Defining Myocardial Injury in COVID-19: Is Troponin Enough? The COVID-19 Disease and Cardiac Events (Covicare) Study

Background: Myocardial injury is a complication of COVID-19 infection and is associated with adverse outcome, but the definition is variable and based on troponin elevation alone. We utilised a revised definition of myocardial injury using biomarkers, electrocardiography (ECG) and echocardiography and assessed its predictive efficacy. Methods and Results: 100 patients (age 64.8 ± 13.2yr, 53% female) with COVID-19 had admission highsensitivity c-troponin-T (hs-cTnT), N-terminal-pro-B-type-natriuretic-peptide (NTproBNP), interleukins (IL), tumour necrosis factor-α (TNFα), ECG and echocardiography. 51(53%) of patients had hs-cTnT >14ng/L; 10(20%) died vs 3(7%) without hs-cTnT elevation (p=0.059). 30-day major adverse cardiac events (MACE) increased with increasing hs-cTnT (HR 1.69 [1.0-2.86]; p=0.05). IL-6, IL-8 and TNFα were associated with 30-day MACE and were higher in those with hs-cTnT >14ng/L. 36(38%) of patients had an abnormal ECG, which was associated with higher NTproBNP (589 [211–1696] vs 146 [79–390]ng/L, p=0.001). 55 (71%) of 78 patients with interpretable echocardiograms were abnormal; NTproBNP was higher in those with abnormal echocardiography (390 [131-1118] vs 129 [96-460]ng/L, p=0.036). Combining hs-cTnT elevation with ECG and echocardiographic abnormalities identified a group with markedly elevated NTproBNP (1163 [565-3156] vs 147[78-404]ng/L, p<0.001). Conclusions: A refined definition of myocardial injury using ECG/echocardiography and biomarkers may identify higher risk patients with COVID-19.