key: cord-1018387-uo88b0mk authors: Montone, Rocco A; Iannaccone, Giulia; Meucci, Maria Chiara; Gurgoglione, Filippo; Niccoli, Giampaolo title: Myocardial and Microvascular Injury Due to Coronavirus Disease 2019 date: 2020-06-23 journal: Eur Cardiol DOI: 10.15420/ecr.2020.22 sha: 253c05bde544faa3fd755270e1ab287a1fb509ce doc_id: 1018387 cord_uid: uo88b0mk Over the past few months, health systems worldwide have been put to the test with the coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Even though the leading clinical manifestations of the SARS-CoV-2 infection involve the respiratory tract, there is a non-negligible risk of systemic involvement leading to the onset of multi-organ failure with fatal consequences. Since the onset of COVID-19, patients with underlying cardiovascular disease have been at increased risk of poor clinical outcomes with higher death rates. Moreover, the occurrence of new-onset cardiac complications is not uncommon among patients hospitalised for COVID-19. Of importance, a significant portion of COVID-19 patients present with myocardial injury. Herein, the authors discuss the mechanisms leading to myocardial and microvascular injury in SARS-CoV-2 infection and their clinical implications. necrosis may be useful in predicting the risk of in-hospital death. 5 Of importance, the area under the receiver operating characteristic curve of initial cardiac troponin I for predicting in-hospital mortality was 0.92 (95% CI [0.87-0.96], sensitivity: 0.86, specificity: 0.86, p<0.001), and in the multivariable logistic regression, older age, comorbidities (e.g. hypertension, coronary heart disease, chronic renal failure and chronic obstructive pulmonary disease), and a high level of C-reactive protein were predictors of myocardial injury. Myocardial injury could be due to different pathogenic mechanisms (ischaemic or non-ischaemic), and thus have different clinical consequences. 4 In particular, cardiac ischaemia can arise from an imbalance between oxygen supply and demand, a type 2 MI, a situation that can prevail in acute infections, particularly those that affect the lungs, such as COVID- 19 . As with other pneumonias, cardiac troponins are often increased in COVID-19 as a result of pre-existing CVD and/or the acute stress related to the viral infection, thereby mild elevations in patients without signs or symptoms of heart involvement nor ECG changes do not require further investigation. However, cardiac biomarker levels correlate with disease severity and prognosis, so attention should be paid to increments that are two to three times the upper limit, which could be associated with typical angina and/or newonset ECG abnormalities as possible markers of cardiac ischaemic or non-ischaemic damage. 6 Type 2 MI is typically related to imbalanced myocardial oxygen demand and supply, and several different mechanisms could lead to this complication in COVID-19 patients. For example, the hypotension determined by the septic state and the blood hypoxemia as a consequence of respiratory function impairment could reduce oxygen supply to the heart, thus leading to acute myocardial injury, particularly in patients with underlying chronic coronary syndrome. 7 Moreover, increased myocardial oxygen demand could be a consequence of sustained/repetitive cardiac arrhythmias, which has been reported in 16 increase in pneumonia-associated short-term mortality. 16, 17 The occurrence of myocardial injury in particular has been shown to be associated with higher mortality among COVID-19 patients. 9 A highly fatal possible consequence of myocardial injury due to SARS- The ACE2 expression in human heart indicates new potential mechanism of heart injury among patients infected with SARS-CoV-2 The trinity of COVID-19: immunity, inflammation and intervention COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China Characteristics and clinical significance of myocardial injury in patients with severe coronavirus disease 2019 European Society of Cardiology. 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