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CME / ABIM MOC / CE

Does High Troponin Predict Cardiac Issues With COVID-19?

  • Authors: News Author: Marilynn Larkin; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 3/24/2023
  • Valid for credit through: 3/24/2024
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for cardiologists, internists, infectious disease physicians, nurses, pulmonologists, pharmacists, physician assistants, and other members of the healthcare team who treat and manage patients with COVID-19 and elevated troponin levels.

The goal of this activity is for learners to be better able to describe the presence, nature, and extent of myocardial damage in hospitalized patients with COVID-19 and troponin elevation, according to a large, multicenter, prospective, case-control study conducted at 25 UK hospitals, which compared 342 patients with COVID-19 and elevated troponin (COVID-19+/troponin+) with 2 prospective control groups (64 patients with COVID-19 and normal troponin [COVID-19+/troponin−] and 113 patients without COVID-19 or elevated troponin matched by age and cardiovascular comorbidities [COVID-19−/comorbidity+]).

Upon completion of this activity, participants will:

  • Describe the presence, nature, and extent of myocardial damage in hospitalized patients with COVID-19 and troponin elevation
  • Identify clinical implications of the presence, nature, and extent of myocardial damage in hospitalized patients with COVID-19 and troponin elevation
  • Outline implications for the healthcare team


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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Marilynn Larkin

    Freelance writer, Medscape

    Disclosures

    Marilynn Larkin has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor/Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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CME / ABIM MOC / CE

Does High Troponin Predict Cardiac Issues With COVID-19?

Authors: News Author: Marilynn Larkin; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 3/24/2023

Valid for credit through: 3/24/2024

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Note: The information on the coronavirus outbreak is continually evolving. The content within this activity serves as a historical reference to the information that was available at the time of this publication. We continue to add to the collection of activities on this subject as new information becomes available. It is the policy of Medscape Education to avoid the mention of brand names or specific manufacturers in accredited educational activities. However, manufacturer names related to the approved COVID-19 vaccines are provided in this activity in an effort to promote clarity. The use of manufacturer names should not be viewed as an endorsement by Medscape of any specific product or manufacturer.  

Clinical Context

Multiorgan involvement in hospitalized patients with COVID-19 is common, particularly among persons with cardiovascular disease (CVD) or risk factors. Elevated cardiac troponin, reflecting acute myocardial injury (AMI), predicts worse prognosis.

Cardiac magnetic resonance (CMR) imaging is the reference standard for AMI, as it reveals structure, function, scar, and inflammation. Initial imaging studies of COVID-19 reported a myocarditis-like injury pattern, but these were small and had other limitations.

Study Synopsis and Perspective

Hospitalized patients with COVID-19 with high troponin levels are twice as likely to have cardiac abnormalities than patients with normal troponin, with or without COVID-19, a multicenter UK study suggests.

The causes were diverse, myocarditis prevalence was lower than previously reported, and myocardial scar emerged as an independent risk factor for adverse cardiovascular (CV) outcomes at 12 months.

"We know that multiorgan involvement in hospitalized patients with COVID-19 is common... and may result in [AMI], detected by an increase in cardiac troponin concentrations," John P. Greenwood, PhD, of the University of Leeds in England, told theheart.org |Medscape Cardiology. "Elevated cardiac troponin is associated with a worse prognosis.

"Multiple mechanisms of myocardial injury have been proposed and... mitigation or prevention strategies likely depend on the underpinning mechanisms," he continued. "The sequelae of scar may predispose to late events."

The study, published January 27 in Circulation, also identified a new pattern of microinfarction on CMR imaging, highlighting the pro-thrombotic nature of SARS-CoV-2, Greenwood said.

Injury Patterns Different

A total of 342 patients with COVID-19 and elevated troponin levels (COVID-19+/troponin+) across 25 centers were enrolled between June 2020 and March 2021 in COVID-HEART, deemed an "urgent public health study" in the United Kingdom. The aim was to characterize myocardial injury and its associations and sequelae in convalescent patients after hospitalization with COVID-19.

Enrollment took place during the Wuhan and Alpha waves of COVID-19, before vaccination, and when dexamethasone and anticoagulant protocols were emerging. All participants underwent CMR imaging at a median of 21 days after discharge.

Researchers also recruited 2 prospective control groups: 64 patients with COVID-19 and normal troponin levels (COVID-19+/troponin−) and 113 without COVID-19 or elevated troponin matched by age and CV comorbidities (COVID-19−/comorbidity+).

Overall, participants' median age was 61 years, and 69% were men. Common comorbidities included hypertension (47%), obesity (43%), and diabetes (25%).

The frequency of any heart abnormality (eg, left or right ventricular impairment, scar, or pericardial disease) was twice as great (61%) in COVID-19+/troponin+ cases compared with control participants (36% for patients with COVID-19+/troponin− vs 31% for patients with COVID-19−/comorbidity+).

Specifically, more cases than control participants had ventricular impairment (17.2% vs 3.1% and 7.1%) or scar (42% vs 7% and 23%).

The myocardial injury pattern differed between cases and control participants, with cases more likely to have infarction (13% vs 2% and 7%) or microinfarction (9% vs 0 and 1%).

Still, there was no between-group difference in nonischemic scar (13% vs 5% and 14%).

The prevalence of probable recent myocarditis was 6.7% in cases compared with 1.7% in control participants without COVID-19: "much lower" than in previous studies, Greenwood noted.

During follow-up, 4 patients with COVID-19+/troponin+ (1.2%) died, and 34 (10.2%) experienced a subsequent major adverse cardiovascular event (MACE), which was similar to control participants (6.1%).

Myocardial scar, but not previous COVID-19 or troponin level, was an independent predictor of MACE (odds ratio [OR] 2.25 [95% CI: 1.12, 4.57).

"These findings suggest that macroangiopathic and microangiopathic thrombosis may be the key pathologic process for myocardial injury in COVID-19 survivors," the authors concluded.

Greenwood added, "We are currently analyzing the 6-month follow-up CMR scans, the quality-of-life questionnaires, and the 6-minute walk tests. These will give us great understanding of how the heart repairs after [AMI] associated with COVID-19. It will also allow us to assess the impact on patient quality of life and functional capacity."

"Tour de Force"

Commenting on the study for theheart.org | Medscape Cardiology, James A. de Lemos, MD, co-chair of the American Heart Association's COVID-19 CVD Registry Steering Committee and a professor of medicine at The University of Texas Southwestern Medical Center in Dallas, Texas, said, "This is a tour de force collaboration -- obtaining this many MRIs across multiple centers in the pandemic is quite remarkable. The study highlights the multiple different processes that lead to cardiac injury in COVID patients, complements autopsy studies and prior smaller MRI studies [and] also provides the best data on the rate of myocarditis to date among the subset of COVID patients with cardiac injury."

Overall, he said, the findings "do support closer follow-up for patients who had COVID and elevated troponins. We need to see follow-up MRI results in this cohort, as well as longer term outcomes. We also need studies on newer, more benign variants that are likely to have lower rates of cardiac injury and even fewer MRI abnormalities."

Matthias Stuber, PhD, and Aaron L. Baggish, MD, both of Lausanne University Hospital and University of Lausanne in Lausanne, Switzerland, noted in a related editorial,[2] "We are also reminded that the clinical severity of COVID-19 is most often dictated by the presence of preexisting comorbidity, with antecedent ischemic scar now added to the long list of bad actors. Although not the primary focus of the COVID-HEART study, the question of whether cardiac troponin levels should be checked routinely and universally during the index admission for COVID-19 remains unresolved.

"In general, we are most effective as clinicians when we use tests to confirm or rule out the specific disease processes suspected by careful basic clinical assessment rather than in a shotgun manner among undifferentiated all-comers," they concluded.

No commercial funding or relevant financial relationships were reported.

Study Highlights

  • Across 25 UK hospitals, 342 cases (COVID-19+/troponin+) were enrolled between June 2020 and March 2021 and had CMR imaging within 28 days of discharge.
  • These were compared with 2 prospective control groups (COVID-19+/troponin− [n = 64] and COVID-19−/comorbidity+ [n = 113]).
  • Of the 519 participants, 69% were men; median age was 61 (interquartile range, 53.8-68.8) years.
  • Frequency of any heart abnormality (left or right ventricular impairment, scar, or pericardial disease) was 2-fold greater in cases (61%) than in control participants (36% [COVID-19+/troponin−] vs 31% [COVID-19−/comorbidity+]; P < .001 for both).
  • More cases than control participants had ventricular impairment (17.2% vs 3.1% and 7.1%) or scar (42% vs 7% and 23%; P < .001 for both).
  • Myocardial injury pattern was different, as cases were more likely than control participants to have infarction (13% vs 2% and 7%; P < .01) or microinfarction (9% vs 0 and 1%; P < .001), but nonischemic scar was similar (13% vs 5% and 14%; P = .1).
  • Lake Louise CMR imaging criteria showed prevalence of probable recent myocarditis of 6.7% in cases and 1.7% in control participants without COVID-19 (P = .045).
  • During follow-up, 4 cases (1.2%) died and 34 (10.2%) experienced MACE, as did 6.1% of control participants; P = .7.
  • Regression modeling showed that myocardial scar, but not previous COVID-19 or troponin, was an independent predictor of MACE at 12 months (OR 2.25 [95% CI: 1.12, 4.57]; P = .02).
  • The investigators concluded that compared with control participants, patients with COVID-19 and elevated cardiac troponin level were twice as likely to have cardiac abnormalities, with more left and right systolic ventricular impairment, pericardial effusions, and myocardial scar during early convalescence.
  • Presence of scar was independently associated with cardiovascular outcomes at 12 months, supporting it as an adverse prognostic marker of future vulnerability to subsequent insults.
  • Presence of scar can therefore help inform appropriate management decisions.
  • As myocardial scar was not more prevalent in those with severe lung involvement, respiratory disease severity during hospitalization may not reflect cardiac disease severity.
  • Prevalence of probable recent myocarditis was much lower than previously reported and scar pathogenesis was diverse, including a newly described pattern of microinfarction on CMR imaging, highlighting the prothrombotic nature of COVID-19.
  • Excess scar was typically that of myocardial infarction or microinfarction, with less frequent myocardial inflammation and probable recent myocarditis, suggesting that macroangiopathic and microangiopathic thrombosis may be the key pathologic process for myocardial injury in COVID-19 survivors.
  • Future research should examine the longer-term prognostic, functional, and quality-of-life effects of these changes.
  • Study limitations include survivor bias and case ascertainment bias, warranting caution in interpreting COVID-19--specific myocardial injury.
  • An accompanying editorial noted that the findings may support closer follow-up for patients with COVID-19 and elevated troponins, but the question of whether cardiac troponin levels should be checked routinely and universally during the index hospitalization remains unanswered.

Clinical Implications

  • Patients with COVID-19 and elevated cardiac troponin were twice as likely to have cardiac abnormalities as control participants.
  • A newly described CMR imaging pattern of microinfarction highlights the prothrombotic nature of COVID-19.
  • Implications for the Healthcare Team: The clinical severity of COVID-19 is most often dictated by the presence of preexisting comorbidity, with antecedent ischemic scar now included on the list of preexisting conditions that clinicians should take into account when making management decisions.

 

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