Imaging Study Looks at Myocardial Pathology in Recovered COVID-19 Patients

Main, Germany—More and more evidence is pointing to the inescapable conclusion that, even when the COVID-19 pandemic is over, healthcare effects will linger.

A study in JAMA Cardiology recently looked at the cardiovascular effects in patients with recent coronavirus disease 2019 treated between April and June 2020.

Led by German researchers from University Hospital in Frankfurt, the cohort study included 100 patients recently recovered from COVID-19 identified from a test center. Researchers report that cardiac magnetic resonance imaging revealed cardiac involvement in 78 patients (78%) and ongoing myocardial inflammation in 60 patients (60%). The myocardial injury was independent of preexisting conditions, severity, overall course of the acute illness, and the time from the original diagnosis, they said.

Researchers point out that much of COVID-19 research has focused on acute respiratory complications, especially in critically ill patients, but increasing reports suggest that the infection prominently affects the cardiovascular system by exacerbating heart failure in patients with preexisting cardiac conditions and troponin elevation in critically ill patients.

Some of the previous studies suggest that fulminant myocarditis was a possibility in 7% of patients with lethal outcome, while others proposed pathophysiologic mechanisms of cardiac injury that include inflammatory plaque rupture, stent thrombosis, cardiac stress due to high cardiac output, and infection via the angiotensin-converting enzyme 2 receptors causing systemic endothelitis.

“There remains poor insight into the cardiovascular sequelae in unselected patients, including those with no preexisting conditions, who were not hospitalized, or had no or only mild symptoms,” researchers explained. “To better understand the prevalence, extent, and type of cardiovascular sequelae, we proactively examined patients with a documented recent COVID-19 infection using serological markers of cardiac injury and highly standardized in-depth imaging with CMR.”

To do that, this international study team obtained demographic characteristics, cardiac blood markers, and cardiovascular magnetic resonance (CMR) images. The team compared age-matched and sex-matched control groups of 50 healthy volunteers to 57 risk-factor–matched patients.

Of the 100 included patients, 53 (53%) were male, and the median (interquartile range [IQR]) age was 49 (45-53) years. The median (IQR) time interval between COVID-19 diagnosis and cardiovascular magnetic resonance imaging was 71 (64-92) days. While 67 of the 100 patients recently over COVID-19 recovered at home, 33 required hospitalization.
At the time of CMR, high-sensitivity troponin T (hsTnT) was detectable (3 pg/mL or greater) in 71 patients recently recovered from COVID-19 (71%) and significantly elevated (13.9 pg/mL or greater) in five patients (5%).

“Compared with healthy controls and risk factor–matched controls, patients recently recovered from COVID-19 had lower left ventricular ejection fraction, higher left ventricle volumes, higher left ventricle mass, and raised native T1 and T2,” the researchers advise. In addition, they said, 78 patients recently recovered from COVID-19 (78%) had abnormal CMR findings, including raised myocardial native T1 (n = 73), raised myocardial native T2 (n = 60), myocardial late gadolinium enhancement (n = 32), and pericardial enhancement (n = 22).

Researchers identified a small but significant difference between patients who recovered at home versus in the hospital for native T1 mapping (median [IQR], 1,122 [1,113-1,132] ms vs. 1,143 [1,131-1,156] ms; P = .02) but not for native T2 mapping or hsTnT levels.

The study reports that none of the measures were correlated with time from COVID-19 diagnosis (native T1: r = 0.07; P = .47; native T2: r = 0.14; P = .15; hsTnT: r = −0.07; P = .50). High-sensitivity troponin T was significantly correlated with native T1 mapping (r = 0.35; P < .001) and native T2 mapping (r = 0.22; P = .03), it adds.

“Endomyocardial biopsy in patients with severe findings revealed active lymphocytic inflammation. Native T1 and T2 were the measures with the best discriminatory ability to detect COVID-19–related myocardial pathology,” according to the article.

“In this study of a cohort of German patients recently recovered from COVID-19 infection, CMR revealed cardiac involvement in 78 patients (78%) and ongoing myocardial inflammation in 60 patients (60%), independent of preexisting conditions, severity and overall course of the acute illness, and time from the original diagnosis,” the authors conclude. “These findings indicate the need for ongoing investigation of the long-term cardiovascular consequences of COVID-19.”


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