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Cardiac injury among hospitalized Covid-19 patients tied to higher risk of death in new study

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Posted: Mar 27, 2020 12:00 PM
Updated: Mar 27, 2020 12:00 PM

Heart injury could be a common condition in patients hospitalized with Covid-19, according to a new study that also shows it's linked to a greater risk of death among those patients.

The study, published in the medical journal JAMA Cardiology on Wednesday, found that among a group of Covid-19 patients hospitalized in Wuhan China, 19.7% suffered cardiac injury, which was found to be a risk factor for dying in the hospital.

Cardiac injury, also referred to as myocardial injury, occurs when there is damage to the heart muscle, and such damage can occur when blood flow to the heart is reduced -- which is what causes a heart attack.

Cardiac damage and higher risk of early death

The new study, conducted from January to February, included data on 416 adults who were confirmed to have Covid-19 and were hospitalized at Renmin Hospital of Wuhan University in China.

The data showed that 82 of the patients, or 19.7%, had cardiac injury and 334 patients, or 80.3%, did not. Cardiac injury is defined by an elevation of a protein called troponin that can be measured in the blood, according to the American Heart Association. Troponin and other biomarkers were used to identify cardiac injury in the study.

"An elevated troponin doesn't always mean a heart attack but it does mean myocardial injury or heart damage," said Dr. Erin Michos, the associate director of preventive cardiology at Johns Hopkins Medicine in Baltimore, who was not involved in the study.

The data also revealed that the death rate was higher among patients with cardiac injury versus those without: 42 of the patients with cardiac injury, or 51.2%, died versus 15 of those without, or 4.5%.

"We know that cardiac damage is a marker for more mortality," Michos said. "This study clearly showed that even after you account for age and pre-existing cardiovascular disease, there was a still four-fold increased risk of dying. That's really important."

The new study had some limitations, including that the findings are based on observational data, and more research is needed to determine whether similar findings would emerge among a larger and more diverse group of Covid-19 patients.

Though the study showed cardiac injury is a common condition among patients hospitalized with Covid-19, it did not indicate whether Covid-19 directly causes cardiac injury. The mechanism of cardiac injury, or the process in which it occurs, among the patients with Covid-19 remains uncertain, and more evidence is needed to demonstrate whether Covid-19 directly injures the heart, the authors said.

"We need to figure out the mechanism of why do people with evidence of cardiac injury have higher morbidity or mortality? Is it related to the fact that they have underlying conditions that make them more susceptible to dying? Is it a marker of individuals that have a more robust immune response that is leading to heart damage?" said Michos of Johns Hopkins.

This and other studies suggest that those with elevated troponin, which measures cardiac injury, seem to be at a greater risk than when the elevation of other types of markers are present, such as inflammatory markers, Michos said.

The researchers also offered some ideas, writing in the study that people with preexisting cardiovascular diseases might be more susceptible to heart injury induced by Covid-19.

"Approximately 30% and 60% of patients with cardiac injury in the present study had a history of coronary heart disease and hypertension, respectively, which were significantly more prevalent than in those without cardiac injury," the researchers wrote in the study.

Also, acute inflammatory responses due to an infection can lead to reduced blood flow in patients with preexisting cardiovascular diseases, the researchers noted. They wrote that "based on these lines of evidence, we hypothesize that an intense inflammatory response superimposed on preexisting cardiovascular disease may precipitate cardiac injury."

Earlier this month, the American College of Cardiology released clinical guidance for cardiovascular care team professionals treating Covid-19 patients. In that guidance, the ACC noted that, so far, the case fatality rates for Covid-19 patients who also have cardiovascular disease is 10.5% and for those who also have hypertension, it's 6%.

A 'potentially important long-term issue'

The new study findings "make a lot of sense," Kevin Heffernan, director of the Human Performance Laboratory at Syracuse University in New York, who was not involved in the study, wrote in an email on Wednesday.

A separate study published in the New England Journal of Medicine in 2018 found a significant association between respiratory infections, especially influenza, and acute heart attack, he said.

Overall, "this is a solid and important study," said Brooks Gump, the Falk Family Endowed Professor of Public Health at Syracuse University in New York, who was not involved in the study.

When it comes to the public health impacts of Covid-19 and cardiac injury, the study suggests that "two key take-aways are that it's an important marker of those at high-risk for mortality as a consequence of Covid-19 infection and it may be an indicator of future risks associated with the cardiovascular injury from this infection, even if you recover," Gump said.

"Even though they're not dying from that cardiac injury, something about that biomarker is providing some prognostic value beyond other risk factors that were controlled, so it could still be important in terms of identifying high-risk patients that enter the hospital with Covid-19," Gump said.

"The other key here is the potentially important long-term issue," he said. "Many patients who pull through may still have cardiac injury and associated long-term cardiovascular issues as a consequence of Covid-19 infection."

Drs. Chengzhi Yang and Zening Jin, both of Beijing Tiantan Hospital and Capital Medical University in China, co-authored an editorial that published alongside the new study in JAMA Cardiology on Wednesday.

They noted in the editorial that so far there have been only scarce data with respect to cardiovascular complications of Covid-19.

"To date, many patients with COVID-19 are still hospitalized in China and other countries, such as Italy and Iran. Therefore, continued observations of the cardiovascular complications of the disease are needed. In addition, further assessment is needed to identify risk factors for poor prognosis," Yang and Jin wrote. "Emerging as an acute infectious disease, COVID-19 may become a chronic epidemic similar to influenza because of genetic recombination. Therefore, we should be ready for the reemergence of COVID-19 or other coronaviruses."

Mississippi Coronavirus Cases

Data is updated nightly.

Cases: 343505

Reported Deaths: 7543
CountyCasesDeaths
Hinds23932444
DeSoto23229283
Harrison20527329
Rankin15411291
Jackson15232252
Madison10959227
Lee10719179
Jones9047169
Forrest8723159
Lauderdale7884244
Lowndes7054151
Lamar702989
Lafayette6548124
Washington5595139
Pearl River5196152
Bolivar4954134
Oktibbeha494398
Panola4771112
Warren4728128
Marshall4701106
Pontotoc447773
Union433279
Monroe4330137
Neshoba4281181
Hancock428088
Lincoln4176116
Pike3667113
Leflore3627125
Tate353388
Alcorn350974
Sunflower347694
Scott341176
Adams340988
Yazoo339376
Copiah324968
Simpson322891
Itawamba314680
Coahoma314085
Tippah306568
Prentiss298863
Covington293484
Leake285475
Marion284181
Wayne277543
George272251
Grenada269488
Newton262364
Tishomingo239770
Winston236784
Jasper230648
Stone229637
Attala226373
Chickasaw219060
Holmes200174
Clay197654
Clarke186880
Tallahatchie183742
Calhoun181332
Smith179235
Yalobusha171540
Walthall145748
Lawrence142826
Greene140134
Amite137543
Noxubee135235
Perry133538
Montgomery133044
Carroll126431
Webster121232
Jefferson Davis116734
Tunica114227
Benton106725
Claiborne105331
Kemper102429
Humphreys100133
Franklin87923
Quitman84719
Choctaw82619
Wilkinson78032
Jefferson71328
Sharkey51618
Issaquena1736
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Alabama Coronavirus Cases

Cases: 587405

Reported Deaths: 11536
CountyCasesDeaths
Jefferson853851591
Mobile48932864
Madison37517533
Shelby27280257
Tuscaloosa27171465
Montgomery26172627
Baldwin25399329
Lee17224181
Calhoun15401334
Morgan15170291
Etowah14954370
Marshall13116235
Houston12077293
Elmore10915219
St. Clair10763252
Limestone10725158
Cullman10546205
Lauderdale10255254
DeKalb9508192
Talladega8949188
Walker7793288
Autauga7563114
Jackson7400117
Blount7362139
Colbert6703142
Coffee6365132
Dale5650117
Russell480243
Chilton4771117
Covington4749125
Franklin458181
Tallapoosa4519156
Escambia441383
Chambers3949125
Dallas3743163
Clarke371263
Marion3463107
Pike332579
Lawrence3263100
Winston298773
Bibb290465
Geneva283983
Marengo262467
Barbour250961
Pickens245562
Butler240872
Hale235578
Fayette227065
Henry213945
Monroe202141
Randolph201144
Cherokee199248
Washington185239
Macon170552
Crenshaw168358
Clay166259
Cleburne161345
Lamar151038
Lowndes145455
Wilcox132331
Bullock126542
Conecuh121332
Coosa118329
Perry110528
Sumter110333
Greene99137
Choctaw64425
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The heat wave that controlled our area over the past several days is now behind us. The forecast for the next week looks a bit cooler & less humid.
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