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. 2021 Nov 22;117(6):1207–1211. [Article in Portuguese] doi: 10.36660/abc.20201300
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Achados Ecocardiográficos em Pacientes com COVID-19 com e sem Doença Cardiovascular Prévia

Silvio Henrique Barberato 1,2,✉, Rafael Borsoi 3, Fabio Roston 4, Hudson Laerte Machado Miranda 5, Pedro Patriota 6, Maria Estefania Otto 7,8, Adenalva Lima de Souza Beck 7,9, Anderson da Costa Armstrong 6, João Marcos Bemfica Barbosa Ferreira 10, Ana Cristina Camarozano 11, Letícia Braga Paciello da Silva 12, Marcos Valério Coimbra Resende 12, Marcelo Luiz Campos Vieira 12, Miguel Morita Fernandes-Silva 1,3
PMCID: PMC8757145  PMID: 35613177

Introdução

A doença do coronavírus-2019 (COVID-19), causada pelo vírus da síndrome respiratória aguda grave coronavírus 2 (SARS-CoV-2), pode resultar em insuficiência respiratória grave e lesão cardíaca aguda. Disfunção cardíaca e/ou doença cardiovascular (DCV) prévia em pacientes com COVID-19 estão associadas a pior prognóstico. 1 A ecocardiografia transtorácica (ETT) tem um papel central no manejo dos pacientes, pois fornece uma avaliação crucial das anormalidades da função e estrutura cardíacas que impactam em seu prognóstico e tratamento. 2 Estudos relataram taxas variadas de disfunção do ventrículo esquerdo (VE) e ventrículo direito (VD), mas não está claro com que frequência a disfunção cardíaca resulta diretamente da COVID-19. 3 – 6 Descrevemos a prevalência dos principais achados ecocardiográficos anormais em pacientes hospitalizados com COVID-19 com e sem doença cardiovascular DCV prévia através de um estudo colaborativo multicêntrico do mundo real (Registro Brasileiro de Ecocardiografia durante a pandemia de COVID-19, ou ECOVID).

Métodos

O ECOVID é um estudo observacional multicêntrico prospectivo de pacientes hospitalizados com COVID-19 no Brasil, iniciado em 4 de abril de 2020, ao coletar dados clínicos e ecocardiográficos das cinco macrorregiões do país. A descrição completa dos métodos do estudo foi detalhada no Material Suplementar (223.6KB, pdf) . Resumidamente, pacientes hospitalizados consecutivos (>18 anos) com COVID-19 confirmado ou altamente provável foram incluídos. Em cada centro participante, os dados clínicos foram obtidos através dos prontuários médicos e entrevista dos pacientes com cardiologistas, e as medidas ecocardiográficas foram obtidas localmente. Os resultados foram registrados através de um formulário online de relato de caso. A maioria dos exames ecocardiográficos usou um protocolo focado, a fim de diminuir o risco para o profissional de saúde. 7 A aquisição e interpretação das imagens foram realizadas por médicos certificados, de acordo com as diretrizes internacionais. 8 , 9 Especificamente, a disfunção sistólica do VE foi definida pela fração de ejeção do VE (FEVE) <50% (discreta entre 40-49%; moderada entre 30-39% e grave <30%). A disfunção diastólica do VE, a disfunção sistólica do VD e a pressão sistólica da artéria pulmonar (PSAP) foram definidas e classificadas de acordo com as diretrizes (consulte o Material Suplementar (223.6KB, pdf) ). Os achados ecocardiográficos foram resumidos de acordo com a história de DCV prévia, como definida por obstrução ≥50% em qualquer artéria coronária demonstrada por angiotomografia coronariana ou angiografia coronária, revascularização coronária, infarto do miocárdio, insuficiência cardíaca ou fibrilação atrial. Este estudo foi aprovado pelo comitê de ética do centro coordenador (# 4.033.139) e pelos comitês de ética locais de cada centro participante.

Análise estatística

As variáveis contínuas foram apresentadas como média ± desvio padrão. A distribuição Gaussiana dos dados foi analisada observando-se a forma da distribuição, assimetria, curtose e utilizando o teste de Kolmogorov-Smirnov. Os dados categóricos foram expressos como contagens e porcentagens. Os parâmetros clínicos, demográficos e ecocardiográficos foram comparados entre os indivíduos com e sem história de DCV prévia através do teste t de Student não pareado ou teste do qui-quadrado, conforme apropriado. Consideramos valores de p <0,05 como estatisticamente significativos. As análises estatísticas foram realizadas no software Stata versão 15.1 (Stata Corp, College Station, TX).

Resultados

Foram incluídos 223 pacientes hospitalizados entre 4 de abril e 9 de setembro de 2020, com idade de 61,4 ± 15,3 anos (variação de 19 a 94 anos), 59% homens, 83% com COVID-19 confirmado por RT-PCR, e 17% com COVID-19 altamente provável . As principais indicações clínicas para encaminhamento para ecocardiografia foram suspeita de insuficiência cardíaca (50%), suspeita de síndrome coronariana aguda (dor torácica, anormalidades no eletrocardiograma e elevação da troponina) (20%), instabilidade hemodinâmica (18%), suspeita de miocardite (16%), suspeita de embolia pulmonar (6%), arritmias clinicamente relevantes (5%) e outros (como suspeita de derrame pericárdico, endocardite, síncope e fonte cardioembólica de acidente vascular cerebral) (5%).

A Tabela 1 resume os dados demográficos, características clínicas e comorbidades da população. Pacientes sem DCV prévia eram mais jovens e tinham menor prevalência de fatores de risco cardiovascular, como hipertensão, diabetes e tabagismo, e eram menos propensos a ter doença pulmonar obstrutiva crônica e doença renal crônica, quando comparados com pacientes com DCV prévia ( Tabela 1 ). Os sintomas e medidas de suporte relacionados ao COVID-19 foram semelhantes entre os pacientes sem e com DCV prévia ( Tabela suplementar 1 (223.6KB, pdf) ).

Tabela 1. Dados demográficos e comorbidades em pacientes hospitalizados com COVID-19 de acordo com história de doença cardiovascular prévia.

Todos os pacientes Sem DCV anterior Com DCV anterior p-valor
n=223 n=173 n=50
Idade, anos 61,4± 15,3 59 ± 15 68 ± 14 <0,001
Sexo masculino, n (%) 132 (59,2%) 103 (59,5%) 29 (58,0%) 0,85
IMC, Kg/m2 27,6± 5,0 27,6 ± 5,3 27,5 ± 3,6 0,83
Obesidade, n (%) 60 (26,9%) 49 (28,3%) 11 (22,0%) 0,37
Hipertensão, n (%) 115 (51,6%) 78 (45,1%) 37 (74,0%) <0,001
Diabetes mellitus, n (%) 77 (34,5%) 47 (27,2%) 30 (60,0%) <0,001
Tabagismo, n (%) 30 (13,5%) 17 (9,8 %) 13 (26,0%) 0,003
DAC prévia, n (%) 30 (13,5%) 30 (60,0%) ND
IC prévia, n (%) 16 (7,2%) 16 (32,0%) ND
FA prévia, n (%) 9 (4,0%) 9 (18,0%) ND
Doença pulmonar, n (%) 24 (10,8%) 14 (8,1 %) 10 (20,0%) 0,017
Doença Renal Crônica, n (%) 28 (12,6%) 17 (9,8 %) 11 (22,0%) 0,022
Diálise, n (%) 3 (1,3%) 3 (1,7 %) 0 (0,0 %) 0,35
Doença Cerebrovascular, n (%) 7 (3,1%) 4 (2,3 %) 3 (6,0 %) 0,19
Câncer, n (%) 5 (2,2%) 2 (1,2 %) 3 (6,0 %) 0,042
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DCV: doença cardiovascular; IMC: índice de massa corporal; DAC: doença arterial coronariana; IC: insuficiência cardíaca; FA: fibrilação atrial; DPOC: doença pulmonar obstrutiva crônica.

A Tabela 2 mostra os principais achados ecocardiográficos em pacientes hospitalizados com COVID-19 de acordo com história de DCV prévia. Como esperado, os pacientes sem DCV eram menos propensos a apresentar achados ecocardiográficos sugerindo estrutura e / ou função do VE anormais, incluindo hipertrofia do VE (27 vs. 52%, p <0,001), disfunção sistólica do VE (13 vs. 34%, p <0,001), anormalidades da contratilidade regional (8 vs. 24%, p <0,001) e disfunção diastólica do VE grau II ou III (11 vs. 26%, p = 0,011). Por outro lado, apenas 52% dos pacientes sem DCV prévia apresentavam ecocardiograma normal ( Figura 1 ). A disfunção sistólica do VD (17 vs. 22%, p = 0,40) e hipertensão pulmonar (24 vs. 38%, p = 0,06) foram relativamente comuns e semelhantes entre pacientes sem e com DCV prévia. A disfunção sistólica do VD também foi comum em pacientes sem doença pulmonar prévia (15 vs. 20% para pacientes sem e com DCV prévia, respectivamente, p = 0,45). Derrame pericárdico e regurgitação valvar moderada a grave foram incomuns. Digno de nota, entre os pacientes sem DCV prévia e presumivelmente nova disfunção sistólica do VE (n = 21), 48% deles apresentaram anormalidades da contratilidade regional. Nenhum paciente apresentou evidência de anormalidades regionais sugestivas de cardiomiopatia induzida por estresse. Os resultados da ecocardiografia mudaram o manejo clínico em 25% dos casos, principalmente desencadeando o início da terapia para insuficiência cardíaca ou anticoagulação ou encaminhamento para cateterismo.

Tabela 2. Achados ecocardiográficos em pacientes hospitalizados com COVID-19 de acordo com história de doença cardiovascular prévia.

Parâmetro Todos os pacientes Sem DCV anterior Com DCV anterior p-valor
n=223 n=173 n=50
Hipertrofia do VE, n(%) 73 (32,7%) 47 (27,2%) 26 (52,0%) <0,001
Dilatação do VE, n(%) 31 (14,0%) 13 (7,6%) 18 (36,0%) <0,001
Disfunção sistólica do VE, n(%) 0,005
Nenhuma 183 (82,1%) 150 (86,7%) 33 (66,0%)
Discreta 10 (4,5%) 7 (4,0%) 3 (6,0%)
Moderada 14 (6,3%) 8 (4,6%) 6 (12,0%)
Grave 16 (7,2%) 8 (4,6%) 8 (16,0%)
Disfunção diastólica do VE, n(%) <0,001
Nenhuma 88 (42,5%) 82 (49,7%) 6 (14,3%)
Discreta 90 (43,5%) 65 (39,4%) 25 (59,5%)
Moderada 27 (13,0%) 17 (10,3%) 10 (23,8%)
Grave 2 (1,0%) 1 (0,6%) 1 (2,4%)
Desconhecida 16 (7,2%) 8 (4,6%) 8 (16,0%)
Anormalidade da contratilidade regional do VE, n(%) 25 (11,2%) 13 (7,5%) 12 (24,0%) 0,001
Disfunção do VD, n(%) 0,20
Nenhuma 183 (82,1%) 144 (83,2%) 39 (78,0%)
Discreta 21 (9,4%) 17 (9,8%) 4 (8,0%)
Moderada 9 (4,0%) 7 (4,0%) 2 (4,0%)
Grave 10 (4,5%) 5 (2,9%) 5 (10,0%)
Hipertensão pulmonar 0,06
Nenhuma 160 (72,4%) 129 (75,4%) 31 (62,0%)
Discreta 36 (16,3%) 28 (16,4%) 8 (16,0%)
Moderada 21 (9,5%) 12 (7,0%) 9 (18,0%)
Grave 4 (1,8%) 2 (1,2%) 2 (4,0%)
Regurgitação valvar moderada ou grave, n(%)
Aórtica 2 (0,9%) 1 (0,6%) 1 (2,0%) 0,34
Mitral 10 (4,5%) 6 (3,5%) 4 (8,2%) 0,16
Tricúspide 8 (3,6%) 4 (2,3%) 4 (8,2%) 0,05
Derrame pericárdico, n(%) 5 (2,2%) 5 (2,9%) 0 (0,0%) 0,22
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DCV: doença cardiovascular; VE: ventrículo esquerdo; VD: ventrículo direito.

Figura 1. Achados ecocardiográficos em pacientes hospitalizados com COVID-19 sem doença cardiovascular prévia. HVE: hipertrofia do ventrículo esquerdo; VE: ventrículo esquerdo; VD: ventrículo direito; HP; hipertensão pulmonar. * Refere-se à anormalidade da contratilidade regional do VE. † A disfunção diastólica do VE inclui apenas disfunção diastólica do VE moderada ou grave.

Figura 1

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Discussão

Neste registro multicêntrico, observamos que anormalidades clinicamente relevantes na função ou estrutura cardíacas foram relativamente comuns em pacientes hospitalizados com COVID-19, mesmo entre aqueles sem DCV prévia, com cerca de metade apresentando pelo menos um achado anormal. Além disso, um em cada oito pacientes sem DCV prévia apresentava pelo menos uma anormalidade ecocardiográfica grave.

Estudos anteriores descrevendo achados ecocardiográficos em pacientes com COVID-19 foram consideravelmente heterogêneos. A prevalência de disfunção sistólica do VE, disfunção do VD e dilatação do VD variou de 5,4 10 a 37,4%, 4 3,6, 11 a 33%, 12 e 0,12 a 46,9%, 13 respectivamente. Essa grande variação pode estar relacionada a viés de referência, diferentes protocolos de ETT, definições imprecisas de anormalidades ecocardiográficas e diferenças nas características da população, como a proporção de pacientes com DCV prévia. A fim de diminuir o viés de referência, Szekely et al., 5 realizaram sistematicamente o ETT em 100 pacientes consecutivos hospitalizados por COVID-19, 43% dos quais tinham DCV prévia. Eles encontraram como alteração mais frequente disfunção/dilatação do VD, enquanto apenas uma minoria dos pacientes (10%) apresentava disfunção sistólica do VE. 5

Nosso estudo chama a atenção para a importância da DCV prévia na prevalência de achados ecocardiográficos de pacientes hospitalizados com COVID-19. Enquanto a disfunção do VD foi comum e aparentemente não relacionada à prevalência de DCV prévia, a disfunção sistólica e diastólica do VE foram mais comuns em pacientes com DCV prévia, provavelmente devido em parte a condições cardiovasculares pré-existentes. É digno de nota que 13% dos pacientes sem DCV tinham disfunção sistólica do VE, o que pode refletir um comprometimento “ de novo ” do VE relacionado à COVID-19. Por outro lado, a hipertensão pulmonar e a disfunção sistólica do VD têm maior probabilidade de resultar de uma miríade de fenômenos que afetam os pulmões, como hipóxia, inflamação, síndrome do desconforto respiratório agudo, trombose microvascular pulmonar, tromboembolismo pulmonar e ventilação mecânica.

Como os principais esforços da comunidade científica visam mitigar as graves consequências para a saúde causadas pela pandemia de COVID-19, torna-se um desafio equilibrar o uso da ecocardiografia para fornecer cuidados médicos de alta qualidade sem aumentar excessivamente o risco de infecção cruzada entre profissionais de saúde e pacientes. Nossos resultados ajudam a compreender, através de um registro nacional do mundo real, quais parâmetros da função cardíaca são mais frequentemente acometidos em pacientes hospitalizados com COVID-19, de acordo com a história de DCV prévia. É importante enfatizar que a presença de disfunção cardíaca é independentemente associada a um pior prognóstico em pacientes com COVID-19. 14 A avaliação por ETT deve ser considerada em pacientes com COVID-19 e suspeita de complicações cardiovasculares para caracterizar o substrato cardíaco subjacente, para estratificação de risco, e para potencialmente orientar as estratégias de manejo. 14 Por outro lado, suas indicações devem ser baseadas na consideração crítica dos benefícios para o paciente, risco de contaminação para profissionais de saúde e uso limitado de equipamento de proteção individual.

Nosso estudo tem limitações que merecem atenção. Primeiro, as medidas ecocardiográficas foram realizadas por investigadores locais sem avaliação final por um laboratório central. Apesar disso, todos os ecocardiogramas foram realizados por médicos experientes, que seguiram os procedimentos de acordo com as diretrizes internacionais. Em segundo lugar, os achados anormais podem ter sido superestimados devido ao viés de encaminhamento, uma vez que os ecocardiogramas foram realizados a critério do médico assistente. Terceiro, os biomarcadores séricos de lesão miocárdica não estavam disponíveis neste estudo. Finalmente, embora tenhamos descrito os achados de ETT em pacientes sem DCV prévia, ainda assim não é possível descartar se essas anormalidades cardíacas eram pré-existentes e esses resultados devem ser interpretados com cautela.

Conclusões

Entre os pacientes hospitalizados com COVID-19 submetidos ao ecocardiograma, a disfunção sistólica do VD e do VE foi encontrada em quase um de cada cinco pacientes, mas esta última foi menos comum entre aqueles sem DCV prévia. Somente metade dos pacientes sem DCV prévia apresentou um ETT normal.

*Material suplementar

Para informação adicional, por favor, clique aqui:

Agradecimentos

Gostaríamos de agradecer aos seguintes colegas que auxiliaram na realização desta pesquisa: Francisco de Assis Carvalho Santana; Fernando Melo Netto, Simone Ferreira Leite, Bianca Corrêa Rocha de Mello, Dassis Cajuba, Filipe Lima de Menezes, Nathalia Caetano Lobo, Vanessa Guimarães Esmanhoto Andrioli, Pedro Gabriel Melo de Barros e Silva.

Footnotes

Fontes de financiamento

O presente estudo não teve fontes de financiamento externas.

Vinculação acadêmica

Não há vinculação deste estudo a programas de pós‑graduação.

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Arq Bras Cardiol. 2021 Nov 22;117(6):1207–1211. [Article in English]

Echocardiographic Findings in Patients with COVID-19 with and without Previous Cardiovascular Disease

Silvio Henrique Barberato 1,2,✉, Rafael Borsoi 3, Fabio Roston 4, Hudson Laerte Machado Miranda 5, Pedro Patriota 6, Maria Estefania Otto 7,8, Adenalva Lima de Souza Beck 7,9, Anderson da Costa Armstrong 6, João Marcos Bemfica Barbosa Ferreira 10, Ana Cristina Camarozano 11, Letícia Braga Paciello da Silva 12, Marcos Valério Coimbra Resende 12, Marcelo Luiz Campos Vieira 12, Miguel Morita Fernandes-Silva 1,3

Introduction

Coronavirus disease-2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) may result in severe respiratory distress and acute cardiac injury. Impaired cardiac function and/or prior cardiovascular disease (CVD) in patients with COVID-19 are associated with worse prognosis. 1 Transthoracic echocardiography (TTE) has a central role in the management of patients, as it provides a crucial assessment of abnormalities in cardiac function and structure that impact on their prognosis and treatment. 2 Studies have reported varied rates of left ventricular (LV) and right ventricular (RV) dysfunction, but it is unclear how often cardiac dysfunction result directly from COVID-19. 3 – 6 We described the prevalence of the main abnormal echocardiographic findings in hospitalized patients with COVID-19 with and without previous cardiovascular disease (CVD) through a real-world, multicenter collaborative study (Brazilian Echocardiography Registry during COVID-19 pandemic, or ECOVID).

Methods

ECOVID is a prospective multicenter observational study of hospitalized patients with COVID-19 in Brazil that started on April 4th, 2020, by collecting clinical and echocardiographic data in all five macro-regions of the country. Full description of the study methods was detailed in the Supplemental Material (223.6KB, pdf) . Briefly, consecutive hospitalized patients (> 18 years old) with confirmed or highly probable COVID-19 were included. At each participant center, clinical data was obtained from medical charts and patient interview by cardiologists, and echocardiographic measures were locally obtained. The results were registered using an online case report form. Most echocardiographic scans used a focused protocol aiming to mitigate the risk to the healthcare professional. 7 Imaging acquisition and interpretation were performed by certified physicians according to international guidelines. 8 , 9 Specifically, LV systolic dysfunction was defined by LV ejection fraction (LVEF) below 50% (mild between 40-49%; moderate between 30-39%, and severe <30%). LV diastolic dysfunction, RV systolic dysfunction and pulmonary artery systolic pressure (PASP) were defined and classified according to guidelines (please see Supplemental material (223.6KB, pdf) ). The echocardiographic findings were summarized according to the history of previous CVD, as defined by previous obstruction ≥50% in any major coronary artery demonstrated by coronary computed tomography angiography or coronary angiography, coronary revascularization, myocardial infarction, heart failure or atrial fibrillation. This study was approved by the ethics committee of the coordinating center (# 4.033.139) and the local ethics committees from each respective site.

Statistical analysis

Continuous variables were presented as mean ± standard deviation. The Gaussian distribution of the data was analyzed by looking at the shape of the distribution, skewness, kurtosis, and using the Kolmogorov-Smirnov test. Categorical data were expressed as counts and percentages. Clinical, demographic and echocardiographic parameters were compared between the individuals with and without history of previous CVD using unpaired Student's t test or Chi-squared test, accordingly. We considered statistically significant p-values<0.05. Statistical analyses were performed using Stata version 15.1 (Stata Corp, College Station, TX).

Results

We included 223 hospitalized patients admitted between April 4thand September 9th, 2020, aged 61.4 ± 15.3 years old (range19 to 94), 59% men, 83% with RT-PCR-confirmed COVID-19, 17% with highly probable COVID-19. The main clinical indications for referral for echocardiography were suspected heart failure (50%), suspected acute coronary syndrome (chest pain, electrocardiogram abnormalities and troponin elevation) (20%), hemodynamic instability (18%), suspected myocarditis (16%), suspected pulmonary embolism (6%), clinically relevant arrhythmias (5%), and others (such as suspected pericardial effusion, endocarditis, syncope, and cardioembolic source of brain stroke) (5%).

Table 1 summarizes the demographics, clinical characteristics and comorbidities of the population. Patients without previous CVD were younger and had lower prevalence of cardiovascular risk factors, such as hypertension, diabetes and smoking, and were less likely to have chronic obstructive pulmonary disease and chronic kidney disease, when compared with patients with previous CVD ( Table 1 ). COVID-19-related symptoms and supportive measures were similar between patients without and with previous CVD ( Supplemental table 1 (223.6KB, pdf) ).

Table 1. Demographics and comorbidities in hospitalized patients with COVID-19 according to a history of previous cardiovascular disease.

All patients No previous CVD Previous CVD p value
n=223 n=173 n=50
Age, years 61.4± 15.3 59 ± 15 68 ± 14 <0.001
Male, n (%) 132 (59.2%) 103 (59.5%) 29 (58.0%) 0.85
BMI, Kg/m2 27.6± 5.0 27.6 ± 5.3 27.5 ± 3.6 0.83
Obesity, n (%) 60 (26.9%) 49 (28.3%) 11 (22.0%) 0.37
Hypertension, n (%) 115 (51.6%) 78 (45.1%) 37 (74.0%) <0.001
Diabetes mellitus, n (%) 77 (34.5%) 47 (27.2%) 30 (60.0%) <0.001
Smoking, n (%) 30 (13.5%) 17 (9.8 %) 13 (26.0%) 0.003
Previous CAD, n (%) 30 (13.5%) 30 (60.0%) ND
Previous HF, n (%) 16 (7.2%) 16 (32.0%) ND
Previous AF, n (%) 9 (4.0%) 9 (18.0%) ND
Pulmonary disease, n (%) 24 (10.8%) 14 (8.1 %) 10 (20.0%) 0.017
Chronic Kidney disease, n (%) 28 (12.6%) 17 (9.8 %) 11 (22.0%) 0.022
Dialysis, n (%) 3 (1.3%) 3 (1.7 %) 0 (0.0 %) 0.35
Cerebrovascular disease, n (%) 7 (3.1%) 4 (2.3 %) 3 (6.0 %) 0.19
Cancer, n (%) 5 (2.2%) 2 (1.2 %) 3 (6.0 %) 0.042
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CVD: cardiovascular disease; BMI: body mass index; CAD: coronary artery disease; HF: Heart failure; AF: atrial fibrillation; COPD: Chronic obstructive pulmonary disease.

Table 2 shows the main echocardiographic findings in hospitalized patients with COVID-19 according to a history of previous CVD. As expected, patients without CVD were less likely to have echocardiographic findings suggesting abnormal LV structure and/or function, including LV hypertrophy (27 vs 52%, p<0.001), LV systolic dysfunction (13 vs. 34%, p<0.001), regional wall motion abnormalities (8 vs. 24%, p<0.001) and grade II or III LV diastolic dysfunction (11 vs. 26%, p=0.011). On the other hand, only 52% of patients without previous CVD had a normal echocardiogram ( Figure 1 ). RV systolic dysfunction (17 vs. 22%, p=0.40) and pulmonary hypertension (24 vs. 38%, p=0.06) were relatively common and they were similar between patients without and with previous CVD. RV systolic dysfunction was also common in patients without previous pulmonary disease (15 vs. 20% for patients without and with previous CVD, respectively, p=0.45). Pericardial effusion and moderate-to-severe valve regurgitation were uncommon. Of note, in patients without previous CVD and presumably new LV systolic dysfunction (n=21), 48% of them displayed regional wall motion abnormalities. No patient had evidence of wall motion abnormalities suggestive of stress-induced cardiomyopathy. Echocardiography results changed clinical management in 25% of the cases, mostly triggering the initiation of therapy for heart failure or anticoagulation or referral to catheterization.

Table 2. Echocardiographic findings in hospitalized patients with COVID-19 according to a history of previous cardiovascular disease.

Parameter All patients No previous CVD Previous CVD p value
n=223 n=173 n=50
LV hypertrophy, n(%) 73 (32.7%) 47 (27.2%) 26 (52.0%) <0.001
LV dilation, n(%) 31 (14.0%) 13 (7.6%) 18 (36.0%) <0.001
LV systolic dysfunction, n(%) 0.005
None 183 (82.1%) 150 (86.7%) 33 (66.0%)
Mild 10 (4.5%) 7 (4.0%) 3 (6.0%)
Moderate 14 (6.3%) 8 (4.6%) 6 (12.0%)
Severe 16 (7.2%) 8 (4.6%) 8 (16.0%)
LV diastolic dysfunction, n(%) <0.001
None 88 (42.5%) 82 (49.7%) 6 (14.3%)
Mild 90 (43.5%) 65 (39.4%) 25 (59.5%)
Moderate 27 (13.0%) 17 (10.3%) 10 (23.8%)
Severe 2 (1.0%) 1 (0.6%) 1 (2.4%)
Unknown 16 (7.2%) 8 (4.6%) 8 (16.0%)
LV regional wall abnormality, n(%) 25 (11.2%) 13 (7.5%) 12 (24.0%) 0.001
RV dysfunction, n(%) 0.20
None 183 (82.1%) 144 (83.2%) 39 (78.0%)
Mild 21 (9.4%) 17 (9.8%) 4 (8.0%)
Moderate 9 (4.0%) 7 (4.0%) 2 (4.0%)
Severe 10 (4.5%) 5 (2.9%) 5 (10.0%)
Pulmonary hypertension 0.06
None 160 (72.4%) 129 (75.4%) 31 (62.0%)
Mild 36 (16.3%) 28 (16.4%) 8 (16.0%)
Moderate 21 (9.5%) 12 (7.0%) 9 (18.0%)
Severe 4 (1.8%) 2 (1.2%) 2 (4.0%)
Moderate-to-severe valve regurgitation, n(%)
Aortic 2 (0.9%) 1 (0.6%) 1 (2.0%) 0.34
Mitral 10 (4.5%) 6 (3.5%) 4 (8.2%) 0.16
Tricuspid 8 (3.6%) 4 (2.3%) 4 (8.2%) 0.05
Pericardial effusion, n(%) 5 (2.2%) 5 (2.9%) 0 (0.0%) 0.22
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CVD: cardiovascular disease; LV: left ventricular; RV: right ventricular.

Figure 1. Echocardiographic findings in patients hospitalized for COVID-19 without previous cardiovascular disease. LVH: left ventricular hypertrophy; LV: left ventricle; RV: right ventricle; PH: pulmonary hypertension. *Refers to LV regional wall motion abnormality. †LV diastolic dysfunction includes only moderate or severe LV diastolic dysfunction.

Figure 1

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Discussion

In this multicenter registry, we found that clinically relevant abnormalities in cardiac function or structure were relatively common among hospitalized patients with COVID-19, even in those without previous CVD, with roughly half showing at least one abnormal finding. Moreover, 1 in 8 patients without previous CVD had at least one severe echocardiographic abnormality.

Previous studies describing echocardiographic findings in patients with COVID-19 have been considerable heterogeneous. The prevalence of LV systolic dysfunction, RV dysfunction and RV dilation have ranged from 5.4 10 to 37.4%, 4 3.6, 11 to 33%, 12 and 0,12 to 46.9%, 13 respectively. This wide variation may be related to referral bias, different TTE protocols, inaccurate definitions of echocardiographic abnormalities, and differences in population characteristics, such as the proportion of patients with previous CVD. Aiming to mitigate referral bias, Szekely et al. 5 systematically performed TTE in 100 consecutive patients hospitalized for COVID-19, 43% of which had prior CVD. They found that the most frequent abnormality was RV dysfunction/dilation while only a minority of patients (10%) had LV systolic dysfunction. 5

Our study sheds light on the importance of previous CVD on the prevalence of echocardiographic findings of patients hospitalized with COVID-19. While RV dysfunction was common and apparently unrelated to the prevalence of previous CVD, LV systolic and diastolic dysfunction were more common in patients with previous CVD, likely in part due to pre-existing cardiovascular conditions. Noteworthy, thirteen percent of patients without CVD had LV systolic dysfunction, which may reflect a COVID-19-related “de novo” LV impairment. On the other hand, pulmonary hypertension and RV systolic dysfunction are more likely to result from a myriad of phenomena that affects the lungs, such as hypoxia, inflammation, acute respiratory distress syndrome, pulmonary microvascular thrombosis, pulmonary thromboembolism and mechanical ventilation.

As major efforts by the scientific community aim to mitigate the severe health consequences of the COVID-19 pandemic, it becomes challenging to balance the use of echocardiography to provide high quality of medical care without excessively increasing the risk of cross-infection between healthcare professionals and patients. Our results help understand which cardiac function parameters are most frequently abnormal in hospitalized patients with COVID-19, according to the history of previous CVD through a real-world national registry. It is important to emphasize that the presence of cardiac dysfunction is independently associated with worse prognosis in patients with severe COVID-19. 14 TTE evaluation should be considered in patients with COVID-19 and suspected cardiovascular complications to characterize the underlying cardiac substrate, for risk stratification, and to potentially guide management strategies. 14 On the other hand, its indications should be based in critical consideration of the benefits to patient, contamination risk for healthcare personnel and use of the limited personal protective equipment.

Our study has limitations that deserve attention. First, the echocardiographic measures were performed by local investigators without final assessment by a core lab. Nevertheless, all echocardiograms were performed by experienced physicians, who followed the procedures according to international guidelines. Second, abnormal findings may have been overestimated due to referral bias, as the echocardiograms were performed at the discretion of the attending physician. Third, serum biomarkers of myocardial injury were unavailable in this study. Finally, although we described the TTE findings in patients without previous CVD, we still cannot rule out whether these cardiac abnormalities were pre-existing, and these results should be interpreted with caution.

Conclusions

Among hospitalized patients with COVID-19 submitted to an echocardiogram, RV and LV systolic dysfunction were found in almost one out of five patients, but the latter was less common in those without previous CVD. Only half of the patients without previous CVD had a normal TTE.

*Supplemental Materials

For additional information, please,click here:

Acknowledgments

We would like to thank the following colleagues who provided help in carrying out this research: Francisco de Assis Carvalho Santana; Fernando Melo Netto, Simone Ferreira Leite, Bianca Corrêa Rocha de Mello, Dassis Cajuba, Filipe Lima de Menezes, Nathalia Caetano Lobo, Vanessa Guimarães Esmanhoto Andrioli, Pedro Gabriel Melo de Barros e Silva.

Footnotes

Sources of Funding

There were no external funding sources for this study.

Study Association

This study is not associated with any thesis or dissertation work.

Articles from Arquivos Brasileiros de Cardiologia are provided here courtesy of Sociedade Brasileira de Cardiologia

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