Global evaluation of echocardiography in patients with COVID-19

Abstract

Aims: To describe the cardiac abnormalities in patients with COVID-19 and identify the characteristics of patients who would benefit most from echocardiography.

Methods and results: In a prospective international survey, we captured echocardiography findings in patients with presumed or confirmed COVID-19 between 3 and 20 April 2020. Patient characteristics, indications, findings, and impact of echocardiography on management were recorded. Multivariable logistic regression identified predictors of echocardiographic abnormalities. A total of 1216 patients [62 (52-71) years, 70% male] from 69 countries across six continents were included. Overall, 667 (55%) patients had an abnormal echocardiogram. Left and right ventricular abnormalities were reported in 479 (39%) and 397 (33%) patients, respectively, with evidence of new myocardial infarction in 36 (3%), myocarditis in 35 (3%), and takotsubo cardiomyopathy in 19 (2%). Severe cardiac disease (severe ventricular dysfunction or tamponade) was observed in 182 (15%) patients. In those without pre-existing cardiac disease (n = 901), the echocardiogram was abnormal in 46%, and 13% had severe disease. Independent predictors of left and right ventricular abnormalities were distinct, including elevated natriuretic peptides [adjusted odds ratio (OR) 2.96, 95% confidence interval (CI) 1.75-5.05) and cardiac troponin (OR 1.69, 95% CI 1.13-2.53) for the former, and severity of COVID-19 symptoms (OR 3.19, 95% CI 1.73-6.10) for the latter. Echocardiography changed management in 33% of patients.

Conclusion: In this global survey, cardiac abnormalities were observed in half of all COVID-19 patients undergoing echocardiography. Abnormalities were often unheralded or severe, and imaging changed management in one-third of patients.

Keywords: COVID-19; Echocardiography.

Figure 1

Prevalence of COVID-19 and countries contributing to the global online survey of echocardiography. (A) The prevalence of COVID-19 on 20 April for the 185 countries for which data were available through the Johns Hopkins Center for Systems Science and Engineering COVID-19 dashboard. (B) The location and number of scans reported in the global online survey of echocardiography during a 17-day period from 3 to 20 April 2020.

Figure 2

Central Illustration. Mosaic plot illustrating the findings on echocardiography in patients with COVID-19. Mosaic plot illustrating the distribution of normal and abnormal echocardiogram findings in patients with suspected or confirmed COVID-19 infection. Box size is proportional to the number of patients per category. Left ventricular abnormalities are shown in orange and right ventricular abnormalities are shown in blue, both in the independent boxes and in the biventricular failure box. Survey respondents could enter data for multiple categories of left or right ventricular abnormality, therefore subcategories are not mutually exclusive. Eleven patients had evidence of cardiac tamponade which was an isolated finding in three patients, illustrated in purple. LV, left ventricle; MI, myocardial infarction; PAP, pulmonary arterial pressure.

Figure 3

Alluvial plot illustrating the indications for echocardiography and impact on patient management grouped according to the scan findings. Colours represent findings reported on echocardiography. All patients for whom complete data were available for indication, findings, and change in management were included in this plot [89% (1080/1216)]. The elevated biomarker indication subgroup includes both indication for raised troponin and indication for elevated BNP. Changes in management (impact) include those where changes in disease-specific therapy, titration of haemodynamic support, or changes in the level of patient care were described.

Figure 4

Predictors of an abnormal left (red) and right (blue) ventricle on echocardiography in patients with COVID-19 without pre-existing cardiac disease. Two multivariable logistic regression models examined the associations of clinical covariates with abnormal left ventricular or abnormal right ventricular findings on echocardiography. Categorical covariate data comprised only those answers that were pre-defined in survey questions and were selected a priori based on clinical relevance. *Those with mild symptoms were the referent group for symptom severity. BNP, brain type natriuretic peptide.