key: cord-0895139-tlj2etah
authors: Cannata, Francesco; Bombace, Sara; Stefanini, Giulio G
title: Cardiac biomarkers in patients with COVID-19: pragmatic tools in hard times
date: 2021-01-21
journal: Rev Esp Cardiol (Engl Ed)
DOI: 10.1016/j.rec.2021.01.006
sha: d9afd2d6f61ccdd6b0cb031f2e8b41dc86a4629f
doc_id: 895139
cord_uid: tlj2etah

nan

Compelling evidence has shown that cardiac troponin elevations are strongly associated with disease severity and hard outcomes in patients with COVID-19, irrespective of the underlying mechanism of cardiovascular involvement. In the study by Calvo-Fernández et al. recently published in Revista Española de Cardiología, the authors evaluated the short-term predictive value of high-sensitivity cardiac-specific troponin-T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) assessed at the time of hospital admission in the largest European cohort (n = 872) of laboratoryconfirmed COVID-19 patients reported to date. 6 hs-cTnT and NT-pro-BNP cutoff serum levels were set, respectively, at > 14 ng/L (which is the 99 th percentile upper reference limit, according to the manufacturer) and > 300 pg/mL (which is the recognized threshold for heart failure rule-out in the acute setting). 7 Pathological levels of hs-cTnT and NT-pro-BNP were found in 34.6% and 36.2% of the patients, respectively, and proved to be strong independent predictors of mortality and of the composite Troponins and natriuretic peptides focus on different aspects of cardiovascular involvement in COVID-19. Troponins are the biomarkers of myocardial injury, which may be due to direct viral damage by SARS-CoV-2 and inflammatory myocarditis in the context of cytokine storm, or myocardial ischemia/infarction as a consequence of oxygen supply-demand imbalance or prothrombotic state with acute coronary syndromes or pulmonary embolisms. 5 In contrast, natriuretic peptides are sensitive indicators of hemodynamic cardiac stress, which may be due to ischemic or inflammatory left ventricular systolic/diastolic dysfunction and right heart overload secondary to the pulmonary consequences of the disease (pulmonary embolism, pulmonary hypertension, hypoxic vasoconstriction, acute respiratory distress syndrome). 7 (table 1) and, in particular, BNP and NT-pro-BNP were demonstrated to significantly improve the predictive accuracy of troponins in some of them. 6, [8] [9] [10] [11] [12] [13] On the other hand, in 2 recent registries, cardiovascular biomarkers failed to provide additional prognostic information after adjustment for baseline clinical characteristics, comorbidities, vital parameters, and laboratory values mirroring multiorgan dysfunction. 14, 15 However, these studies focused on a limited sample size and a selected population of critically ill patients, respectively, and also detected higher levels of cardiac biomarkers in patients with worse prognosis.

Whatever the underlying mechanisms and pathophysiology of cardiac involvement in COVID-19, a comprehensive early assessment of cardiac biomarkers may be pragmatically used to differentiate highrisk patients-who require intense monitoring and precociously aggressive treatment, from low-risk participants, who may be managed with a strict outpatient follow-up. Thus, in times of paucity of resources and difficulties in priority setting, low-price and widespread cardiac biomarkers may play a decisive role. Moreover, the identification of a significant cardiac involvement might activate a cardiological work-up and a dedicated cardiovascular follow-up with tailored diagnostic and interventional acts during hospitalization or after COVID-19 recovery. As shown by Giustino et al., the echocardiographic characterization of myocardial injury in COVID-19 might further improve risk stratification and guide appropriate management strategies. 16 We truly congratulate the authors for this interesting piece of evidence, although a few limitations should be considered. 6 First, the observational nature of the study does not prove a causal relationship between cardiac involvement and outcomes. Second, the generalizability of the results may be limited by the single-center nature of the registry. Third, only 75% of patients could be tested for hs-cTnT and 58% for NT-pro-BNP, so selection bias cannot be excluded. However, this work reinforces the role for early systematic surveillance with cardiac biomarkers in a wide population of hospitalized patients with COVID-19. 

None declared. 

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China 264 hs-cTnI > 0.020 ng/mL

BNP > 340 pg/mL In-hospital hs

64 pg/mL In-hospital hs-cTnI (per 1 ng/mL): 1.86 (1.27-2.72) NT-pro-BNP (per 100 pg/mL): 1.37 (1.22-1.54) hs-TnI

Italy 397 hs-cTnI ≥ 19.6 ng/L BNP ≥ 100 pg/mL In-hospital hs-cTnI: 1.9 (1.6-.3) BNP: 2.8 (2.2-3.7)

Spain 872 hs-cTnT > 14 ng/L NT-pro-BNP > 300 pg/mL 30 and 50 days

95% confidence interval; BNP, B-type natriuretic peptide; cTn

hs-cTn, high-sensitivity cardiac troponin; N, number of patients; NT-pro-BNP, N-terminal pro-B-type natriuretic peptide