Death,discharge and arrhythmias among patients with COVID-19 and cardiac injury

BACKGROUND:Cardiac injury is common in severe coronavirus disease 2019 (COVID-19) and is associated with poor outcomes. We aimed to study predictors of in-hospital death, characteristics of arrhythmias and the effects of QT-prolonging therapy in patients with cardiac injury.METHODS:We conducted a retrospective cohort study involving patients with severe COVID-19 who were admitted to Tongji Hospital in Wuhan, China, between Jan. 29 and Mar. 8, 2020. Among patients who had cardiac injury, which we defined as an elevated level of cardiac troponin I (cTnI), we identified demographic and clinical characteristics associated with mortality and need for invasive ventilation.RESULTS:Among 1284 patients with severe COVID-19, 1159 had a cTnI level measured on admission to hospital, of whom 170 (14.7%) had results that showed cardiac injury. We found that mortality was markedly higher in patients with cardiac injury (71.2% v. 6.6%, p < 0.001). We determined that initial cTnI (per 10-fold increase, hazard ratio HR] 1.32, 95% confidence interval CI] 1.06–1.66) and peak cTnI level during illness (per 10-fold increase, HR 1.70, 95% CI 1.38–2.10) were associated with poor survival. Peak cTnI was also associated with the need for invasive ventilation (odds ratio 3.02, 95% CI 1.92–4.98). We found arrhythmias in 44 of the 170 patients with cardiac injury (25.9%), including 6 patients with ventricular tachycardia or fibrillation, all of whom died. We determined that patients who received QT-prolonging drugs had longer QTc intervals than those who did not receive them (difference in medians, 45 ms, p = 0.01), but such treatment was not independently associated with mortality (HR 1.04, 95% CI 0.69–1.57).INTERPRETATION:We found that in patients with COVID-19 and cardiac injury, initial and peak cTnI levels were associated with poor survival, and peak cTnI was a predictor of need for invasive ventilation. Patients with COVID-19 warrant assessment for cardiac injury and monitoring, especially if therapy that can prolong repolarization is started.Trial registration:Chinese Clinical Trial Registry, No. ChiCTR2000031301.

Poor outcomes have been reported recently in patients with pneumonia associated with coronavirus disease 2019 (COVID-19) and cardiac injury.^1–3 These reports did not characterize patients as dead or discharged from hospital because the COVID-19 pandemic had not completed its course at the time of reporting.^1–3 The initial findings suggested that patients admitted to the intensive care unit (ICU) had an arrhythmia burden of 44.4%;⁴ however, the exact nature of these arrhythmias was not characterized. Knowing now that cardiac injury is an important predictor of death, characterizing arrhythmias and determining independent predictors of outcome may allow health care providers to implement aggressive therapy and assign accurate probabilities for the outcome, which can be used to identify high-risk groups. In addition, such data would assist in decisions on discharge from the emergency department, therapy with QT-prolonging drugs, rhythm monitoring and triage of ventilators and ICU beds.⁵In Wuhan, China, the initial outbreak of COVID-19 has run its full course, which provides an opportunity to characterize outcomes and inform strategy for Europe and North America. As such, we evaluated 170 patients from Wuhan who had cardiac injury that was diagnosed early during their admission for pneumonia associated with COVID-19 for the outcomes of death, discharge and arrhythmias. We also characterized the effect of QT-prolonging drugs in these patients. We determined independent predictors of death and mechanical ventilation in this population with cardiac injury and severe COVID-19.