and mortality.

Acknowledgments

The authors acknowledge the excellent efforts of University of Louisville CERID group and Kornhauser Health Sciences Library to assist with this project.

Author Contributions: SP, LR, MK, JH had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis, including and especially any adverse effects. VS, SP, SF, HS, QX, FD, AG, TM, TA, DT, CMJ, SPC, LR, MK, FWA, JH contributed substantially to the study design, data analysis and interpretation, and the writing of the manuscript.

Stephen Furmanek, Vidyulata Salunkhe, Siddharth Pahwa, Harideep Samanapally, Pavani Nathala, Qian Xu: study design, data collection, manuscript preparation.

Stephen Furmanek MS, Qian Xu: study design, statistical analysis, manuscript preparation.

Fnu Deepti, Trevor McGuffin, Tshura Ali, Derek Titus: study design and manuscript writing.

Alex Glynn: literature review, study design, manuscript preparation.

Christopher M Jones, Arnold W Forest, Sean P. Clifford, Siddharth Pahwa, Lynn Roser, Maiying Kong, Jiapeng Huang: study design, data analysis, manuscript preparation.

Data collection was performed by the Center of Excellence for Research in Infectious Diseases (CERID) group at the University of Louisville Division of Infectious Diseases. Statistical analysis and draft writing were performed by Stephen Furmanek under the guidance of Maiying Kong. All authors have read and approved the manuscript.

Funding

This work was supported by the National Center For Advancing Translational Sciences [grant number U18TR003787]; the National Institute of Environmental Health Sciences [grant number P30 (P30ES030283)]; and Gilead Sciences COMMIT COVID-19 RFP Program [grant number IN-US-983-6063]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Gilead Sciences.

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