Hackensack Meridian Cardiologists to Present New Research on Heart and Vascular Abnormalities in Patients with Serious COVID-19 Illness at American College of Cardiology 70th Annual Scientific Session, May 15-17, 2021

Emerging knowledge about cardiovascular complications of COVID-19 may help to inform treatment protocols and lower mortality

Cardiologists from Hackensack Meridian Hackensack University Medical Center will present five new analyses of cardiac and vascular abnormalities in hospitalized patients with serious COVID-19 illness at the ACC.21- American College of Cardiology 70th Annual Scientific Session, an all-virtual experience to be streamed live from May 15 to 17, 2021. The abstracts will be published in an online issue of the Journal of the American College of Cardiology, a top-ranked cardiovascular journal.

The collection of original analyses conducted by the Hackensack Meridian Health heart specialists show insights into heart and vascular abnormalities in patients hospitalized with serious COVID-19 illness. Serious illness in this context indicates a high risk of mortality from the infection with coronavirus. 

It’s estimated that almost 25 percent of people hospitalized with COVID-19 have been diagnosed with cardiovascular complications, which have been shown to contribute to roughly 40 percent of all COVID-19-related deaths.1   Gaining a deeper understanding of these cardiovascular manifestations in COVID-19 can help cardiac clinicians better anticipate clinical issues and outcomes and make optimal treatment decisions.

Cardiac abnormalities observed in patients with serious COVID-19 illness in these analyses are higher air-pressure levels at the end of the respiratory cycle in patients on ventilators and its possible relationship to diminished blood flow from the heart; the presence of cardiogenic shock due to microvascular impairment in COVID-19; the relationship between troponin, a protein released in the blood when the heart muscle is damaged, and how troponin correlates with inflammatory markers in COVID-19. A final study analyzed admission electrocardiograms (EKGs) of hospitalized COVID-19 patients who developed shock, finding that despite high mortality in these patients, the admission EKGs had minor abnormalities.

“Insights into the relationship between severe COVID-19 illness and cardiovascular manifestations are beginning to emerge,” said Joseph E. Parrillo, M.D., chair of the Heart and Vascular Hospital and the Justice Marie L. Garibaldi Endowed Chair at Hackensack Meridian Health Hackensack University Medical Center.  “While we know that coronavirus is primarily an infection of the respiratory system, including the lungs in severe cases, resulting in acute pneumonia, it can have substantial effects on the heart and cardiovascular system as well.  We are closely looking at hemodynamics -- or the heart rate, blood pressure and ability of the heart to pump blood – in COVID-19 patients so we better understand the cardiac and vascular manifestations and how to best treat them.”  Dr. Parrillo and his team conducted the analyses listed below and will present them virtually at the meeting.

One observation from the research, overall, is the need to balance fluid management in COVID lung illness and inflammation, specifically COVID-related pneumonia, with re-establishing or maintaining cardiac function and the need for proper fluid maintenance to accomplish that.

Dr. Parrillo commented that his team’s work also revealed that the COVID-19 patients they studied who had heart attacks do not seem to have the extensive lipid plaques that are seen in heart attacks of patients who do not have COVID-19. They also did not have the same level of thrombosis or local clotting of blood in the heart or circulatory system.  “These patients are less likely to have plaques and clots.  In these seriously ill  COVID-19 patients with cardiovascular abnormalities, the coronavirus may change the pattern of damage that is done to the heart and vascular system.” he said. 

The Hackensack Meridian researchers used a unique database of recorded cardiovascular abnormalities found in patients with serious COVID-19 illness who were treated at Hackensack Meridian Health network hospitals from March to December 2020.   

Abstract 1:  “Effect of PEEP on Hemodynamics in Covid Patients with Shock” 

Authors: Hollenberg Fata Parrillo, et al.  

PEEP is positive-end expiratory pressure in patients on ventilators -- air pressure remaining in the airways at the end of the respiratory cycle that is greater than the atmospheric pressure. Patients with serious COVID infections frequently develop shock, a life-threatening condition that occurs when the body is not getting enough blood flow. In this analysis of 57 patients with serious COVID infections and shock who were on ventilators, higher PEEP levels correlated with low cardiac index, a measure of cardiac output from the left ventricle. These patients had normal left ventricle systolic function, suggesting PEEP and mechanical ventilation contribute to left ventricle underfilling in these patients, possibly by decreasing venous return, although fluid management strategies and other factors might contribute. The researchers concluded that although mortality of 70 percent did not vary with cardiac index in this group of patients (they had low cardiac index and normal left ventricle systolic function), fluids might increase cardiac index. This study has potential to enable cardiovascular clinicians to understand the effects of mechanical ventilation with positive end-expiratory pressure on the dynamics of blood flow in patients with COVID-19.

Abstract 2: Hemodynamic Profiles of Shock in Critically Ill Covid Patients 

Authors: Hollenberg Safi Parrillo, et al 

Patients with serious COVID infections frequently develop shock, a life-threatening condition from lack of sufficient blood flow.  Their hemodynamic profile has not been well characterized. In this analysis of 1275 patients hospitalized with COVID pneumonia, 215 had shock requiring vasopressors, medicines which increase blood pressure and restore blood profusion to the organs. One-hundred and sixty-two had echocardiography to assess ventricular function and volume of blood pumped out of the left ventricle of the heart during each systolic cardiac contraction (stroke volume). Patients were characterized by volumetric fraction of fluid ejected from a heart chamber with each contraction and cardiac index, a measure of cardiac output from the left ventricle, and divided into groups with normal or low values. The mean age of patients was 66.7 years.  Overall hospital mortality for the group was 77 percent. Five patients had obstructive shock, four had pulmonary emboli, one had pneumothorax, or collapsed lung.  The other 157 patients were divided into groups based on ejection fraction and cardiac index.  Mortality did not differ significantly among groups but was highest in the group with low ejection fraction and low cardiac index.  The analysis concluded that the proportion of COVID-19 patients with classic cardiogenic shock (low ejection fraction and low cardiac index) was higher than expected, possibly due to microvascular impairment in COVID-19. Mortality was high, especially with low ejection fraction and cardiac index.  This study will help cardiovascular clinicians to better understand hemodynamic findings in patients with COVID-19.

Abstract 3: “Initial, Maximum and Delta Troponin and Mortality in Covid-19” 

Authors: Go Klinkhammer Hollenberg, et al. 

Troponin is a type of protein found in the muscles of the heart. It is not normally found in the blood. When heart muscles are damaged such as in a heart attack, troponin is sent into the bloodstream. As heart damage increases, greater amounts of troponin are released in the blood. Troponin may serve as a predictor of mortality in COVID-19. In this analysis, the researchers assessed the association between troponin levels (initial, maximum, and delta (percent difference between two troponin results taken within a 3–8-hour time period in same patient) and mortality. The researchers found that maximum troponin and change in troponin, but not initial troponin, were predictive of mortality, suggesting the value of serial troponin measurement in these patients. Maximum troponin levels and shock were independently associated with higher risk of mortality. This analysis will enable cardiologists to predict prognosis from trends in levels of troponin. It also suggests there is another mechanism for cardiac dysfunction and elevation of troponin besides low flow cardiac state from shock. 

Abstract 4: Troponin Correlates with Inflammatory Markers in Covid-19 

Authors: Klinkhammer Go Hollenberg, et al. 

Mortality from COVID-19 is thought to be related to a hyper-inflammatory response. In this analysis the authors characterize the relationship between troponin (initial, maximum, and delta) and inflammatory markers. They reviewed records of 586 COVID-19 patients admitted at Hackensack Meridian Health network hospitals with at least two troponin values between February and June 2020. Statistical analyses were performed for factors correlating with mortality such as age, C reactive protein, interleukin 6, initial, maximum and delta troponins, and hypertension, use of beta blockers, statins, known coronary artery disease, prior percutaneous cardiac intervention, heart failure, hemodialysis and shock. Other statistical analysis showed that age, coronary artery disease, and maximum troponin remained significantly associated with mortality. Spearman’s correlation (SC) showed that maximum troponin was correlated with IL-6, D-dimer, BNP, and creatinine. The authors concluded that correlations of IL-6, a protein that helps regulate immune responses, and D-dimer, a small protein fragment present in the blood after a blood clot is degraded, suggest a hyper-inflammatory response contributes to troponin levels. Elevated beta natriuretic peptide and creatinine may lead to elevated troponin levels or multi-organ dysfunction and can be a sequela of cardiac dysfunction. The authors conclude that further studies are needed to determine if attenuation of inflammatory response may decrease troponin levels and thus reduce cardiac injury. This study will enable cardiovascular clinicians to understand the relationship between troponin levels, inflammatory markers, and mortality in COVID-19, which could reduce cardiac injury. 

Abstract 5: Analysis of Admission Electrocardiograms (EKGs) of Hospitalized COVID-19 Patients Who Developed Shock  

Authors: Glotzer Jamal Parrillo, et al. 

Severe Acute Respiratory Syndrome Coronavirus-2 causes COVID-19 and can have a significant effect on cardiovascular function even leading to shock. The electrocardiogram (EKG) is usually the first cardiovascular assessment and could be used to stratify cardiac risk in patients admitted to the hospital. Between March and May 2020, the authors treated 215 hospitalized COVID-19 patients who developed shock (hypotension requiring vasopressors, to increase blood pressure), 150 of whom had an admission EKG. The authors used statistical analyses that included age, manually adjudicated EKG abnormalities, and clinical characteristics to look for predictors of the adverse outcomes of intubation, death, and prolonged length of stay, greater than 14 days.  The median age was 66 years, with primarily men (65.8%) and non-white (63.3%) patients. EKG abnormalities were: 35.3% abnormal atrial rhythm [defined as other than normal sinus 60-100 bpm] (27.3 % sinus tachycardia >100bpm, 2.67% sinus bradycardia < 50bpm, 7.43% atrial fibrillation), abnormal T waves 17.9%, abnormal axis 21.34%, low voltage 15.99%, high voltage 7.33%, poor R wave progression 30.7%, Q waves 15.3%, and presence of atrial and ventricular premature beats (11.33% and 6% respectively). The patients in this analysis had very poor outcomes with 97.3 % intubation, 80 % mortality, and 56% with prolonged LOS. Statistical analysis revealed no EKGs parameters that predicted adverse outcomes. This is partially explained by the high occurrence of the first 2 endpoints (intubation and death). For the third endpoint (LOS>14 days), the patients that survived had more prolonged hospitalizations. The authors found that older age and male gender were associated with increased mortality, while LOS and duration of ventilation had a protective effect against mortality. The authors concluded that despite the very high mortality observed in these COVID-19 patients with shock, the admission EKGs have relatively minor abnormalities. They did not find any EKG parameter that was associated with the adverse outcomes of intubation, death, or prolonged LOS. Further study of the progression of EKG changes during hospitalization may provide additional insight into predicting poor prognosis. This study will help enable cardiovascular clinicians to predict adverse prognosis in COVID-19.