INTRODUCTION
Since the onset of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease 2019 (COVID-19), media and medical literature have pursued the progress of this infection, its complications, and its implications. The increase in the number of cases and its rapid spread resulted in a worldwide pandemic. To date, >5,800,000 COVID-19-related deaths have been confirmed worldwide which in turn has led to an unprecedented global crisis.[1,2,3] India alone has reported more than 4 crores COVID-19 cases and about 5 lac deaths.[4] The data generated by various hospitals, districts, and states across the country have displayed painstaking efforts put in by health-care professionals involved in diagnosing, reviewing, and reporting patients and their outcomes. The affected nations today face varied challenges on social, environmental, health, and economic fronts.
The clinical manifestations of the disease were mild in most of the patients who tested positive for SARS-CoV-2.[5,6] However, as low as 5% of hospitalized patients required advanced medical support or intensive care.[7] The long-term implications postrecovery are largely unknown. Some research and studies retrospectively have suggested reported signs of cardiovascular (CV) complications present in at least one-quarter of severe cases.[8,9] In one of the studies, persistent cardiac involvement was observed in 78% of patients where authors conducted cardiac magnetic resonance in 100 COVID-19 patients at 2–3 months following the disease.[10] There have been few trials and studies conducted in this regard, but there is still a large scarcity of prospective trials which will be put to examine the true prevalence of these complications.
Hence, long-term studies are required to monitor silent but progressive CV complications postrecovery in COVID-19 patients. Our aim of the study is to assess and determine the presence of CV morbidity and mortality in COVID-19 patients.
MATERIALS AND METHODS
This retrospective study was conducted at our institute. The data were obtained from patient's medical record file, admitted in the intensive care unit (ICU) between April 3, 2020, and May 23, 2021, after ethical clearance (EC/Approval/22/C. Anae/June 13, 2022). A total of 1460 patients (aged 18 years and above) were enrolled and monitored until discharge/death.
Patient demographics, clinical data, and laboratory values were collected by the investigator. The collected data were recorded and evaluated.
Coronary angiography
The patients who complained for chest pain or echocardiography (ECG) changes were subjected to coronary angiography. This procedure was conducted to measure the pressures in the heart chambers. All the available coronary segments were visually scored for the presence of significant stenosis and independently analyzed by a cardiologist.
Statistical analysis
The recorded data were evaluated and presented based on mean, median, and proportion. Pearson correlation coefficient was used to establish the relationship between cardiac markers. All the analyses were performed on SPSS, Version 20.0 (Chicago, IL, USA) Software.
RESULTS
Based on the study sample, the patient characteristics and clinical findings are depicted in Table 1. A total of 1460 patients were enrolled with 933 males and 527 females. Patients were predominantly male (63.9%), and the average age of the study population was 56.9 ± 15.32 years. The total reported deaths was 31%, which indeed was relatively very high when compared to our center's annual average death rate [Figure 1]. Hypertension (35.6%), diabetes (14.45%), CV disease (6.02%), and hypothyroidism (4.17%) were the most common preexisting clinical conditions among these patients [Table 1].
;)
Figure 1:
Mortality among COVID-19 patients and COVID-19 patients with CV complications. COVID-19: Coronavirus disease 2019, CV: Cardiovascular
Table 1:
Patient characteristics and clinical findings
Among these admitted patients, some were clinically evaluated and tested for creatine phosphokinase-MB (CPK-MB) (n = 178), C-reactive protein-Q (n = 1417), D-dimer (n = 1401), ferritin (n = 1297), interleukin 6 (n = 948), lactate dehydrogenase (n = 1355), neutrophil-to-lymphocyte ratio (n = 1430), and hs-TnI (n = 178). This selection among patients was based on the clinician's opinion and suggestion and the patient's requirements. The clinical and diagnostical representation of the study sample is depicted in Table 2.
Table 2:
Clinical and diagnostical representation
Among 178 patients tested for CPK-MB, 149 patients fell above the sequence range of <25. Seventy-one (47.65%) deaths were reported among these patients, which was relatively very high. Eighty-eight patients had preexisting CV disease and among these, 42 fell above the sequence range of <25 for CPK-MB, thus, the remaining 107 patients were newly diagnosed.
A total of 141 patients displayed elevated hs-TnI levels. For further analysis, the correlation between the absolute rise of cardiac troponin (hs-TnI) and CPK-MB was measured. The regression analysis shows a positive correlation but a weaker relationship between the two variables (r: 0.2113, P < 0.01 for correlation).
Forty-two patients underwent elective/emergency coronary angiography and the average time taken for the procedure was 25.71 ± 18.07 min. The results are depicted in Table 3.
Table 3:
Patient characteristics based on coronary angiography
DISCUSSION
With COVID-19 onset, many researchers have focused on its long-term complications, however, there still seems a paucity of large and prospective trials. Thus, the present study was conducted with the primary outcome of (1) determining the CV morbidity in COVID-19 patients and (2) in-hospital deaths among these patients. The study sample presented with high prevalence of hypertension, diabetes, CV disease, and hypothyroidism. Similar results were reported in one of the studies on myocardial inflammation and dysfunction among COVID-19 patients. CV complications were present in about 10% of the study population with a death rate of 47.65%.[11] Similar results were reported where the myocardial injury was found to be a typical COVID-19-related phenomenon present in 20%–30% of patients and contributing to 40% of the deaths.[10]
Eighty-eight patients in the present study reported having preexisting CV disease, however, 107 patients were newly diagnosed. A similar autopsy study of 39 patients who died due to COVID-19 displayed myocardial complications which had not been previously diagnosed.[12] Our study thus attempts to emphasize CV complications following COVID-19. However, the long-term impact of COVID-19-associated CV dysfunction remains unknown. This is one of the limitations of our study and hence we suggest that long-term studies are required to examine the potential damage caused by COVID-19 which will add perspective to determining the incidence and clinical course of myocardial damage and further help them in decreasing CV morbidity and mortality. In the current study, we found that 149 patients had elevated CPK-MB while 141 patients had elevated hs-TnI. Further, we found a positive correlation between the absolute values of CPK-MB and hs-TnI (r: 0.2113) which was significant at P < 0.01. The correlation through positive but displayed a weaker relationship. Similar results have been found in studies conducted over time, where the researchers found a positive correlation between CPK-MB and troponin-I values. The same results of the current study are also found in the study published by Welsh et al.[13] and Januzzi et al.[14] To decipher the impact of COVID-19 on cardiac complications, some patients were also exposed to coronary angiography as recommended by the cardiologist. A total of 42 patients underwent coronary angiography, for 37, the procedure was elective, while 5 cases were under emergency, the procedure approach was radial for 36 cases and femoral for 6 cases. Twenty-two out of 42 patients showed the presence of single/multivessel disease and 31 patients displayed mild-to-severe left ventricular dysfunction. The results of the current study might also be associated with preexisting conditions such as hypertension and diabetes mellitus, which were prevalent in some patients. The results are supported by Bansal[15] study brief CV manifestations in COVID-19 patients. Other studies by Xie et al. also emphasized the long-term CV complications of COVID-19 and found the risk of CV disease in COVID-19 patients substantial.[16]
Our study also has limitations. First, our study sample was small and the results need to be evaluated by larger samples. Second, we only included COVID-19 ICU admissions and hence we were not able to include other COVID-19 hospitalized patients with CV complications. Therefore, we cannot determine the true prevalence. Third, only 42 patients underwent coronary angiography, which is a very small sample size.
CONCLUSIONS
The results of the current study provide CV complications were present in about 10% of the study population with a death rate of 47.65% among COVID-19 patients. Thus, it becomes a clinical challenge as this dreadful combination dictates prognosis and high risk of intensive care mortality. Hence, attention to long-term CV health and disease among COVID-19 survivors is necessary.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Last accessed on 2021 Oct 01 Available from:
https://covid19.who.int/
2. Li Z, Farmanesh P, Kirikkaleli D, Itnai R. A comparative analysis of COVID-19 and global financial crises: Evidence from US economy Econ Res. 2022;35:2427–41
3. Wang C, Wang D, Abbas J, Duan K, Mubeen R. Global financial crisis, smart lockdown strategies, and the COVID-19 spillover impacts: A global perspective implications from Southeast Asia Front Psychiatry. 2021;12:643783.
4. Last accessed on 2021 Oct 01 Available from:
https://www.mohfw.gov.in/
5. Wiersinga WJ, Rhodes A, Cheng AC, Peacock SJ, Prescott HC. Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (COVID-19): A review JAMA. 2020;324:782–93
6. Gandhi RT, Lynch JB, Del Rio C. Mild or moderate COVID-19 N Engl J Med. 2020;383:1757–66
7. World Health Organization. . Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: interim guidance 2020Last accessed on 2023 Feb 20 Available from:
https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf
8. Inciardi RM, Lupi L, Zaccone G, Italia L, Raffo M, Tomasoni D, et al Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19) JAMA Cardiol. 2020;5:819–24
9. Xiong TY, Redwood S, Prendergast B, Chen M. Coronaviruses and the cardiovascular system: Acute and long-term implications Eur Heart J. 2020;41:1798–800
10. Puntmann VO, Carerj ML, Wieters I, Fahim M, Arendt C, Hoffmann J, et al Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19) JAMA Cardiol. 2020;5:1265–73
11. Akhmerov A, Marbán E. COVID-19 and the heart Circ Res. 2020;126:1443–55
12. Lindner D, Fitzek A, Bräuninger H, Aleshcheva G, Edler C, Meissner K, et al Association of cardiac infection with SARS-CoV-2 in confirmed COVID-19 autopsy cases JAMA Cardiol. 2020;5:1281–5
13. Welsh TM, Kukes GD, Sandweiss LM. Differences of creatine kinase MB and cardiac troponin I concentrations in normal and diseased human myocardium Ann Clin Lab Sci. 2002;32:44–9
14. Januzzi JL, Lewandrowski K, MacGillivray TE, Newell JB, Kathiresan S, Servoss SJ, et al A comparison of cardiac troponin T and creatine kinase-MB for patient evaluation after cardiac surgery J Am Coll Cardiol. 2002;39:1518–23
15. Bansal M. Cardiovascular disease and COVID-19 Diabetes Metab Syndr. 2020;14:247–50
16. Xie Y, Xu E, Bowe B, Al-Aly Z. Long-term cardiovascular outcomes of COVID-19 Nat Med. 2022;28:583–90
