key: cord-0689039-x0myqhoa
authors: Yuan, Neal; Wu, Stephanie; Rader, Florian; Siegel, Robert J.
title: Determining which hospitalized COVID-19 patients require an urgent echocardiogram
date: 2021-04-01
journal: J Am Soc Echocardiogr
DOI: 10.1016/j.echo.2021.03.010
sha: 4e2bc516d25513d0ff5c441b6e703d2afa034f40
doc_id: 689039
cord_uid: x0myqhoa

Background Patients hospitalized with COVID-19 infection often have abnormal transthoracic echocardiogram (TTE) findings. However, while not all TTE abnormalities result in changes in clinical management, performing TTEs in recently infected patients increases disease transmission risks. It remains unknown whether common biomarker tests, such as troponin and B-type natriuretic peptide (BNP), can help distinguish in which COVID-19 patients a TTE may be safely delayed until infection risks subside. Method Using electronic health records data and chart review, we retrospectively studied all patients hospitalized with COVID-19 infection at our multi-site healthcare system from 2/27/2020-1/15/2021 who underwent a TTE within 14 days of their first positive COVID-19 test and had a BNP and troponin measured before or within 7 days of TTE. The primary outcome was presence of ≥1 urgent echocardiographic finding defined as left ventricular ejection fraction ≤35%, wall motion score index ≥1.5, ≥moderate right ventricular dysfunction, ≥moderate pericardial effusion, intracardiac thrombus, pulmonary artery systolic pressure >50mmHg, or ≥moderate-severe valvular disease. We conducted stepwise logistic regression to determine biomarkers and comorbidities associated with the outcome. We evaluated the performance of a rule for classifying TTEs using troponin and BNP. Results We included 434 hospitalized and 151 ICU COVID-19 patients. Urgent TTE findings were present in 105 (24.2%) patients. Troponin and BNP were abnormal in 311 (71.7%). Heart failure (OR (95%CI) 5.41 (2.61-11.68)), troponin >0.04ng/mL (4.40 (2.05-10.05)), BNP >100pg/mL (5.85 (2.35-16.09)) remained significant predictors of urgent TTE findings after stepwise selection. 95.1% of all patients and 91.3% of ICU patients with normal troponin and BNP had no urgent TTE findings. Conclusions Troponin and BNP were highly associated with urgent echocardiographic findings and may be used in triaging algorithms for determining which patients may safely delay their TTE studies until after their peak infectious window has passed.

Ba ckground 23 P a tie nts hos pita lize d with COVID-19 infe ction ofte n ha ve a bnorma l tra ns thora cic 24 e choca rdiogra m (TTE) findings . Howe ve r, while not a ll TTE a bnorma litie s re s ult in 25 cha nge s in clinica l ma na ge me nt, pe rforming TTEs in re ce ntly infe cte d pa tie nts 26 incre a s e s dis e a s e tra ns mis s ion ris ks . It re ma ins unknown whe the r common bioma rke r 27 te s ts , s uch a s troponin a nd B-type na triure tic pe ptide (BNP ), ca n he lp dis tinguis h in 28 which COVID-19 pa tie nts a TTE ma y be s a fe ly de la ye d until infe ction ris ks s ubs ide . 29

Us ing e le ctronic he a lth re cords da ta a nd cha rt re vie w, we re tros pe ctive ly s tudie d a ll 31 pa tie nts hos pita lize d with COVID-19 infe ction a t our multi-s ite he a lthca re s ys te m from 32 2/27/2020-1/15/2021 who unde rwe nt a TTE within 14 da ys of the ir firs t pos itive COVID-33 19 te s t a nd ha d a BNP a nd troponin me a s ure d be fore or within 7 da ys of TTE. The 34 prima ry outcome wa s pre s e nce of ≥1 urge nt e choca rdiogra phic finding de fine d a s le ft 35 ve ntricula r e je ction fra ction ≤35%, wa ll motion s core inde x ≥1.5, ≥mode ra te right 36 ve ntricula r dys function, ≥mode ra te pe rica rdia l e ffus ion, intra ca rdia c thrombus , 37 pulmona ry a rte ry s ys tolic pre s s ure >50mmHg, or ≥mode ra te -s e ve re va lvula r dis e a s e . 38

We conducte d s te pwis e logis tic re gre s s ion to de te rmine bioma rke rs a nd comorbiditie s 39 a s s ocia te d with the outcome . We e va lua te d the pe rforma nce of a rule for cla s s ifying 40 100 pg/mL had no urgent TTE findings with a false negative rate of 5.7% (Figure 2A) . 177

When applying this same rule to 151 patients admitted to the ICU during their TTE, we 178 found that the negative predictive value was 91.3% and the false negative rate was 12.1% 179 ( Figure 2B ). 180 181 Six (5%) patients had urgent abnormal echocardiographic findings despite negative 182 troponin and BNP levels ( Table 3) . All patients had either significant LV or RV 183 dysfunction. In two of these patients, the findings were already known from TTEs prior 184 to COVID-19 diagnosis and in one patient the urgent diagnosis (pulmonary embolism) BNP screening rule also performed well amongst ICU patients, although with a slightly 232 lower negative predictive value of 91% likely due to the higher pre-test probability for 233 cardiac abnormalities in critically ill patients. We considered a range of other 234 comorbidities and laboratory tests as screening criteria, but after stepwise predictor 235 selection, troponin and BNP were the two markers that persisted as the main predictors 236 of urgent echocardiographic findings. Heart failure was also a significant predictor, 237 which is not surprising given that many of the echocardiographic abnormalities we 238 considered urgent are found with high frequency at baseline in heart failure patients. We 239 did not include heart failure in our screening criteria given that it did not substantially 240 add to the performance of the screening rule when using troponin and BNP alone. In recently infected COVID-19 patients, the benefits of performing echocardiograms 291 must be weighed against the risks of COVID-19 exposure and transmission. After 292 evaluation of multiple comorbidities and biomarkers, we found that troponin and BNP 293 were highly sensitive for echocardiographic abnormalities. More than 95% of patients 294 with a normal troponin and BNP had no urgent echocardiographic findings. We thus 295

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