Association of Troponin Levels With Mortality in Italian Patients Hospitalized With Coronavirus Disease 2019: Results of a Multicenter Study

IMPORTANCE Myocardial injury, detected by elevated plasma troponin levels, has been
associated with mortality in patients hospitalized with coronavirus disease 2019 (COVID-19).
However, the initial data were reported from single-center or 2-center studies in Chinese
populations. Compared with these patients, European and US patients are older, with more
comorbidities and higher mortality rates.
OBJECTIVE To evaluate the prevalence and prognostic value ofmyocardial injury, detected by
elevated plasma troponin levels, in a large population of White Italian patients with COVID-19.
DESIGN, SETTING, AND PARTICIPANTS This is a multicenter, cross-sectional study enrolling
consecutive patients with laboratory-confirmed COVID-19 who were hospitalized in 13 Italian
cardiology units from March 1 to April 9, 2020. Patients admitted for acute coronary
syndrome were excluded. Elevated troponin levels were defined as values greater than the
99th percentile of normal values.
MAIN OUTCOMES AND MEASURES Clinical characteristics and outcomes stratified as elevated
or normal cardiac troponin levels at admission, defined as troponin T or troponin I at a level
greater than the 99th percentile of normal values.
RESULTS A total of 614 patients with COVID-19 were included in this study (mean age [SD],
67 [13] years; 70.8%male), of whom 148 patients (24.1%) died during the hospitalization.
Elevated troponin levels were found in 278 patients (45.3%). These patients were older
(mean [SD] age, 64.0 [13.6] years vs 71.3 [12.0] years; P < .001) and had higher prevalence of
hypertension (168 patients [50.5%] vs 182 patients [65.9%]; P < .001), heart failure (24
[7.2%]; 63 [22.8%]; P < .001), coronary artery disease (50 [15.0%] vs 87 [31.5%]; P < .001),
and atrial fibrillation (33 [9.9%] vs 67 [24.3%]; P < .001). Elevated troponin levels were
associated with an increased in-hospital mortality (37%vs 13%; HR, 1.71 [95%CI, 1.13-2.59];
P = .01 via multivariable Cox regression analysis), and this was independent from
concomitant cardiac disease. Elevated troponin levels were also associated with a higher risk
of in-hospital complications: heart failure (44 patients [19.2%] vs 7 patients [2.9%]; P < .001),
sepsis (31 [11.7%] vs 21 [6.4%]; P = .03), acute kidney failure (41 [20.8%] vs 13 [6.2%];
P < .001), multiorgan failure (21 [10.9%] vs 6 [2.9%]; P = .003), pulmonary embolism
(27 [9.9%] vs 17 [5.2%]; P = .04), delirium (13 [6.8%] vs 3 [1.5%]; P = .02), and major bleeding
(16 [7.0%] vs 4 [1.6%]; P = .008).
CONCLUSIONS AND RELEVANCE In this multicenter, cross-sectional study of Italian patients
with COVID-19, elevated troponin was an independent variable associated with in-hospital
mortality and a greater risk of cardiovascular and noncardiovascular complications during a
hospitalization for COVID-19.