Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)
Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)
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DOI：
10.1001/jamacardio.2020.1017
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发表时间：
2020-07-01
期刊：
影响因子：
24
通讯作者：
Lu, Zhibing
中科院分区：
文献类型：
--
作者：
Guo, Tao;Fan, Yongzhen;Lu, Zhibing
重要性2019冠状病毒病（COVID-19）的确诊病例和死亡率在多个国家和大洲不断增加。关于心血管并发症对致死性结局影响的信息很少。目的评估COVID-19患者基础心血管疾病（CVD）和心肌损伤与致死性结局的相关性。设计、设置和参与者本回顾性单中心病例系列分析了2020年1月23日至2020年2月23日在中国武汉市第七医院接受治疗的COVID-19患者。分析开始于2020年2月25日。主要结果和测量收集和分析肌钙蛋白T（TnT）水平升高和未升高患者的人口统计学数据、实验室检查结果、合并症和治疗。结果187例确诊COVID-19患者中，144例（77%）患者出院，43例（23%）患者死亡。平均（SD）年龄为58.50（14.66）岁。总体而言，66例（35.3%）有基础CVD，包括高血压、冠心病和心肌病，52例（27.8%）表现出心肌损伤，表现为TnT水平升高。住院期间死亡率：无心血管疾病但TnT正常者为7.62%（8/105），有心血管疾病但TnT正常者为13.33%（4/30），无心血管疾病但TnT升高者为37.50%（6/16），有心血管疾病但TnT升高者为69.44%（25/36）。与无CVD的患者相比，有基础CVD的患者更可能表现出TnT水平升高（36 [54.5%] vs 16 [13.2%]）。血浆TnT水平与血浆高敏C反应蛋白水平（β = 0.530，P <0.001）和N末端脑钠肽前体（NT-proBNP）水平（β = 0.613，P <0.001）呈高度显著正线性相关。住院期间血浆TnT和NT-proBNP水平（中位数[四分位距（IQR）]，0.307 [0.094-0.600]; 1902.00 [728.35-8100.00]）和即将死亡（中位数[IQR]，0.141 [0.058-0.860]; 5375 [1179.50-25695.25]）与入院值相比显著增加（中位数[IQR]，0.0355 [0.015-0.102]; 796.90 [401.93-1742.25]）（P = .001; P < .001），而TnT无明显动态变化（中位数[IQR]，0.010 [0.007-0.019]; 0.013 [0.007-0.022]; 0.011 [0.007-0.016]）和NT-proBNP在存活者中观察到（中位数[IQR]，352.20 [174.70-636.70]; 433.80 [155.80-1272.60]; 145.40 [63.4-526.50]）（P = 0.96; P = 0.16）。住院期间，TnT水平升高的患者更频繁发生恶性心律失常，与TnT水平正常的患者相比，糖皮质激素治疗（37 [71.2%] vs 69 [51.1%]）和机械通气（31 [59.6%] vs 14 [10.4%]）的使用率更高。使用和未使用血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂患者的死亡率分别为36.8%（7/19）和21.4%（36/168）（P = 0.13）。结论和相关性心肌损伤与COVID-19的致死性结局显著相关，而有基础CVD但无心肌损伤的患者的预后相对有利。心肌损伤与心功能不全和心律失常有关。炎症反应可能是心肌损伤的一种潜在机制。心肌损伤高危患者可考虑积极治疗。问题基础心血管疾病（CVD）和心肌损伤对2019冠状病毒病（COVID-19）患者的致死性结局有何影响？在这项对187名COVID-19患者的病例系列研究中，27. 8%的患者有心肌损伤，导致心功能障碍和心律失常。心肌损伤与COVID-19的致死性结局显著相关，而有基础CVD但无心肌损伤的患者预后相对较好。根据潜在心血管疾病和心肌损伤的证据，对COVID-19患者进行分诊是合理的，可以优先治疗甚至采取更积极的策略。本病例系列研究评估了2019冠状病毒病（COVID-19）患者的潜在心血管疾病和心肌损伤与致命结局的关系。
Importance Increasing numbers of confirmed cases and mortality rates of coronavirus disease 2019 (COVID-19) are occurring in several countries and continents. Information regarding the impact of cardiovascular complication on fatal outcome is scarce. Objective To evaluate the association of underlying cardiovascular disease (CVD) and myocardial injury with fatal outcomes in patients with COVID-19. Design, Setting, and Participants This retrospective single-center case series analyzed patients with COVID-19 at the Seventh Hospital of Wuhan City, China, from January 23, 2020, to February 23, 2020. Analysis began February 25, 2020. Main Outcomes and Measures Demographic data, laboratory findings, comorbidities, and treatments were collected and analyzed in patients with and without elevation of troponin T (TnT) levels. Results Among 187 patients with confirmed COVID-19, 144 patients (77%) were discharged and 43 patients (23%) died. The mean (SD) age was 58.50 (14.66) years. Overall, 66 (35.3%) had underlying CVD including hypertension, coronary heart disease, and cardiomyopathy, and 52 (27.8%) exhibited myocardial injury as indicated by elevated TnT levels. The mortality during hospitalization was 7.62% (8 of 105) for patients without underlying CVD and normal TnT levels, 13.33% (4 of 30) for those with underlying CVD and normal TnT levels, 37.50% (6 of 16) for those without underlying CVD but elevated TnT levels, and 69.44% (25 of 36) for those with underlying CVD and elevated TnTs. Patients with underlying CVD were more likely to exhibit elevation of TnT levels compared with the patients without CVD (36 [54.5%] vs 16 [13.2%]). Plasma TnT levels demonstrated a high and significantly positive linear correlation with plasma high-sensitivity C-reactive protein levels (beta = 0.530, P < .001) and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels (beta = 0.613, P < .001). Plasma TnT and NT-proBNP levels during hospitalization (median [interquartile range (IQR)], 0.307 [0.094-0.600]; 1902.00 [728.35-8100.00]) and impending death (median [IQR], 0.141 [0.058-0.860]; 5375 [1179.50-25695.25]) increased significantly compared with admission values (median [IQR], 0.0355 [0.015-0.102]; 796.90 [401.93-1742.25]) in patients who died (P = .001; P < .001), while no significant dynamic changes of TnT (median [IQR], 0.010 [0.007-0.019]; 0.013 [0.007-0.022]; 0.011 [0.007-0.016]) and NT-proBNP (median [IQR], 352.20 [174.70-636.70]; 433.80 [155.80-1272.60]; 145.40 [63.4-526.50]) was observed in survivors (P = .96; P = .16). During hospitalization, patients with elevated TnT levels had more frequent malignant arrhythmias, and the use of glucocorticoid therapy (37 [71.2%] vs 69 [51.1%]) and mechanical ventilation (31 [59.6%] vs 14 [10.4%]) were higher compared with patients with normal TnT levels. The mortality rates of patients with and without use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers was 36.8% (7 of 19) and 21.4% (36 of 168) (P = .13). Conclusions and Relevance Myocardial injury is significantly associated with fatal outcome of COVID-19, while the prognosis of patients with underlying CVD but without myocardial injury is relatively favorable. Myocardial injury is associated with cardiac dysfunction and arrhythmias. Inflammation may be a potential mechanism for myocardial injury. Aggressive treatment may be considered for patients at high risk of myocardial injury.Question What is the impact of underlying cardiovascular disease (CVD) and myocardial injury on fatal outcomes in patients with coronavirus disease 2019 (COVID-19)? Findings In this case series study of 187 patients with COVID-19, 27.8% of patients had myocardial injury, which resulted in cardiac dysfunction and arrhythmias. Myocardial injury has a significant association with fatal outcome of COVID-19, while the prognosis of patients with underlying CVD but without myocardial injury were relatively favorable. Meaning It is reasonable to triage patients with COVID-19 according to the presence of underlying CVD and evidence of myocardial injury for prioritized treatment and even more aggressive strategies.This case series study evaluates the association of underlying cardiovascular disease and myocardial injury on fatal outcomes in patients with coronavirus disease 2019 (COVID-19).