Epidemiology of Acute Heart Failure in Critically Ill Patients With COVID-19: An Analysis From the Critical Care Cardiology Trials Network.

BACKGROUND: Acute heart failure (HF) is an important complication of coronavirus disease 2019 (COVID-19) and has been hypothesized to relate to inflammatory activation. METHODS: We evaluated consecutive intensive care unit (ICU) admissions for COVID-19 across 6 centers in the Critical Care Cardiology Trials Network, identifying patients with vs without acute HF. Acute HF was subclassified as de novo vs acute-on-chronic, based on the absence or presence of prior HF. Clinical features, biomarker profiles and outcomes were compared. RESULTS: Of 901 admissions to an ICU due to COVID-19, 80 (8.9%) had acute HF, including 18 (2.0%) with classic cardiogenic shock (CS) and 37 (4.1%) with vasodilatory CS. The majority (n = 45) were de novo HF presentations. Compared to patients without acute HF, those with acute HF had higher cardiac troponin and natriuretic peptide levels and similar inflammatory biomarkers; patients with de novo HF had the highest cardiac troponin levels. Notably, among patients critically ill with COVID-19, illness severity (median Sequential Organ Failure Assessment, 8 [IQR, 5-10] vs 6 [4-9]; P = 0.025) and mortality rates (43.8% vs 32.4%; P = 0.040) were modestly higher in patients with vs those without acute HF. CONCLUSIONS: Among patients critically ill with COVID-19, acute HF is distinguished more by biomarkers of myocardial injury and hemodynamic stress than by biomarkers of inflammation.

Spectrum of Cardiac Involvement in COVID-19.

Cardiac involvement in coronavirus disease 2019 (COVID-19) commonly accompanies multi-organ system failure with acute respiratory syndrome; however, infrequently myocarditis and pericardial effusions may be isolated, yet fulminant. In this report, we highlight significant variations in cardiac involvement and presentation among patients with COVID-19. This article reports two cases of fulminant myocarditis in COVID-19 positive patients who presented to our facility with contrasting symptoms, laboratory and imaging findings. A 65-year-old patient A had a more typical presentation including respiratory distress, chest pain, ST-segment elevations on electrocardiogram (EKG), lymphopenia, elevated levels of inflammatory markers and cardiac troponin I. A 34-year-old patient B presented with shortness of breath and chest pain similar to patient A; however, she had isolated cardiac involvement with systolic dysfunction and an acute pericardial effusion causing tamponade physiology. Inflammatory marker and cardiac troponin I levels for patient B were within normal range. Patient A had a rapid progression of multi-organ system failure leading to her death within 24 hours from presentation on maximal inopressor support. Patient B, however, is one of few reported cases of cardiac tamponade and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use in COVID-19 who underwent pericardiocentesis and was additionally managed with colchicine and steroids, leading to complete recovery in systolic function within three weeks from initial presentation. Isolated myocardial dysfunction and pericardial effusions in COVID-19 may have catastrophic sequalae even in the absence of elevated biomarkers described in literature. Therefore, early detection and management of cardiac involvement is warranted. Additionally, the role of mechanical circulatory support devices and VA-ECMO in COVID-19 needs further investigation.