key: cord-0898101-1hvihwkz
authors: Mahajan, Kunal; Chand Negi, Prakash; Ganju, Neeraj; Asotra, Sanjeev
title: Cardiac biomarker-based risk stratification algorithm in patients with severe COVID-19
date: 2020-06-18
journal: Diabetes Metab Syndr
DOI: 10.1016/j.dsx.2020.06.027
sha: c141374769423caa8afd1995b26441ddab01aa00
doc_id: 898101
cord_uid: 1hvihwkz

BACKGROUND AND AIMS: Cardiac biomarkers like cardiac troponins and natriuretic peptides are elevated in a substantial proportion of patients with coronavirus disease 2019 (COVID-19). We propose an algorithmic approach using cardiac biomarkers to triage, risk-stratify and prognosticate patients with severe COVID-19. METHODS: We systematically searched the PubMed and Google Scholar databases until May 31st, 2020, and accessed the available data on the role of cardiac biomarkers in patients with COVID-19. RESULTS: COVID-19 is associated with acute cardiac injury in around 7–28% of patients, significantly increasing its associated complications and mortality. Patients with underlying cardiovascular disease are more prone to develop acute cardiac injury as a result of COVID-19. The use of cardiac biomarkers may aid in differentiating the cardiac cause of dyspnea in patients with severe COVID-19. Cardiac biomarkers may also aid in triaging, risk-stratification, clinical decision-making, and prognostication of patients with COVID-19. However, there are concerns that routine testing in all patients with COVID-19 irrespective of severity, may result in unnecessary downstream investigations which may be misleading. In this brief review, using an algorithmic approach, we have tried to rationalize the use of cardiac biomarkers among patients with severe COVID-19. This approach is also likely to lessen the infection exposure risk to the cardiovascular team attending patients with severe COVID-19. CONCLUSION: It appears beneficial to triage, risk-stratify, and prognosticate patients with COVID-19 based on the evidence of myocardial injury and the presence of underlying cardiovascular disease. Future research studies are, however, needed to validate these proposed benefits.

. We propose an algorithmic approach using cardiac biomarkers to triage, risk-stratify and prognosticate patients with severe COVID-19.

We systematically searched the PubMed and Google Scholar databases until May 31st, 2020, and accessed the available data on the role of cardiac biomarkers in patients with COVID-19.

COVID-19 is associated with acute cardiac injury in around 7-28% of patients, significantly increasing its associated complications and mortality. Patients with underlying cardiovascular disease are more prone to develop acute cardiac injury as a result of COVID-19. The use of cardiac biomarkers may aid in differentiating the cardiac cause of dyspnea in patients with severe COVID-19.

Cardiac biomarkers may also aid in triaging, risk-stratification, clinical decision-making, and prognostication of patients with COVID-19. However, there are concerns that routine testing in all patients with COVID-19 irrespective of severity, may result in unnecessary downstream investigations which may be misleading. In this brief review, using an algorithmic approach, we have tried to rationalize the use of cardiac biomarkers among patients with severe COVID-19. This approach is also likely to lessen the infection exposure risk to the cardiovascular team attending patients with severe COVID-19.

It appears beneficial to triage, risk-stratify, and prognosticate patients with COVID-19 based on the evidence of myocardial injury and the presence of underlying cardiovascular disease. Future research studies are, however, needed to validate these proposed benefits. with COVID-19 is likely to be non-specific and multifactorial, and less likely to be due to atherothrombotic coronary occlusion; therefore, this approach would favour unnecessarily downstream testing. ACC did not mention any words regarding its prognostic role. Furthermore, ACC made a similar recommendation for measuring natriuretic peptides in COVID patients, recommending its use only if one suspects heart failure on clinical grounds. 4 However, in a study by Shaobo Shi et al., 2 3 , which showed that 52 (27.8%) out of 187 confirmed severe COVID-19 patients developed acute cardiac injury (measured by elevated Troponin T in this study). Troponin levels showed a high and significantly positive linear correlation with NT-pro BNP levels. Interestingly, there was a dynamic escalation of difference in Troponin T and NT-pro BNP levels between the patients who died and those who recovered/discharged successfully. Both Troponin T and NT-pro BNP levels increased significantly during hospitalization in those who ultimately died, but no such dynamic changes of Troponin T or NT-pro BNP levels were evident in survivors. This study also revealed an important finding that the risk of mortality was higher in patients with elevated Troponin T and underlying cardiovascular disease compared to those with elevated Troponin T but without underlying cardiovascular disease.

Thus, it is evident that cardiac injury plays a significant role in the disease progression and outcome associated with COVID-19. Thus, it is reasonable to include the indicators of cardiac injury in the patient's diagnosis, triaging, treatment, and prognosis, while recognizing that their abnormality may not be related to direct coronary involvement. The usefulness is enhanced among patients with prior cardiovascular disease. If we continue to ignore their importance, we are likely to miss a significant number of ischemic and non-ischemic causes of myocardial injury associated with COVID-19.

Eventually, many patients are going to be mismanaged and deprived of potentially useful therapies like inotropes, vasopressors, and diuretics for heart failure, and perhaps immunosuppressants for myocarditis. The use of biomarker-based risk stratification may identify a substantial proportion of severe COVID-19 patients with normal or mildly elevated Troponin and BNP values (<3 times the upper limit of normal) , thus avoiding the need for further cardiac consultation, electrocardiogram, and echocardiogram. This strategy will translate into lesser infection exposure to the cardiovascular team and a reduction in the need for additional PPE.

Therefore, in this COVID-19 era, we urge the cardiology community to stop using troponin just as a test to rule out myocardial infarction and to decide whether patients should be shifted for coronary angiography or not.

Instead, we propose using both troponin and natriuretic peptides in all severe COVID-19 patients for risk stratification (as advised in our proposed algorithm), clinical decision making, rationale use of ECG/echocardiography, initiating aggressive treatment strategies, and for risk prognostication of the patients.

Such an approach might enhance cardiovascular care among COVID-19 patients, as well as reduce the risk of infection exposure to the cardiovascular care team. However, future research is needed to validate whether cardiac biomarker testing improves triage, assists in treatment decisions, and alters outcomes. 

Cardiovascular comorbidities and complications associated with coronavirus disease

Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. JAMA Cardiol

Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)

American College of Cardiology: Troponin and BNP Use in COVID-19