Ultrasound Reveals Cardiac Injury Caused By COVID-19

October 26, 2020
Whitney J. Palmer

The modality is the only one that can be safely conducted at the bedside with patients on a ventilator.

Cardiac ultrasound can reveal how COVID-19 damages the heart, not only potentially helping doctors identify patients who are at risk faster, but also guiding future therapies.

In a study published Oct. 26 in the Journal of the American College of Cardiology, investigators from the Icahn School of Medicine and Mount Sinai Hospital revealed that cardiac ultrasound (echocardiograms) can identify different types of post-cardiac injury structural damage that can occur in COVID-19 patients. These injuries can be linked to several deadly conditions associated with higher mortality risks in hospitalized patients, such as heart attack, pulmonary embolism, heart failure, and myocarditis.

“Early detection of structural abnormalities may dictate more appropriate treatments, including anti-coagulation and other approaches for hospitalized and post-hospitalized patients,” said study author Valentin Fuster, M.D., Ph.D., director of Mount Sinai Heart and physician-in-chief of The Mount Sinai Hospital.”

Echocardiograms are particularly suited for providing this type of information, the team said, because it is the only modality that can be safely used at the beside for patients who are on ventilators.

This new retrospective study, the team said, builds on Mount Sinai’s existing body of research into troponin levels that shows heart damage is common in COVID-19 hospitalized patients. This investigation focuses on elevated cardiac troponin levels that are present alongside echocardiographic abnormalities. Based on their analysis, the team determined this combination was linked to a worse prognosis and mortality for the patient than having an elevated troponin level by itself.

“We found that among COVID-19 patients who underwent transthoracic echocardiography, these cardiac structural abnormalities were diverse and present in nearly two-thirds of patients,” said first and corresponding author Gennaro Giustino, M.D, cardiology fellow at The Mount Sinai Hospital, noting this is one of the first studies to generate detailed echocardiographic and electrocardiographic data in hospitalized COVID-19 patients who have lab evidence of myocardial injury.

To gather this data, the team analyzed transthoracic echocardiographic (TTE) and electrocardiographic (ECG) scans from 305 adult, COVID-19-positive patients who were admitted to four New York City hospitals in the Mount Sinai system, as well as one hospital in Queens and two hospitals in Milan, Italy, between March 2020 and May 2020. The average patient age was 63, and 67.2 percent of participants were men.

Evidence of myocardial injury was present in 190 individuals – 62.6 percent of the study population. Heart damage was present in 118 of them when they were admitted to the hospital, and 72 developed a myocardial injury during their hospitalization. Those patients with injuries had more electrocardiographic abnormalities, higher inflammatory biomarkers, and an increased prevalence of TTE abnormalities than patients without heart injury.

According to their analysis, the identified abnormalities were diverse, and some patients had multiple abnormalities. For example, 26.3 percent had right ventricular dysfunction, an abnormality that can be linked to pulmonary embolism and severe respiratory failure, and 23.7 percent had regional left ventricular wall motion abnormalities that can be associated with heart attacks. In addition, diffuse left ventricular dysfunction – an abnormality associated with heart failure and myocarditis – was present in 18.4 percent, and 13.2 percent of patients had grade II or III diastolic dysfunction, a condition that can lead to stiffer cardiac chambers. Lastly, 7.2 percent had pericardial effusions that can cause abnormal heart pumping.

The team also went further to examine in-hospital morality and troponin elevation, adjusting for major COVID-19 complications, including shock, acute respiratory distress syndrome, and renal failure. Their findings revealed troponin elevation was 5.2 percent in patients without heart injury and 18.6 percent in whose who did have myocardial injury without echocardiographic abnormalities. The elevation was 31.7 percent in patients with heart injury and echocardiographic abnormalities.

Overall, the team said, cardiac ultrasound can play a significant role in managing COVID-19 patients and determining their course of treatment.

“Our study shows that an echocardiogram performed with appropriate personal protection considerations is a useful and important tool in early identification of patients at greater risk for COVID-19 related cardiac injury, who may benefit from a more aggressive therapeutic approach earlier in their hospitalization,” said Martin Goldman, M.D., cardiology professor at Ichan. “Additionally, because this is a new disease with lingering symptoms, we plan on following these patients closely using imaging to evaluate the evolution and, hopefully, resolution of these cardiac issues.”

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