Role of cardiac biomarkers in cardiovascular manifestation of covid-19

ABSTRACT

Since early December 2019, an outbreak of pneumonia of unknown etiology has been reported in Wuhan, China The pathogen was then named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) by WHO, and the illness caused by it was termed as the Coronavirus Disease 2019 (COVID-19). Currently, the disease has rapidly spread to the whole world and become an international public health emergency. Although the SARS novel coronavirus (SARS-CoV-2) or COVID-19 is a viral illness, in fact it is systemic illness in which most of the organ systems are affected with varying degree. There are various patterns of cardiovascular involvement in COVID 19. First, cardiovascular disease present as pre-existing comorbidity which becomes apparent or becomes more complicated and decompensated during COVID 19. Second, cardiovascular system involvement results due to systemic inflammatory response during the course COVID 19. Third, cardiovascular system can be affected during treatment due to the side effects of some medication or secondary hospital-acquired infections and complications. Arrhythmias, acute coronary syndrome (ACS), myocarditis, Heart Failure and cardiomyopathy are the most common cardiovascular disease in COVID-19. The Fourth Universal Definition of Myocardial Infarction defines myocardial injury (acute or chronic) as cTn concentrations >99th percentile upper reference limit (URL). In COVID-19, cardiac injury is believed to be through multiple overlapping factors such as severe inflammatory response with uncontrolled cytokine activation and/or direct injury due to Virus infiltration in cardiomyocytes through angiotensin-converting enzyme 2 (ACE 2) receptors. Increases in cardiac biomarkers, especially, cardiac troponin (cTn) are common in patients with COVID-19, particularly in patients with underlying cardiovascular conditions and severe COVID-19 presentations, and are associated with worse outcomes and mortality. Thus, it is evident that cardiac injury plays a significant role in the disease progression and outcome associated with COVID-19. Thus, it is reasonable to include the indicators of cardiac injury in the patient's diagnosis, triaging, treatment, and prognosis, while recognizing that their abnormality may not be related to direct coronary involvement. Incorporation of cardiac biomarkers measurement (cTn and/or B-type natriuretic peptide [BNP]) to a set of other inflammatory and thrombotic markers may facilitate the understanding of COVID-19 stages, risk profiles, and disease phenotypes. Baseline measurements can facilitate stage classification and initial triage, and serial measurements help with short- and long-term risk stratification (likelihood for survival and/or adverse events). This information is likely to be most beneficial in patients in whom disease stage and risk status is uncertain, as well as in patients in whom risk is particularly high. In both cases, cardiac biomarkers can help with decisions about COVID19 patients' triage, management, therapeutic treatment and level of care.