Cardiac Troponin I Is an Independent Predictor for Mortality in Hospitalized Patients With COVID-19
2020; Lippincott Williams & Wilkins; Volume: 142; Issue: 6 Linguagem: Inglês
10.1161/circulationaha.120.048789
ISSN1524-4539
AutoresShao-Fang Nie, Miao Yu, Tian Xie, Fen Yang, Hong-Bo Wang, Zhao-Hui Wang, Ming Li, Xing-Li Gao, Bing-Jie Lv, Shijia Wang, Xiao-Bo Zhang, Shao-Lin He, Zhi-Hua Qiu, Yu-Hua Liao, Zihua Zhou, Xiang Cheng,
Tópico(s)Sepsis Diagnosis and Treatment
ResumoHomeCirculationVol. 142, No. 6Cardiac Troponin I Is an Independent Predictor for Mortality in Hospitalized Patients With COVID-19 Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBCardiac Troponin I Is an Independent Predictor for Mortality in Hospitalized Patients With COVID-19 Shao-Fang Nie, Miao Yu, Tian Xie, Fen Yang, Hong-Bo Wang, Zhao-Hui Wang, Ming Li, Xing-Li Gao, Bing-Jie Lv, Shi-Jia Wang, Xiao-Bo Zhang, Shao-Lin He, Zhi-Hua Qiu, Yu-Hua Liao, Zi-Hua Zhou and Xiang Cheng Shao-Fang NieShao-Fang Nie Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. , Miao YuMiao Yu https://orcid.org/0000-0002-8298-1679 Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. , Tian XieTian Xie https://orcid.org/0000-0002-4310-5289 Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. , Fen YangFen Yang https://orcid.org/0000-0001-6050-9448 Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. , Hong-Bo WangHong-Bo Wang https://orcid.org/0000-0002-3547-5706 Obstetrics and Gynecology (H.-B.W.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. , Zhao-Hui WangZhao-Hui Wang https://orcid.org/0000-0002-1981-0551 Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. , Ming LiMing Li https://orcid.org/0000-0002-2118-6970 Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. , Xing-Li GaoXing-Li Gao https://orcid.org/0000-0002-2118-6970 Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. , Bing-Jie LvBing-Jie Lv https://orcid.org/0000-0003-4587-6754 Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. , Shi-Jia WangShi-Jia Wang https://orcid.org/0000-0002-1154-2791 Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. , Xiao-Bo ZhangXiao-Bo Zhang https://orcid.org/0000-0002-1138-4287 Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. , Shao-Lin HeShao-Lin He https://orcid.org/0000-0001-9961-0551 Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. , Zhi-Hua QiuZhi-Hua Qiu https://orcid.org/0000-0002-0787-5796 Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. , Yu-Hua LiaoYu-Hua Liao https://orcid.org/0000-0002-7787-2953 , Zi-Hua ZhouZi-Hua Zhou Zi-Hua Zhou, MD, PhD, Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China. Email E-mail Address: [email protected] Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. and Xiang ChengXiang Cheng Xiang Cheng, MD, PhD, Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China. Email E-mail Address: [email protected] Departments of Cardiology (S.-F.N., M.Y., T.X., F.Y., Z.-H.W., M.L., X.-L.G., B.-J.L., S.-J.W., X.-B.Z., S.-O.H., Y.-H.L., Z.-H.Z., X.C.), Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. Originally published15 Jun 2020https://doi.org/10.1161/CIRCULATIONAHA.120.048789Circulation. 2020;142:608–610Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: June 15, 2020: Ahead of Print Since December 2019, coronavirus disease 2019 (COVID-19) has caused a global pandemic with thousands of pneumonia-related deaths.1 Recently, Wang et al2 reported the existence of myocardial injury in 7.2% of all patients with COVID-19 and in 22.2% of patients admitted to the intensive care unit versus only 2.0% patients not treated in the intensive care unit. Thus, we hypothesized that cardiac troponin I (cTNI), an established biomarker of cardiac injury, may be a clinical predictor of outcomes for patients with COVID-19.Patients with laboratory-confirmed COVID-19 admitted to Union Hospital (West Campus), Huazhong University of Science and Technology from January 12 to March 12, 2020, were enrolled, and the final date of follow-up was March 20, 2020. This study was approved by the ethics committee of Union Hospital, Huazhong University of Science and Technology ([2020]0087) and conducted in accordance with the guidelines of the Declaration of Helsinki. Written informed consent was waived by the ethics commission based on the retrospective nature of the study and the emerging worldwide crisis caused by this infectious disease.A total of 311 laboratory-confirmed COVID-19 cases were included on the basis of available cTNI concentrations measured during hospitalization. The data of laboratory and imaging tests performed for the first time after admission were used for analysis. The ARCHITECTSTAT high-sensitivity troponin I assay (Abbott Laboratories) was used to measure cTnI concentrations.3 Cardiac injury was diagnosed if the level of serum cTNI with at least 1 value was above the 99th percentile upper reference limit during hospitalization. We defined the severity of COVID-19 on admission by using the Chinese management guideline for COVID-19 (version 6.0).4 The primary composite end point was all-cause death. The included patients were assigned to 1 of 2 groups according to clinical outcomes: the discharged group and the nonsurvivor group. To explore the risk factors associated with mortality, univariable and then multivariable logistic regression models (backward elimination) were applied. We chose age, sex, comorbidity, body temperature, blood oxygen saturation, disease severity, lymphocyte count, D-dimer, C-reactive protein, and cTNI as the 10 variables for our multivariable logistic regression model on the basis of our univariable analysis results and previous findings.4 With the exception of age and blood oxygen saturation, the continuous variables of laboratory and imaging indicators were included with log2 transformation and report odds ratio (OR) per doubling of concentration (Table). A 2-tailed P 37.312.622.65 (1.55–4.52)0.251.31 (0.45–3.81)Blood oxygen saturation, %*57.830.76 (0.71–0.82)10.670.85 (0.77–0.94)Disease severity Moderate1 (ref)1 (ref) Severe/critical37.6811.19 (5.18–24.20)0.431.55 (0.42–5.70)White blood cell count, ×109/L33.553.24 (2.18–4.82)Neutrophil count, ×109/L51.333.69 (2.58–5.28)Lymphocyte count, ×109/L67.500.21 (0.15–0.31)4.550.52 (0.29–0.95)Platelet count, ×109/L29.870.34 (0.23–0.50)D-Dimer, µg/mL74.442.25 (1.87–2.70)7.231.55 (1.13–2.13)Prothrombin time, s24.6140.52 (9.39–174.92)Fibrinogen, g/L5.170.67 (0.48–0.95)Total bilirubin, µmol/L20.782.13 (1.54–2.96)Alanine aminotransferase, U/L17.201.70 (1.32–2.18)Aspartate aminotransferase, U/L24.952.29 (1.65–3.17)Albumin, g/L42.860.03 (0.01–0.08)Creatinine, μmol/L14.182.16 (1.44–3.22)C-reactive protein, mg/L56.822.49 (1.97–3.16)11.901.98 (1.34–2.92)Cardiac troponin I, ng/L69.802.50 (2.02–3.10)17.661.92 (1.41–2.59)Creatine kinase-MB, ng/mL45.154.02 (2.68–6.03)Creatine kinase, U/L27.631.64 (1.36–1.96)Lactate dehydrogenase, U/L82.7419.24 (10.18–36.39)Numbers of pulmonary lobes involved6.951.90 (1.18–3.07)COVID-19 indicates coronavirus disease 2019; OR, odds ratio; and Ref, reference.* Per 1 U increase.For 311 included patients, the median age was 63 years (interquartile range [IQR], 54–70 years), and 190 (61.1%) patients were male. Overall, 62.7% of patients had at least 1 comorbidity, including hypertension, cardiovascular disease (coronary heart disease/arrhythmia/heart failure), cerebrovascular disease, chronic obstructive pulmonary disease, diabetes mellitus, malignancy, chronic kidney disease, and thyroid disease. The most common symptoms on admission were fever (77.5%), cough (32.5%), and dyspnea (24.4%). With regard to disease severity on admission, there were 101 patients (32.5%) with moderate-type, 180 (57.9%) with severe-type, and 30 (9.6%) with critical-type COVID-19. One hundred eleven patients died during hospitalization and 200 were discharged. The median time from illness onset to death was 23 days (IQR, 15–32 days). In laboratory findings, the lymphocyte count (0.5×109/L [IQR, 0.4–0.8×109/L] versus 1.2×109/L [IQR, 0.9–1.7×109/L]) was lower in the nonsurvivor group than in the discharged group. The concentrations of D-dimer (4.0 µg/mL [IQR, 1.2–8.0 µg/mL] versus 0.5 µg/mL [IQR, 0.2–1.5µg/mL]), C-reactive protein (80.2 mg/L [IQR, 48.4–121.8 mg/L] versus 8.1 mg/L [IQR, 2.4–43.6 mg/L]), and cTNI (32.5 ng/L [IQR, 11.4–304.4 ng/L] versus 2.8 ng/L [IQR, 1.5–5.8 ng/L]) in the nonsurvivor group were elevated in comparison with those in the discharged group. There were 103 patients (33.1%) with cardiac injury, including 12 patients in the discharged group and 91 patients in the nonsurvivor group. Multivariable logistic regression analysis identified cTNI concentration (OR, 1.92 [95% CI, 1.41–2.59]), lymphocyte count (OR, 0.52 [95% CI, 0.29–0.95]), C-reactive protein concentration (OR, 1.98 [95% CI, 1.34–2.92]), D-dimer concentration (OR, 1.55 [95% CI, 1.13–2.13]), comorbidity (OR, 9.07 [95% CI, 2.52–32.66]), and blood oxygen saturation (OR, 0.85 [95% CI, 0.77–0.94]) as independent risk factors for death in patients with COVID-19 (Table).Although respiratory symptoms are the primary clinical manifestations of COVID-19, a portion of patients will experience severe cardiovascular injury.2, 5 cTnI is the most important biomarker of cardiac injury. Our results indicate that the serum cTnI concentration was significantly higher in nonsurviving patients with severe acute respiratory syndrome coronavirus 2 infection than in discharged patients, and the further multivariable logistic regression identified increased cTnI concentration as an independent predictor of mortality in patients with COVID-19.This study is limited by selection bias based on cTnI measurement. The determination of whether cTnI would be measured in each case was an individual decision by the clinician. The results do not totally represent the epidemiological data of COVID-19.DisclosuresNone.Footnotes*Drs Nie, Yu, and Xie contributed equally.https://www.ahajournals.org/journal/circThe data that support the findings of this study are available from the corresponding author upon reasonable request by email.Xiang Cheng, MD, PhD, Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China. Email nathancx@hotmail.comZi-Hua Zhou, MD, PhD, Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China. Email zzhua2001@163.comReferences1. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DSC, et al. Clinical characteristics of coronavirus disease 2019 in China.N Engl J Med. 2020; 382:1708–1720. doi: 10.1056/NEJMoa2002032CrossrefMedlineGoogle Scholar2. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, Xiang H, Cheng Z, Xiong Y, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.JAMA. 2020; 323:1061–1069. doi: 10.1001/jama.2020.1585CrossrefMedlineGoogle Scholar3. Cullen L, Mueller C, Parsonage WA, Wildi K, Greenslade JH, Twerenbold R, Aldous S, Meller B, Tate JR, Reichlin T, et al. Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary syndrome.J Am Coll Cardiol. 2013; 62:1242–1249. doi: 10.1016/j.jacc.2013.02.078CrossrefMedlineGoogle Scholar4. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, Xiang J, Wang Y, Song B, Gu X, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.Lancet. 2020; 395:1054–1062. doi: 10.1016/S0140-6736(20)30566-3CrossrefMedlineGoogle Scholar5. Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, Gong W, Liu X, Liang J, Zhao Q, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China [published online March 25, 2020].JAMA Cardiol. doi: 10.1001/jamacardio.2020.0950Google Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. 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Ramos Tuarez F, Jazaerly M, Menchaca K, Kothari V, Cornett B and Chait R Negative Troponin I as a Predictor of Survival in SARS-Cov-2 (COVID-19), SSRN Electronic Journal, 10.2139/ssrn.3968917 August 11, 2020Vol 142, Issue 6 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.120.048789PMID: 32539541 Originally publishedJune 15, 2020 KeywordsbiomarkersCOVID-19heart injurieshospital mortalitypatient outcome assessmenttroponin IPDF download Advertisement SubjectsBiomarkers
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