COVID-19 Latest: Cornell University Study Shows That Damage To Heart's Right Ventricle Indicates Higher COVID-19 Mortality Risk
: According to a new study by researchers from Weill Cornell Medicine and New York-Presbyterian when a patient is hospitalized with COVID-19, signs of damage to the right side of the heart may indicate a greater risk of death.
The study findings suggest that doctors should consider looking for such damage using a readily available and non-invasive ultrasound test called an echocardiogram.
The study findings were published in the peer reviewed Journal of the American College of Cardiology. https://www.sciencedirect.com/science/article/pii/S0735109720365505?via%3Dihub
Physicians commonly assess lung X-rays, medical history, blood-oxygen levels, blood markers of inflammation and other indicators to determine which incoming COVID-19 patients are most at risk of developing severe disease.
Study team studied in detail 510 patients and found that signs of damage to the heart's right ventricle on an echocardiogram are another strong and independent predictor of severe disease.
It was found that patients who had signs of impaired right ventricle pumping capacity were on average two and a half times more likely to die from COVID-19 during their hospitalization.
It is long known that the heart's right ventricle is the pump that pushes blood into the lungs to be oxygenated.
Physicians have long known that problems affecting lung function, including inflammation triggered by respiratory viruses, can stress and impair this pump, usually by increasing the lungs' resistance to blood flow. But the investigators believe the new study is the first to show that such an impairment is an independent predictor of COVID-19 mortality risk, with predictive value over and above that of other risk markers.
Lead author Dr Jiwon Kim, an associate professor of medicine in the Division of Cardiology at Weill Cornell Medicine and a cardiologist at NewYork-Presbyterian/Weill Cornell Medical Center told Thailand Medical News, "We looked at the standard markers that are used to predict COVID-19 mortality, and right heart dysfunction was an even stronger predictor."
Senior author Dr Jonathan Weinsaft, professor of medicine in the Division of Cardiology at Weill Cornell Medicine and a cardiologist at NewYork-Presbyterian/Weill Cornell Medical Center added, "This study tells us that non-invasive cardiovascular imaging plays an important role in decision-making in COVID-19 cases."
The study team analyzed diagnostic and prognostic tests, and clinical outcomes, for a series of 510 consecutive COVID-19 patients, covering multiple ethnicities, who were admitted to NewYork-Presbyterian/Weill Cornell Medical Center, NewYork-Presbyterian Lower Manhattan, or NewYork-Presbyterian Queens and received echocardiograms from mid-March to mid-May. The research included a broad collaboration between investigators in cardiology, general internal medicine and biostatistics at Weill Cornell Medicine, and leveraged an institutional registry developed by Dr Monika Safford and Dr Parag Goyal.
The typical median age of the patients was 64, and two-thirds were male.
The study team found that patients with a standard sign of right ventricle damage, the expansion or "dilation," of the pumping chamber, were 1.43 times as likely to die during initial hospitalization for COVID-19. Patients whose right ventricles showed significantly below-normal contraction while pumping ie a condition called "right ventricular dysfunction" were nearly 3-fold as likely to die. These two heart signs were relatively common in the patients, being present in 35 percent and 15 percent, respectively.
Importantly in the study team's analysis, no other standard marker of severe COVID-19 risk predicted mortality as strongly as right ventricular dysfunction.
The study details are as follows: In total, 510 patients (age 64 ± 14 years, 66% men) were studied; RV dilation and dysfunction were present in 35% and 15%, respectively. RV dysfunction increased stepwise in relation to RV chamber size (p = 0.007). During inpatient follow-up (median 20 days), 77% of patients had a study-related endpoint (death 32%, discharge 45%). RV dysfunction (hazard ratio [HR]: 2.57; 95% confidence interval [CI]: 1.49 to 4.43; p = 0.001) and dilation (HR: 1.43; 95% CI: 1.05 to 1.96; p = 0.02) each independently conferred mortality risk. Patients without adverse RV remodeling were more likely to survive to hospital discharge (HR: 1.39; 95% CI: 1.01 to 1.90; p = 0.041). RV indices provided additional risk stratification beyond biomarker strata; risk for death was greatest among patients with adverse RV remodeling and positive biomarkers and was lesser among patients with isolated biomarker elevations (p ≤ 0.001). In multivariate analysis, adverse RV remodeling conferred a >2-fold increase in mortality risk, which remained significant (p < 0.01) when controlling for age and biomarker elevations; the predictive value of adverse RV remodeling was similar irrespective of whether analyses were performed using troponin, D-dimer, or ferritin.
Dr Weinsaft added, "A big question for us was whether these right ventricular findings were independent predictors of mortality, or whether they were secondary markers of other prognostic factors, and it turns out they are strong and independent predictors."
The study findings support wider use of cardiovascular imaging to assess the risk of severe COVID-19 and to tailor patient care accordingly, the researchers concluded.
Current ongoing research by Dr Kim and Dr Weinsaft is focused on predictive value of right ventricular dysfunction in COVID-19 survivors, as well as testing whether COVID-19 induced changes in cardiac structure and function stem from underlying changes in myocardial tissue properties: The long term goal of their team is to improve cardiovascular treatments and clinical outcomes for patients with COVID-19.
Findings of this study demonstrate adverse RV remodeling as assessed by echo-quantified RV dilation or dysfunction, to be a powerful prognostic indicator in patients with COVID-19, for which predictive utility is incremental to routine clinical and/or biomarker-based assessments. Future research is warranted to elucidate inflammatory pathways and myocardial tissue properties responsible for RV dysfunction in patients with acute COVID-19, as well as whether COVID-19 survivors with adverse RV remodeling are at residual risk for adverse clinical outcomes.
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