Table 1.

Summary of Studies Addressing Cardiac Troponin and/or Myocardial Injury in Patients With COVID-19

First Author (Ref. #)	Location	Population	Prevalence of Cardiovascular Disease	Cardiac Troponin Assay and Myocardial Injury Definition	Frequency	Outcomes	Comments
Arentz et al. (8)	Evergreen Hospital, Washington, United States	21 intensive care unit patients	CHF, 42.9%	cTn assay details NR Threshold: >0.3 ng/ml	3 patients (14%) had cTn concentrations >0.3 ng/ml	NR by cTn results Entire cohort: Cardiomyopathy, 33.3% Death, 52.4%	BNP mean: 4,720 (69–33,423) Vasopressors: 67%
Bhatraju et al. (9)	9 hospital ICUs in Seattle, Washington, United States	24 intensive care unit patients	NR	cTn assay details NR Threshold: ≥0.06 ng/ml	cTn concentrations were elevated (≥0.06 ng/ml) in 2 of 13 (15%) patients early in their ICU course (maximum value, 0.80 ng/dl)	NR by cTn results In-hospital death: 50%	Echocardiogram completed in 9 of 24 (38%), with none showing left ventricular dysfunction Vasopressors: 71%
Chen et al. (3)	Tongji Hospital, Wuhan, China	799 moderately to severely ill or critically ill patients with confirmed COVID-19 transferred from other hospitals or isolation sites or admitted from fever clinics to Tongji Hospital, of which the final study cohort included 113 who died and 161 who had recovered	Among deaths, CVD (14%) Among recovered patients, CVD (4%)	cTn assay details NR Threshold: >15.6 pg/ml	Entire cohort (n = 203): >URL: 41% Deceased cohort Median: 40.8 (14.7–157.8) >threshold: 68 of 94, 72% 8 deceased patients with cTnI >1,000 pg/ml and 2 >10,000 pg/ml Recovered cohort Median: 3.3 (1.9–7.0) >threshold: 15 of 109 (14)	NR by cTn results Deaths Acute cardiac injury: 72 of 94 (77%) With history of HTN or CVD: 37 of 48 (77%) Without history of HTN or CVD: 35 of 46 (76%) HF: 41 of 83 (49%) With history of HTN or CVD: 21 of 42 (50%) Without history of HTN or CVD: 20 of 41 (49%) Recovered Acute cardiac injury: 18 of 109 (17%) With history of HTN or CVD: 11 of 30 (37%) Without history of HTN or CVD: 7 of 80 (9%) HF: 3 of 94 (3%) With history of HTN or CVD: 2 of 25 (8%) Without history of HTN or CVD: 1 of 68 (1%)	Chest tightness 49% in deaths and 30% in recovered patients NT-proBNP (threshold ≥285 pg/ml) Deaths: Median: 800.0 (389.8–1,817.5) >threshold: 68 of 80 (85%) Recovered: Median: 72.0 (20.0–185.0) >threshold: 17 of 93 (18%)
Cummings et al. (19)	New York Presbyterian, New York, United States	1,150 adult patients admitted with laboratory-confirmed COVID-19 who were critically ill with acute hypoxemic respiratory failure	Chronic cardiac disease, 19%	hs-cTnT (ng/l)	hs-cTnT measured in 254 of 257 patients Median 19 (IQR: 9–52) ng/l	NR by cTn results	cTn not included in multivariable Cox model
Guo et al. (5)	Seventh Hospital, Wuhan, China	187 hospitalized patients with COVID-19 at a designated hospital to treat such patients	Normal cTnT HTN: 20.7% CHD: 3.0% Cardiomyopathy, 0% ACE inhibitor/ARB: 5.9% Increased cTnT HTN: 63.5% CHD: 32.7% Cardiomyopathy, 15.4% ACE inhibitor/ARB: 21.1%	cTn assay details NR Patients were considered to have acute myocardial injury if serum levels of cTnT were above the 99th percentile URL	Myocardial injury: 52 of 187 (27.8%)	Death Normal cTnT: 12 (8.9%) Increased cTnT: 31 (59.6%) Death according to CVD: Normal cTnT/without CVD: 8 of 105 (7.6%) Normal cTnT/with CVD: 4 of 30 (13.3%) Increased cTnT/without CVD: 6 of 16 (37.5%) Increased cTnT/with CVD: 69.44% (25 of 36)	Patients with underlying CVD were more likely to exhibit elevation of cTnT (54.5%) compared with patients without CVD (13.2%) Both cTnT and NT-proBNP levels increased significantly during the course of hospitalization in those who ultimately died, but no such dynamic changes were evident in survivors
Han et al. (10)	Renmin Hospital, Wuhan University, China	273 patients with SARS-CoV-2 infection	NR	Ultra-TnI measured in serum using Siemens ADVIA Centaur XP URL: 0.04 ng/ml	>URL (0.04 ng/ml) in 27 of 273 (9.9%) By disease severity: Mild: 10 of 198 (5%) Severe: 14 of 60 (23%) Critical: 3 of 15 (20%)	Cases in abnormal parameters group (i.e., increased CK-MB, myoglobin, cTnI, and NT-proBNP) had a case fatality rate of 22.8% (13 of 57) compared with a rate of 5.1% (11 of 216) in normal parameters group	Increase in cTnI showed significant difference between mild and severe cases
He et al. (11)	Sino-French New City Campus of Tongji Hospital, Tongji Medical College, and Huazhong University of Science and Technology	Retrospective analysis of 54 confirmed cases of severe/critical COVID-19	HTN: 44% CHD: 15% DLD: 7.4%	Troponin >34.2 ng/l was considered abnormal Study defined myocardial damage as cTn concentrations ≥3× ULN	24 of 54 (44%) had cTn ≥3× ULN Deaths Myocardial injury: 69% (18 of 26) Survivors Myocardial injury: 21% (6 of 28)	In-hospital mortality: Myocardial injury: 75% (18 of 24) Without injury: 26.7% (8 of 30)	None
Huang et al. (1)	Jin Yintan Hospital, Wuhan, China	41 patients with COVID-19 admitted to designated hospital	Hypertension: 15% CVD: 15%	hs-cTnI, threshold >28 ng/l (99th percentile). Other details NR Cardiac injury was defined as 1 or more of the following: Blood levels of cardiac biomarkers (cTnI or CK-MB) >99th percentile URL New abnormalities in electrocardiography, including supraventricular tachycardia, ventricular tachycardia, atrial fibrillation, ventricular fibrillation, bundle branch block, ST-segment elevation/depression, T-wave flattening/inversion, and QT interval prolongation New abnormalities in echocardiography, including decreased EF value (<50%) or a worsening of the underlying state, regional/global ventricular wall motion abnormalities, the presence of pericardial effusion, and pulmonary arterial hypertension	Hs-cTnI was substantially increased in 5 of 41 (12%) patients in whom the diagnosis of virus-related cardiac injury was made Hs-cTnI >99th URL All: 5 of 41 (12%) ICU: 4 of 13 (31%) Non-ICU: 1 of 28 (4%) Median hs-cTnI (pg/ml) All: 3.4 (1.1-9.1) ICU: 3.3 (3.0-163.0) Non-ICU: 3.5 (0.7–5.4)	NR by cTn results Acute cardiac injury: All: 5 of 41 (12%) ICU: 4 of 13 (31%) Non-ICU: 1 of 28 (4%) Shock: All: 3 of 41 (7%) ICU: 3 of 12 (23%) Non-ICU: 0 of 28 (0%) Death: All: 6 of 41 (15%) ICU: 5 of 13 (38%) Non-ICU: 1 of 28 (4%)	None
Hui et al. (12)	Beijing Youan Hospital, China	41 consecutive COVID-19 patients at Beijing Hospital	9 of 41 patients had cardiac-related chronic disease	cTn assay details NR cTnI (ng/ml) was available in 20 of 41 patients	cTnI increased: 4 of 20, including 1 severe patient and 3 critical patients cTnI according to disease severity: Light: 0.01 ng/ml Mild: 0.01 ng/ml Severe 0.1 ng/ml Critical: 0.54 (0.05–5.90) ng/ml	Major clinical outcomes NR	SpO2 was lower in severe/critical patients, and 2 patients in the critical group had onset of atrial fibrillation
Lala et al. (13)	Mount Sinai System Hospitals, New York City, United States	2,736 patients with COVID-19 with cTnI measured within 24 h of admission	cTnI 0–0.03 ng/ml (normal) CAD: 9.8% CHF: 4.3% HTN: 34% cTnI 0.03–0.09 ng/ml (mildly elevated) CAD: 21.3% CHF: 14.7% HTN: 45.1% cTnI >0.09 ng/ml (elevated) CAD: 34.9% CHF: 25.3% HTN: 50.0%	Abbott ARCHITECT cTnI 99th percentile 0.028 ng/ml URL: 0.03 ng/ml	1,751 (64%) had initial cTnI within normal range Admission cTnI Normal: 1,751 of 2,736 (64%) Mildly elevated: 455 of 2,736 (16.6%) Elevated: 530 of 2,736 (19.4%) Overall injury: 36%	Mildly elevated cTnI: adjusted HR: 1.77, 95% CI: 1.39–2.26 Elevated cTnI: adjusted HR: 3.23, 95% CI: 2.59–4.02	None
Liu et al. (14)	Shenzhen Third People’s Hospital, China	12 patients with COVID-19	CHD: 4 of 12 HTN: 3 of 12	cTn assay details NR cTnI (ug/ml): normal range 0–0.1	1 of 12 patients had concentrations exceeding URL, with a concentration of 11.37 ug/ml	NR by cTn results Cardiac failure, 1 of 12 Shock, 1 of 12	None
Shi et al. (6)	Renmin Hospital of Wuhan University, Wuhan, China	416 consecutive patients admitted to hospital with laboratory-confirmed COVID-19. Cases without cardiac biomarkers, including values of cTnI and CK-MB were excluded	With cardiac injury: HTN: 59.8% CHD: 29.3% CHF: 14.6% Without injury: HTN: 23.4% CHD: 6.0% CHF: 1.5%	cTn assay details NR cTnI (Siemens ADVIA Centaur); lowest measurable value <0.006 ng/ml; >0.04 ng/ml was considered indicative of cardiac injury and >0.78 ng/ml suggesting myocardial infarction possible Cardiac injury was defined as blood levels of cardiac biomarkers (hs-cTnI) above the 99th percentile upper reference limit, regardless of new abnormalities in electrocardiography and echocardiography	Cardiac injury: 82 of 416 (19.7%) cTnI (median) All: <0.006 (IQR: <0.006–0.02) Cardiac injury: 0.19 (IQR: 0.08–1.12) Without injury: <0.006 (IQR: <0.006–0.009)	Death Cardiac injury, 51.2% Without injury, 4.5% Mortality rate increased in association with the magnitude of the reference value of cTnI Cox proportional hazard regression model showed significant higher risk of death in patients with cardiac injury than in those without, either during time from symptom onset (HR: 4.2; 95% CI: 1.92–9.49) or time from admission to study endpoint (HR: 3.41; 95% CI: 1.62–7.16)	Chest pain: Cardiac injury, 13.4% Without injury, 0.9%
Shi et al. (16)	Renmin Hospital, Wuhan University, China	671 hospitalized patients with severe COVID-19 Cases missing cardiac biomarkers, including cTnI were excluded	With myocardial injury: HTN: 59.4% CHD: 27.4% CHF: 12.3% CVD: 10.4% AF: 0.9% Without injury; HTN: 24.1% CHD: 5.5% CHF: 1.6% CVD: 1.9% AF: 1.1%	Myocardial injury was defined as blood levels of cTnI increased above the 99th percentile Siemens ADVIA Centaur XP Immunoassay system, cTnI; range: 0–0.04 ng/ml	Myocardial injury: 106 of 671 (15.8%) Median: 0.159 (IQR: 0.075–0.695) ng/ml	Median cTnI by patient status: All: 0.006 ng/ml Death: 0.235 ng/ml Survivors: 0.005 ng/ml Myocardial injury by alive/death status: Nonsurvivor: 75.8% Survivor: 9.7%	cTnI of 0.026 ng/l was identified as the concentration predictive of in-hospital mortality HR: 4.56; 95% CI: 1.28–16.28, p = 0.019 cTnI (ln-transformed): HR 1.90, 95% CI: 1.44-2.49 for in-hospital mortality Predictors of myocardial injury: age, hypertension, coronary heart disease, chronic renal disease, chronic obstructive pulmonary disease, and C-reactive protein
Ruan et al. (15)	Jin Yin-Tan Hospital and Tongji Hospital, China	Retrospective, multicenter study of 68 death cases and 82 discharged cases with laboratory confirmed SARS-CoV-2	Among deaths: HTN: 43% CVD: 19% Among discharged: HTN: 28% CVD: 0%	cTn assay details NR cTn (pg/ml) normal range: 2.0–28.0	cTn (pg/ml), mean ± SD Deaths: 30.3 ± 151.0 Discharged: 3.5 ± 6.2	NR by cTn results Patients with CVD had a significantly increased risk of death when infected with SARS-CoV-2 (p < 0.001)	None
Wang et al. (4)	Zhongnan Hospital of Wuhan University, China	138 consecutive hospitalized patients with confirmed coronavirus-infected pneumonia	Hypertension All: 31.2% ICU: 58.3% Non-ICU: 21.6% CVD All: 14.5% ICU: 25.0% Non-ICU: 10.8%	cTn assay details NR hs-cTnI (“hypersensitive”) (pg/ml), threshold 26.2 pg/ml Cardiac injury was defined if the serum levels of cardiac biomarkers (e.g., troponin I) were above the 99th percentile URL or new abnormalities in electrocardiography and echocardiography	hs-cTnI (pg/ml), median (IQR) All: 6.4 (2.8–18.5) ICU: 11.0 (5.6–26.4) Non-ICU: 5.1 (2.1–9.8)	NR by cTn results Acute cardiac injury All: 7.2% ICU: 22.2% Non-ICU: 2.0% Shock All: 8.7% ICU: 30.6% Non-ICU: 1.0% Arrhythmia All: 16.7% ICU: 44.4% Non-ICU: 6.9%	None
Yang et al. (17)	Jin Yin-tan Hospital, Wuhan, China	Retrospective, observational study of 52 critically ill adult patients with SARS-CoV-2 pneumonia admitted to the ICU	Chronic cardiac disease All: 10% Survivors: 10% Nonsurvivors: 9%	cTn assay details NR Cardiac injury was diagnosed if the serum concentration of hs-cTnI (“hypersensitive”) was above the upper limit of the reference range, >28 pg/ml	Cardiac injury All, 12 of 52 (23%) Survivors, 3 of 20 (15%) Nonsurvivors, 9 of 32 (28%) Median hs-cTnI was 161.0 (IQR: 41.8–766.1) pg/ml	NR by cTn results 32 (61.5%) had died at 28 days	None
Zhou et al. (2)	Jinyintan Hospital and Wuhan Pulmonary Hospital, Wuhan, China	Retrospective study including 2 cohorts of adult inpatients diagnosed with COVID-19 Enrolled all adult inpatients who were hospitalized for COVID-19 and had a definite outcome (dead or discharged)	HTN All: 30% Nonsurvivor: 48% Survivor: 23% CHD All: 8% Nonsurvivor: 24% Survivor: 1%	cTn assay details NR hs-cTnI (pg/ml), threshold >28 pg/ml Acute cardiac injury was diagnosed if serum levels of cardiac biomarkers (e.g., high-sensitivity cardiac troponin I) were above the 99th percentile upper limit, or if new abnormalities were shown in electrocardiography and echocardiography Routine blood examination included myocardial enzymes	hs-cTnI (pg/ml), median (IQR) All: 4.1 (2.0–14.1) Nonsurvivor: 22.2 (5.6–83.1) Survivor: 3.0 (1.1–5.5) hs-cTnI > threshold All: 24 of 145 (17%) Nonsurvivor: 23 of 50 (46%) Survivor: 1 of 95 (1%)	NR by cTn results Heart failure All: 23% Nonsurvivor: 52% Survivor: 12% Acute cardiac injury All: 17% Nonsurvivor: 59% Survivor: 1% hs-cTnI >28 pg/ml was identified as a risk factor associated with in-hospital death on univariable analysis (OR: 80.07; 95% CI: 10.34–620.36)	hs-cTnI was not included in multivariate logistic regression model as it was deemed that it “might be unavailable in emergency circumstances.” In nonsurvivors, hs-cTnI increased rapidly from day 16 after disease onset Median onset of acute cardiac injury: All, 15 days (10.0–17.0) Nonsurvivors, 14.5 days (9.5–17.0)
Zhou et al. (18)	West District of Union Hospital of Tongji Medical College, China	34 patients admitted to hospital		cTn assay details NR; cTnI URL: <26.2 ng/l	cTnI >URL All: 9 of 34 (26%) Severe: 1 of 26 (3.8%) Very severe: 8 of 8 (100%) cTnI median (IQR) (ng/l) Severe: 4.8 (2.5–8.4) Very severe: 46.8 (34.2–299.8)	NR	None

ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; BNP = B-type natriuretic peptide; CAD = coronary artery disease; CHD = chronic heart disease; CHF = coronary heart failure; CI = confidence interval; CK-MB = creatine kinase myocardial band; COVID-19 = coronavirus disease-2019; cTn = cardiac troponin; CVD = cardiovascular disease; DLD = dyslipidemia; EF = ejection fraction; HF = heart failure; HR = hazard ratio; hs-cTnT = high-sensitivity cardiac troponin T; HTN = hypertension; ICU = intensive care unit; IQR = interquartile range; NR = not reported; NT-proBNP = N-terminal pro–B-type natriuretic peptide; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; URL = upper reference limit.