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Myocardial injury associated with coronavirus disease 2019 in pregnancy

  • Sarah L. Pachtman Shetty
    Affiliations
    Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY
    Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital, Northwell Health, New York, NY
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  • Natalie Meirowitz
    Affiliations
    Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY
    Department of Obstetrics and Gynecology, Long Island Jewish Medical Center, New Hyde Park, NY 11040
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  • Matthew J. Blitz
    Affiliations
    Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY
    Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, South Shore University Hospital, Northwell Health, Bay Shore, NY
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  • Therese Gadomski
    Affiliations
    Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY
    Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lenox Hill Hospital, Northwell Health, New York, NY
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  • Catherine R. Weinberg
    Affiliations
    Division of Cardiology, Department of Internal Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, NY
    Division of Cardiology, Department of Internal Medicine, Lenox Hill Hospital, Northwell Health, New York, NY
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Published:October 09, 2020DOI:https://doi.org/10.1016/j.ajog.2020.10.014

      Objective

      The coronavirus disease 2019 (COVID-19) is associated with cardiac injury
      • Liu J.
      • Virani S.S.
      • Alam M.
      • Denktas A.E.
      • Hamzeh I.
      • Khalid U.
      Coronavirus disease-19 and cardiovascular disease: a risk factor or a risk marker?.
      • Ghio S.
      • Baldi E.
      • Vicentini A.
      • et al.
      Cardiac involvement at presentation in patients hospitalized with COVID-19 and their outcome in a tertiary referral hospital in Northern Italy.
      • López-Otero D.
      • López-Pais J.
      • Antúnez-Muiños P.J.
      • Cacho-Antonio C.
      • González-Ferrero T.
      • González-Juanatey J.R.
      Association between myocardial injury and prognosis of COVID-19 hospitalized patients, with or without heart disease. CARDIOVID registry.
      and bradycardia
      • Capoferri G.
      • Osthoff M.
      • Egli A.
      • Stoeckle M.
      • Bassetti S.
      Relative bradycardia in patients with COVID-19.
      in the nonpregnant population. The incidence of these complications in pregnancy is unknown. The objective of this study was to determine the rate of abnormal serum cardiac biomarkers or bradycardia among pregnant and immediately postpartum women admitted for treatment of severe or critical COVID-19 in a large integrated health system in New York.

      Study Design

      This is a retrospective review of all pregnant and immediately postpartum women hospitalized for COVID-19 at 7 hospitals within Northwell Health, the largest academic health system in the state of New York, from March 1, 2020, to April 30, 2020. Women who tested positive for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction (PCR) assay and who met the National Institute of Health criteria for severe or critical illness
      Coronavirus disease 2019 (COVID-19) treatment guidelines. National Institutes of Health.
      were included. Women with a positive PCR test who were admitted for a reason other than treatment of COVID-19 (eg, labor) were excluded. The Northwell Health Institutional Review Board approved the study as minimal-risk research using data collected for routine clinical practice and waived the requirement for informed consent.
      Clinical records were manually reviewed. Data collected included demographics, medical comorbidities, pregnancy characteristics, laboratory and imaging results, medications administered, and clinical outcomes. Laboratory and imaging studies were ordered at the discretion of the attending physician. The primary outcomes evaluated were elevated cardiac troponins (I, T, or high sensitivity), elevated brain natriuretic peptide (BNP), bradycardia (defined as <60 bpm), and maternal heart rate (HR) nadir. Descriptive statistics were used to characterize the data.

      Results

      A total of 31 women met the inclusion criteria; among those women, 20 (65%) had cardiac biomarkers measured during hospitalization (Table). Cardiac troponins and BNP were elevated in 4 of 18 (22%) and 3 of 10 (30%) of these patients, respectively. Furthermore, 4 patients had transthoracic echocardiograms performed, and all were reported as normal. No patient had preexisting cardiovascular disease or hypertension. Of note, 2 maternal mortalities in this cohort were previously reported
      • Blitz M.J.
      • Rochelson B.
      • Minkoff H.
      • et al.
      Maternal mortality among women with coronavirus disease 2019 admitted to the intensive care unit.
      ; both patients had elevated cardiac troponins, and 1 also had an elevated BNP.
      TableCharacteristics of patients with normal and abnormal cardiac markers
      CharacteristicPatients with normal cardiac biomarkers (n=13)Patients with elevated cardiac biomarkers (n=7)
      Maternal age (y)33.0±4.432.0±4.5
       ≥35 y2 (15.4)3 (42.9)
      Race or ethnicity
       White5 (38.5)2 (28.5)
       African American2 (15.4)0
       Hispanic6 (42.8)0
       Asian03 (42.8)
       Other, unknown, or multiracial02 (28.5)
      Multiparous9 (69.2)7 (100)
      Parity of 3 or more3 (23.1)2 (28.5)
      BMI prepregnancy (kg/m2)34.7±6.732.5±6.0
       ≥30 kg/m28 (61.5)5 (71.4)
      Medical comorbidities
       Hypertension00
       Diabetes01 (14.3)
       Asthma1 (7.7)1 (14.3)
       Preexisting cardiac disease00
      Pregnancy complications
       Gestational diabetes1 (7.7)0
       Gestational hypertension or preeclampsia3 (23.1)2 (28.5)
      COVID-19
       Gestational age at hospitalization (wk)33.5 (10.8)34.5 (4.5) (1 postpartum)
       Reported symptoms
      Fever, subjective or measured9 (69.2)6 (85.7)
      Cough8 (61.5)6 (85.7)
      Dyspnea9 (69.2)6 (85.7)
      Nausea or diarrhea1 (7.7)1 (14.3)
      Other01 (14.3) (abdominal pain)
       Medications
      Hydroxychloroquine11 (84.6)3 (42.8)
      Corticosteroids5 (38.5)4 (57.1)
      Remdesivir02 (28.5)
      Interleukin inhibitors1 (7.7)3 (42.8)
      Convalescent plasma01 (14.3)
      Vital signs
       Temperature, ≥100.4°F or 38.0°C6 (42.8)5 (71.4)
       Max HR, >100 bpm10 (76.9)6 (85.7)
       Min HR, <60 bpm6 (42.8)3 (42.8)
       Respiratory rate, >30 bpm4 (30.7)4 (57.1)
       Oxygen saturation (min), %87.8±6.284.6±10.2
       ≤93%11 (84.6)5 (71.4)
      Biomarkers
       BNP, >300 pg/mL04 (57.1)
       hs-Trop, >6–14 ng/L01 (14.3)
       Troponin T, >0.06 ng/mL01 (14.3)
       Troponin I, >0.045 ng/mL02 (28.5)
      Echocardiogram1 (7.7)3 (42.8)
      Number of d admitted to hospital8 (11.0)4 (9.0)
      Intensive care unit admission5 (38.5)6 (85.7)
      Maternal mortality02 (28.5)
      Data are presented as number (percentage), median (interquartile range), or mean±standard deviation unless otherwise specified.
      Reference ranges: high sensitivity cardiac troponins, <6–14 ng/L; troponin T, 0.00–0.06 ng/mL; troponin I, 0.000–0.045; BNP, <300 pg/mL.
      BMI, body mass index; BNP, brain natriuretic peptide; COVID-19, coronavirus disease 2019; HR, heart rate; Max, maximum; Min, minimum.
      Shetty. Myocardial injury associated with coronavirus disease 2019. Am J Obstet Gynecol 2021.
      The nadir HR ranged from 30 to 92 bpm, and bradycardia occurred in 10 of 31 patients (one-third). Half of the women with elevated troponin and three-fourths of the women with elevated BNP had an episode of bradycardia recorded during their hospital course.

      Conclusion

      Myocardial injury as demonstrated by abnormal cardiac biomarkers and bradycardia may be common among pregnant women with severe or critical COVID-19. In this study, one-fifth of the patients who had troponin levels measured were found to have elevations (one-eighth of the overall study population). Among patients who had BNP levels measured, 30% were elevated (10% of the overall study population). One-third of the women had bradycardia.
      This study is limited by a small sample size. Laboratory testing and imaging were not uniform because of the retrospective nature of the study. Sampling bias was unavoidable because the decision to measure cardiac markers or perform imaging studies was made by the patient’s care team, based on clinical presentation rather than a formal protocol.
      Few studies have evaluated the risk of cardiac injury or arrhythmia among pregnant women with COVID-19. It is also unknown whether there are long-term sequelae that affect maternal health or future pregnancy outcomes. This is an important area of focus for future research.

      Acknowledgments

      We would like to acknowledge the efforts of the healthcare workers caring for pregnant women during the global COVID-19 pandemic.

      References

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