Relationship between Right Ventricular Strain Signs in Electrocardiography and Levels of Biomarkers Associated with COVID-19 Pneumonia Severity

Polat, Veli; Bozcali, Evin; Yasar, Kadriye Kart; Karaosmanoglu, Hayat Kumbasar; Akturk, Ibrahim Faruk

doi:10.36660/abc.20200724

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Original Article • Arq. Bras. Cardiol. 117 (4) • Oct 2021 • https://doi.org/10.36660/abc.20200724 copy

Relationship between Right Ventricular Strain Signs in Electrocardiography and Levels of Biomarkers Associated with COVID-19 Pneumonia Severity

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background

The novel coronavirus disease (COVID-19) may lead to severe disease that can cause death. COVID-19 is known to affect the cardiovascular system. Early detection of the progression to the severe disease stage that affects the cardiovascular system may play a critical role in the treatment of COVID-19.

Objectives

To explore the possible relationship between the COVID-19 pneumonia and right ventricular strain findings on electrocardiography (ECG).

Methods

We conducted a retrospective study of 141 hospitalized patients with COVID-19. Spearman’s correlation and logistic regression analyses were applied to assess relationships between ECG manifestations of right ventricular strain and levels of biomarkers and other laboratory and chest imaging findings. The significance level was considered as < 0.05.

Results

The ECG signs of right ventricular stress were significantly more frequent and the levels of fibrinogen, CRP, and ferritin were significantly higher in COVID-19 patients with elevated levels of hs-cTnI, procalcitonin and D-dimer. The univariate analysis showed there are significant relations between the presence of bilateral pneumonia, most of the ECG signs of right ventricular strain and cardiac injury and inflammatory and thrombotic biomarkers. The multivariate analysis revealed that ST-segment elevation in V₁and the S₁Q₃T₃pattern are independent predictors of cardiac damage (odds ratio=0.23; 95% CI, 0.06 to 0.90; p=0.035) and elevated procalcitonin levels (odds ratio=0.19; 95% CI, 0.06 to 0.62; p=0.006), respectively.

Conclusion

The findings of the present study suggest that right heart damage is prevalent in COVID-19. In addition, our study shows the clinical value of ECG in evaluating and monitoring the patients with COVID-19 pneumonia.

COVID-19; Betacoronavirus; Cardiovascular Diseases; Ventricular Function Right; Stress; Eletrocardiography/methods; Biomarkers; Pneumonia/complications

	Patients (n=141)
Smoking	21 (14.9%)
Comorbidities
Hypertension	44 (31.2%)
Diabetes	36 (25.5%)
Coronary artery disease	27 (19.1%)
Chronic obstructive pulmonary disease	5 (3.5%)
Malignancy	2 (1.4%)
ECG signs
Sinus tachycardia	87 (61.7%)
Incomplete RBBB	62 (44.0%)
Complete RBBB	28 (19.9%)
T-wave inversion in V1 to V4	37 (26.2%)
S₁Q₃T₃pattern	52 (36.9%)
Qr in V₁	35 (24.8%)
ST-segment elevation in V₁	54 (38.3%)
Chest computed tomography findings	7 (5%)
Unilateral pneumonia	55 (39.0%)
Bilateral pneumonia	86 (61.0%)
Clinical outcome	35 (24.8%)
In-hospital death	5 (3.5%)

Characteristics	Normal hs-cTnI (n = 69)	Elevated hs-cTnI (n = 72)	p Value	Procalcitonin < 0.5 ng/mL (n = 74)	Procalcitonin ≥ 0.5 ng/mL (n = 67)	p Value	D-dimer < 0.5 µg/mL (n = 39)	D-dimer ≥ 0.5 µg/mL (n = 102)	p Value
Age	62.6 ± 12.3	63.4 ± 12.5	0.69^†	60.1 ± 12.1	66.3 ± 11.1	0.003^†	57.0 ± 12.6	65.3 ± 11.5	< 0.001^†
Female	29 (42%)	28 (38.9%)	0.70^∗	29 (39.2%)	28 (41.8%)	0.75^∗	13 (33.3%)	44 (43.1%)	0.289^∗
ECG signs
Sinus tachycardia	34 (49.3%)	53 (73.6%)	0.003^∗	30 (40.5%)	57 (85.1%)	< 0.001^∗	9 (23.1%)	78 (76.5%)	< 0.001^∗
Incomplete RBBB	21 (30.4%)	41 (56.9%)	0.002^∗	28 (37.8%)	34 (50.7%)	0.123^∗	16 (41%)	46 (45.1%)	0.66^∗
Complete RBBB	8 (11.6%)	20 (27.8%)	0.016^∗	4 (5.4%)	24 (35.8%)	< 0.001^∗	2 (5.1%)	26 (25.5%)	0.007^∗
T inversion in V1 to V4	3(4.3%)	34 (47.2%)	< 0.001^∗	4 (5.4%)	33(49.3%)	< 0.001^∗	1 (2.6%)	36 (35.3%)	< 0.001^∗
S₁Q₃T₃pattern	14 (20.3%)	38 (52.8%)	< 0.001^∗	8 (10.8%)	44 (65.7%)	< 0.001^∗	2 (5.1%)	50 (49%)	< 0.001^∗
Qr in V₁	1 (1.4%)	34 (47.2%)	< 0.001^∗	3 (4.1%)	32 (47.8%)	< 0.001^∗	1 (2.6%)	34 (33.3%)	< 0.001^∗
ST elevation in V₁	5 (7.2%)	49 (68.1%)	< 0.001^∗	5 (6.8%)	49 (73.1%)	< 0.001^∗	0 (0.0%)	54 (52.9%)	< 0.001^∗
Chest CT findings
Unilateral pneumonia	40 (58%)	15 (20.8%)	< 0.001^∗	52 (70.3%)	3 (4.5%)	< 0.001^∗	31 (79.5%)	24 (23.5%)	< 0.001^∗
Bilateral pneumonia	29 (42%)	57 (79.2%)		22 (29.7%)	64 (95.5%)		8 (20.5%)	78 (76.5%)
Clinical outcome
In-hospital death	0 (0.0%)	5 (6.9%)	0.026^γ	0 (0.0%)	5 (7.5%)	0.017^γ	0 (0.0%)	5 (4.9%)	0.322^γ
Laboratory data
Leukocyte count ×10³/μL	6.6 (5.6-7.8)	6.9 (5.3-8.9)	0.66^‡	6.5 (5.3-8.2)	7.3 (5.7-8.6)	0.104^‡	6.8 (5.4-7.7)	6.7 (5.6-6.6)	0.269^‡
Neutrophil count ×10³/μL	4.9 (3.3-5.9)	4.7 (3.9 – 6.8)	0.22^‡	4.7 (3.2-5.7)	5.4 (4-7.8)	0.004^‡	4.9 (3.2-5.8)	4.9 (3.8-6.8)	0.203^‡
Neutrophil/ Leukocyte ratio, %	70.5 ± 8.9	74.0 ± 10.2	0.033^†	69.6 ± 9.2	75.3 ± 9.5	< 0.001^†	69.4 ± 9.4	73.4± 9.7	0.03^†
Lymphocyte count ×10³/μL	1.1 (0.9- 1.3)	0.9 (0.8-1.2)	0.006^‡	1.05 (0.9-1.1)	0.96 (0.9-1.2)	0.019^‡	1.10 (0.9-1.6)	0.97 (1-1.2)	0.009^‡
Lymphocyte / Leukocyte ratio, %	15.6 (13.6 -20)	15 (10-19.7)	0.06^‡	16.7 (14.3-20)	13.6 (9.5 -19)	0.003^‡	17 (14-17)	15 (10-18)	0.007^‡
Platelets ×10³/μL	220 (168 – 256)	221 (163-285)	0.98^‡	219 (167-256)	220 (166-306)	0.82^‡	218 (163-243)	220 (167-291)	0.411^‡
Creatinine (mg/dL)	0.86 (0.7-1)	0.98 (0.8 -1.2)	0.16^‡	0.86 (0.7-1.1)	0.98 (0.8-1.3)	0.09^‡	0.83 (0.7-1)	0.97 (0.8-1.2)	0.13^‡
ALT (U/L)	31 (25-45)	31.5 (20-49)	0.74^‡	30 (21-45)	32 (23-47)	0.55^‡	31 (25-43)	31 (21-45)	0.32^‡
AST (U/L)	30 (24-38)	35.5 (26-47)	0.11^‡	30 (23-39)	36 (26-46)	0.23^‡	30 (23-40)	34 (26-44)	0.37^‡
Fibrinogen, mg/dL	472 (413-542)	590 (505-736)	< 0.001^‡	449 (409-507)	626 (550-740)	< 0.001^‡	415 (396-428)	577 (505-683)	< 0.001^‡
D-dimer, µg/mL	0.45 (0.2-0.9)	1.40 (0.7-3.7)	< 0.001^‡	0.41 (0.2-0.8)	2.04 (1-3.8)	< 0.001^‡	0.24 (0.2-0.3)	1.20 (0.7-2.8)	< 0.001^‡
CRP, mg/L	58 (44-88)	136 (89-203)	< 0.001^‡	54 (43-87)	153 (153-204)	< 0.001^‡	49 (41-61)	114 (77-179)	< 0.001^‡
Ferritin, µg/L	294 (236-400)	612 (397-975)	< 0.001^‡	282 (232- 382)	662 (450-980)	< 0.001^‡	254 (226-292)	532 (356-806)	< 0.001^‡
Procalcitonin, ng/mL	0.06 (0.02-0.38)	2.76 (0.31-6.69)	< 0.001^‡	0.055 (0.02-0.07)	2.76 (1-7.7)	< 0.001^‡	0.05 (0.02-0.06)	0.96 (0.07-5.30)	< 0.001^‡
CK-MB, ng/mL	3 (2-3)	8.5 (5-15.5)	< 0.001^‡	3 (2-4)	9 (4-16)	< 0.001^‡	3 (2-4)	5.5 (3-12)	< 0.001^‡
hs-cTnI, ng/L	15 (12-16)	62.5 (26-348)	< 0.001^‡	16 (13-18)	67 (18-356)	< 0.001^‡	16 (13-16)	31 (16-173)	< 0.001^‡

	Univariate		Multivariate

	OR (95% CI)		p Value	OR (95% CI)	p Value
Sinus tachycardia	0.35 (0.17-0.70)	0.003
Incomplete RBBB	0.33 (0.17-0.66)	0.002
Complete RBBB	0.34 (0.14-0.84)	0.019
T inversion in V₁-V₄	0.05 (0.01-0.18)	< 0.001
S₁Q₃T₃pattern	0.23 (0.11-0.48)	< 0.001
Qr in V₁	0.02 (0.00-0.12)	< 0.001
ST elevation in V₁	0.04 (0.01-0.10)	< 0.001		0.23 (0.06-0.90)	0.035
Presence of bilateral pneumonia	0.19 (0.09-0.40)	< 0.001
Neutrophil count	1.04 (1.00-1.08)	0.036
Fibrinogen, mg/dL	1.01 (1.01-1.01)	< 0.001
D-dimer, µg/mL	3.14 (1.91-5.17)	< 0.001
CRP, mg/L	1.02 (1.01-1.03)	< 0.001
Ferritin, µg/L	1.01 (1.00-1.01)	< 0.001
Procalcitonin, ng/mL	2.03 (1.45-2.83)	< 0.001
CK-MB, ng/mL	2.09 (1.58-2.76)	< 0.001

	Univariate		Multivariate

	OR (95% CI)		p Value	OR (95% CI)	p Value
Age	1.04 (1.01-1.08)	0.004
Complete RBBB	0.10 (0.03-0.32)	< 0.001
T inversion in V₁-V₄	0.06 (0.02-0.18)	< 0.001
S₁Q₃T₃pattern	0.06 (0.03-0.15)	< 0.001		0.19 (0.06-0.62)	0.006
Qr in V₁	0.05 (0.01-0.16)	< 0.001
ST elevation in V₁	0.03 (0.01-0.08)	< 0.001
Presence of bilateral pneumonia	0.02 (0.01-0.07)	< 0.001		0.15 (0.03-0.84)	0.031
Neutrophil count	1.27 (1.09-1.48)	0.002		1.35 (1.07-1.71)	0.011
Neutrophil/Leukocyte ratio	1.07 (1.03-1.11)	0.001
Lymphocyte/Leukocyte ratio	0.93 (0.88-0.98)	0.009
Fibrinogen, mg/dL	1.02 (1.01-1.02)	< 0.001
D-dimer, µg/mL	8.64 (3.67-20.35)	< 0.001
CRP, mg/L	1.03 (1.02-1.04)	< 0.001
Ferritin, µg/L	1.01 (1.01-1.01)	< 0.001
CK-MB, ng/mL	1.35 (1.18-1.53)	< 0.001
hs-cTnI, ng/L	1.02 (1.01-1.02)	< 0.001

	Univariate		Multivariate

	OR (95% CI)		p Value	OR (95% CI)	p Value
Age	1.06 (1.02-1.10)	0.001
Complete RBBB	0.16 (0.04-0.70)	0.015
T inversion in V₁-V₄	0.05 (0.01-0.37)	0.003
S₁Q₃T₃pattern	0.06 (0.01-0.25)	< 0.001
Qr in V₁	0.05 (0.01-0.40)	0.004
Presence of bilateral pneumonia	0.08 (0.03-0.20)	< 0.001
Neutrophil count	1.04 (1.00-1.09)	0.033
Lymphocyte count	0.41 (0.17-0.96)	0.041
Lymphocyte/Leukocyte ratio	0.93 (0.88-0.98)	0.007
Fibrinogen, mg/dL	1.04 (1.02-1.06)	< 0.001		1.05 (1.03-1.07)	< 0.001
Procalcitonin, ng/mL	17.73 (2.82-111.30)	0.002
CRP, mg/L	1.05 (1.03-1.07)	< 0.001
Ferritin, µg/L	1.01 (1.01-1.02)	< 0.001
CK-MB, ng/mL	1.34 (1.12-1.61)	0.001
hs-cTnI, ng/L	1.10 (1.03-1.18)	0.006

	hs-cTnI		Procalcitonin		D-dimer		CRP		Neutrophil count		Fibrinogen		Ferritin

	r	p	r	p	r	p	r	p	r	p	r	p	r	p
hs-cTnI	1	.	0.666	< 0.001	0.633	< 0.001	0.599	< 0.001	0.175	0.04	0.618	< 0.001	0.625	< 0.001
Procalcitonin	0.666	< 0.001	1	.	0.776	< 0.001	0.811	< 0.001	0.213	0.01	0.748	< 0.001	0.841	< 0.001
D-dimer	0.633	< 0.001	0.776	< 0.001	1	.	0.821	< 0.001	0.172	0.04	0.924	< 0.001	0.842	< 0.001
CRP	0.599	< 0.001	0.811	< 0.001	0.821	< 0.001	1	.	0.271	0.001	0.811	< 0.001	0.962	< 0.001
Neutrophil count	0.175	0.04	0.213	0.01	0.172	0.04	0.271	0.001	1	.	0.174	0.04	0.222	0.008
Fibrinogen	0.618	< 0.001	0.748	< 0.001	0.924	< 0.001	0.811	< 0.001	0.174	0.04	1	.	0.832	< 0.001
Ferritin	0.625	< 0.001	0.841	< 0.001	0.842	< 0.001	0.962	< 0.001	0.222	0.008	0.832	< 0.001	1	.

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[1] Mailing Address: Veli Polat • Department of Cardiology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Zuhuratbaba Mah, Dr. Tevfik Sağlam Cd No:11, 34147 Bakırköy/Istanbul - Turkey Email: dr.velipolat@gmail.com