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Correlations of Before and After Event Echocardiographic Parameters with Troponin and BNP in Hospitalized COVID-19 Patients With Cardiovascular Events

  • Author Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    Stephen Furmanek
    Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    Affiliations
    Division of Infectious Diseases, Center of Excellence for Research in Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY

    Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY
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  • Author Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    Vidyulata Salunkhe
    Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    Affiliations
    Division of Infectious Diseases, Center of Excellence for Research in Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY
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  • Author Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    Siddharth Pahwa
    Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    Affiliations
    Department of Cardiovascular & Thoracic Surgery, University of Louisville, Louisville, KY
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  • Author Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    Harideep Samanapally
    Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    Affiliations
    Division of Infectious Diseases, Center of Excellence for Research in Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY
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  • Author Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    Pavani Nathala
    Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    Affiliations
    Division of Infectious Diseases, Center of Excellence for Research in Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY
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  • Qian Xu
    Affiliations
    Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, KY
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  • Tshura Ali
    Affiliations
    Division of Infectious Diseases, Center of Excellence for Research in Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY
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  • Fnu Deepti
    Affiliations
    Division of Infectious Diseases, Center of Excellence for Research in Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY
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  • Alex Glynn
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    Division of Infectious Diseases, Center of Excellence for Research in Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY
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  • Trevor McGuffin
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    School of Nursing, University of Louisville, Louisville, KY
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  • Derek Titus
    Affiliations
    Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY
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  • Ian Farah
    Affiliations
    Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY
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  • Author Footnotes
    3 S. Pahwa, C. M. Jones, S. P. Clifford, L. Roser, M. Kong, F. W. Arnold and J. Huang are Senior Authors.
    Christopher M Jones
    Footnotes
    3 S. Pahwa, C. M. Jones, S. P. Clifford, L. Roser, M. Kong, F. W. Arnold and J. Huang are Senior Authors.
    Affiliations
    Division of Transplantation, Department of Surgery, University of Louisville, Louisville, KY
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  • Julio A Ramirez
    Affiliations
    Division of Infectious Diseases, Center of Excellence for Research in Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY

    Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY
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  • Author Footnotes
    3 S. Pahwa, C. M. Jones, S. P. Clifford, L. Roser, M. Kong, F. W. Arnold and J. Huang are Senior Authors.
    Sean P Clifford
    Footnotes
    3 S. Pahwa, C. M. Jones, S. P. Clifford, L. Roser, M. Kong, F. W. Arnold and J. Huang are Senior Authors.
    Affiliations
    Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY
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  • Author Footnotes
    3 S. Pahwa, C. M. Jones, S. P. Clifford, L. Roser, M. Kong, F. W. Arnold and J. Huang are Senior Authors.
    Forest W Arnold
    Footnotes
    3 S. Pahwa, C. M. Jones, S. P. Clifford, L. Roser, M. Kong, F. W. Arnold and J. Huang are Senior Authors.
    Affiliations
    Division of Infectious Diseases, Center of Excellence for Research in Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY
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  • Author Footnotes
    3 S. Pahwa, C. M. Jones, S. P. Clifford, L. Roser, M. Kong, F. W. Arnold and J. Huang are Senior Authors.
    Maiying Kong
    Footnotes
    3 S. Pahwa, C. M. Jones, S. P. Clifford, L. Roser, M. Kong, F. W. Arnold and J. Huang are Senior Authors.
    Affiliations
    Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, KY
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  • Author Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    ,
    Author Footnotes
    3 S. Pahwa, C. M. Jones, S. P. Clifford, L. Roser, M. Kong, F. W. Arnold and J. Huang are Senior Authors.
    Lynn Roser
    Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    3 S. Pahwa, C. M. Jones, S. P. Clifford, L. Roser, M. Kong, F. W. Arnold and J. Huang are Senior Authors.
    Affiliations
    School of Nursing, University of Louisville, Louisville, KY
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  • Author Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    ,
    Author Footnotes
    3 S. Pahwa, C. M. Jones, S. P. Clifford, L. Roser, M. Kong, F. W. Arnold and J. Huang are Senior Authors.
    Jiapeng Huang
    Correspondence
    Address correspondence to Jiapeng Huang MD, PhD, Department of Anesthesiology & Perioperative Medicine, University of Louisville, 530 South Jackson Street, Louisville, KY 40202.
    Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    3 S. Pahwa, C. M. Jones, S. P. Clifford, L. Roser, M. Kong, F. W. Arnold and J. Huang are Senior Authors.
    Affiliations
    Division of Infectious Diseases, Center of Excellence for Research in Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY

    Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY

    Department of Pharmacology & Toxicology, University of Louisville, Louisville, KY

    Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY
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  • Center of Excellence for Research in Infectious Diseases Coronavirus Study Group on behalf of the COVID-19 CardioVascular Research Group
  • Author Footnotes
    2 S. Furmanek, V.Salunkhe, S. Pahwa, H. Samanapally, P. Nathala contributed equally to this work; in addition, L. Roser, S. Pahwa, and J. Huang contributed equally to this work.
    3 S. Pahwa, C. M. Jones, S. P. Clifford, L. Roser, M. Kong, F. W. Arnold and J. Huang are Senior Authors.
Published:September 01, 2022DOI:https://doi.org/10.1053/j.jvca.2022.08.024
      To the Editor:
      Right and left ventricular (RV and LV, respectively) dysfunction was found to be significantly related to adverse outcomes in patients with COVID-19.
      • Babu A
      • Meng Z
      • Eden N
      • et al.
      Evaluating the role of transthoracic echocardiography in hospitalized patients with COVID-19 infection.
      • Ghantous E
      • Szekely Y
      • Lichter Y
      • et al.
      Pericardial involvement in patients hospitalized with COVID-19: Prevalence, associates, and clinical implications.
      • Díaz JJS
      • Rincon JM
      • López MAR
      • et al.
      Echocardiographic 60-day mortality markers in patients hospitalized in intensive care for COVID-19.
      • Barman HA
      • Atici A
      • Tekin EA
      • et al.
      Echocardiographic features of patients with COVID-19 infection: A cross-sectional study.
      • Rodríguez-Santamarta M
      • Minguito-Carazo C
      • Echarte-Morales JC
      • et al.
      Echocardiographic findings in critical patients with COVID-19.
      • D'Alto M
      • Marra AM
      • Severino S
      • et al.
      Right ventricular-arterial uncoupling independently predicts survival in COVID-19 ARDS.
      • Kim J
      • Volodarskiy A
      • Sultana R
      • et al.
      Prognostic utility of right ventricular remodeling over conventional risk stratification in patients with COVID-19.
      There is no study to specifically evaluate echocardiography in the cohort of patients who suffered cardiovascular events. We examined the echocardiographic parameters before and after cardiovascular events to predict myocardial injuries so that clinicians could be better prepared to manage pending cardiovascular events or their sequalae.
      Forty-nine patients from a multicenter, retrospective database of 700 adult patients hospitalized with a diagnosis of COVID-19 from March 7, 2020, to July 1, 2020 who suffered ≥1 cardiovascular event and underwent echocardiography were selected.
      • Xu Q
      • Samanapally H
      • Nathala P
      • et al.
      Outcomes and risk factors for cardiovascular events in hospitalized COVID-19 patients.
      ,
      • Nathala P
      • Salunkhe V
      • Samanapally H
      • et al.
      Electrocardiographic features and outcome: Correlations in 124 hospitalized patients with COVID-19 and cardiovascular events.
      Cardiovascular events included heart failure, cardiogenic shock, acute myocardial infarction, cardiomyopathy, myocarditis, cardiac arrhythmias, cerebrovascular events, pulmonary embolism, pulmonary edema, deep vein thrombosis, and cardiac arrest. Clinical diagnoses of cardiovascular events were made by individual physicians at each site. In this cohort, 30 patients (61%) had echocardiography performed before their cardiac event, and 19 (39%) had echocardiography performed after their cardiac event. Our endpoints of analysis were admission troponin, peak troponin, and brain natriuretic peptide (BNP) concentrations. The echocardiographic parameters and laboratory values were stratified by the timing of the echocardiography. Correlations among the before-event echocardiographic parameters and admission troponin are detailed in Table 1. Significant correlations were found among LV ejection fraction, LV volume, mitral valve E/E’, and admission troponin. Correlations among the before-event echocardiographic parameters and BNP also are shown in Table 1. No before-event echocardiographic parameters were found to have significant correlations with BNP. Correlations of the after-event echocardiographic parameters with peak troponin and BNP are detailed in Table 2. A significant correlation was found between the RV diameter and peak troponin (r = 0.98; p = 0.019); however, no after-event echocardiographic parameters were found to be correlated significantly with BNP. Thus, LV systolic and diastolic dysfunction (indicated by an increased mitral valve E/E’ ratio) before a cardiovascular event were correlated with initial myocardial injury levels as indicated by admission troponin. An increase in RV size on after-event echocardiography was correlated with maximal myocardial injury, as indicated by peak troponin in COVID-19 patients.
      Table 1Pearson Correlations Between Before-event Echocardiographic Parameters and Log Admission Troponin and Log BNP
      Log TroponinLog BNP
      Variabler
      Pearson correlation coefficient.
      p Valuer
      Pearson correlation coefficient.
      p Value
      LV ejection fraction, %–0.68< 0.001–0.140.51
      LV volume, mL0.450.0390.040.87
      LA volume, mL–0.340.14–0.040.89
      RV diameter, cm0.250.280.420.08
      RA volume, mL0.240.270.180.45
      Ascending aorta size, cm0.040.91–0.460.35
      Peak E-wave, m/s–0.070.74–0.350.09
      TV TAPSE0.070.75–0.050.84
      Estimated RVSP, mmHg–0.150.590.160.54
      Estimated RAP, mmHg0.140.600.320.21
      MV E' Lateral Velocity, m/s–0.110.60–0.080.71
      MV E/E' Lateral0.430.0380.080.72
      Abbreviations: BNP, brain natriuretic peptide; LA, left atrium; LV, left ventricle; MV, mitral valve; RA, right atrium; RAP, right atrial pressure; RV, right ventricle; RVSP, right ventricle systolic pressure; TAPSE, tricuspid annular plane systolic excursion; TV, tricuspid valve.
      low asterisk Pearson correlation coefficient.
      Table 2Pearson Correlations Between After-event Echocardiographic Parameters and Log Peak Troponin and Log BNP
      Log TroponinLog BNP
      Variabler
      Pearson correlation coefficient.
      p Valuer
      Pearson correlation coefficient.
      p Value
      LV ejection fraction, %–0.200.61–0.410.11
      LV volume, mL–0.650.110.290.36
      LA volume, mL–0.620.38–0.080.86
      RV diameter, cm0.980.0190.550.10
      RA volume, mL0.320.540.220.51
      Ascending aorta size, cm–0.420.31–0.390.13
      Peak E-wave, m/s–0.790.420.100.81
      TV TAPSE0.030.96–0.310.39
      Estimated RVSP, mmHg–0.060.89–0.350.24
      Estimated RAP, mmHg–0.290.63–0.310.33
      MV E' Lateral Velocity, m/s0.800.100.510.13
      MV E/E' Lateral–0.200.61–0.410.11
      Abbreviations: BNP, brain natriuretic peptide; LA, left atrium; LV, left ventricle; MV, mitral valve; RA, right atrium; RAP, right atrial pressure; RV, right ventricle; RVSP, right ventricle systolic pressure; TAPSE, tricuspid annular plane systolic excursion; TV, tricuspid valve.
      low asterisk Pearson correlation coefficient.
      The novelties of this current study included the identification of before-event echocardiographic parameters, which correlated with initial myocardial injury levels, and the discovery of after-event echocardiographic parameters, which correlated with maximal myocardial injury levels. Changes in these echocardiographic parameters should alert physicians to imminent hemodynamic instability and mortality.
      This work was supported by the National Center for Advancing Translational Sciences [grant number U18TR003787]; the National Institute of Environmental Health Sciences [grant number P30 (P30ES030283)]; and Gilead Sciences COMMIT COVID-19 RFP Program [grant number IN-United States-983-6063]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Gilead Sciences.

      Acknowledgments

      The authors would like to acknowledge the excellent efforts of University of Louisville CERID group and Kornhauser Health Sciences Library to assist with this project.

      Conflict of Interest

      None.

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        Echocardiographic 60-day mortality markers in patients hospitalized in intensive care for COVID-19.
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