1. bookVolume 60 (2022): Issue 1 (March 2022)
Journal Details
First Published
30 Mar 2015
Publication timeframe
4 times per year
access type Open Access

Cardiac biomarkers alterations in patients with SARS-CoV-2 infection

Published Online: 17 Mar 2022
Page range: 6 - 13
Received: 02 Jun 2021
Journal Details
First Published
30 Mar 2015
Publication timeframe
4 times per year

Reliable biomarkers are necessary for the risk stratification of patients infected with SARS-CoV-2. This novel coronavirus is now established to affect several organs in addition to the lungs, most prominently the heart. This is achieved through direct damage to the myocardium and indirect immune-associated effects during the cytokine storm. We performed a literature review aiming to identify the prognostic value of alterations of cardiac biomarkers in SARS-CoV-2 infection. Cardiac biomarkers are significantly elevated in patients with severe COVID-19 and are independent predictors of mortality. High-sensitivity troponin I and T are correlated with multiple inflammatory indexes and poor outcomes. Although cut-off values have been established for most of cardiac biomarkers, lower limits for troponins may have better prognostic values and longitudinal monitoring of cardiac biomarkers can help the clinician assess the patient’s course. Additional measurements of NT-proBNP, can detect the subgroup of patients with poor prognosis.


1. KURZ DJ, EBERLI FR. Cardiovascular aspects of COVID-19. Swiss Med Wkly. 2020;150:w20417.10.4414/smw.2020.20417Search in Google Scholar

2. BHALLA V, BLISH CA, SOUTH AM. A historical perspective on ACE2 in the COVID-19 era [published online ahead of print, 2020 Dec 14]. J Hum Hypertens. 2020;1–5.10.1038/s41371-020-00459-3Search in Google Scholar

3. BADER F, MANLA Y, ATALLAH B, STARLING RC. Heart failure and COVID-19. Heart Fail Rev. 2021;26(1):1–10.10.1007/s10741-020-10008-2Search in Google Scholar

4. IMAZIO M, KLINGEL K, KINDERMANN I, BRUCATO A, DE ROSA FG, ADLER Y, et al. COVID-19 pandemic and troponin: indirect myocardial injury, myocardial inflammation or myocarditis?. Heart. 2020;106(15):1127–1131.10.1136/heartjnl-2020-317186Search in Google Scholar

5. LI L, ZHOU Q, XU J. Changes of Laboratory Cardiac Markers and Mechanisms of Cardiac Injury in Coronavirus Disease 2019. Biomed Res Int. 2020;2020:7413673.10.1155/2020/7413673Search in Google Scholar

6. ABOUGHDIR M, KIRWIN T, ABDUL KHADER A, WANG B. Prognostic Value of Cardiovascular Biomarkers in COVID-19: A Review. Viruses. 2020;12(5):527.10.3390/v12050527Search in Google Scholar

7. SHI X, CHEN M, ZHANG Y. The cardiovascular disorders and prognostic cardiac biomarkers in COVID-19. Mol Biol Rep. 2021;48(2):1763–1771.10.1007/s11033-021-06148-9Search in Google Scholar

8. WU L, O’KANE AM, PENG H, BI Y, MOTRIUK-SMITH D, REN J. SARS-CoV-2 and cardiovascular complications: From molecular mechanisms to pharmaceutical management. Biochem Pharmacol. 2020;178:114114.10.1016/j.bcp.2020.114114Search in Google Scholar

9. ADEGHATE EA, EID N, SINGH J. Mechanisms of COVID-19-induced heart failure: a short review. Heart Fail Rev. 2021;26(2):363–369.10.1007/s10741-020-10037-xSearch in Google Scholar

10. COSTA IBSDS, BITTAR CS, RIZK SI, ARAÚJO FILHO AE, SANTOS KAQ, MACHADO TIV, et al. The Heart and COVID-19: What Cardiologists Need to Know. O Coração e a COVID-19: O que o Cardiologista Precisa Saber. Arq Bras Cardiol. 2020;114(5):805–816.10.36660/abc.20200279Search in Google Scholar

11. HUANG C, WANG Y, LI X, REN L, ZHAO J, HU Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506.10.1016/S0140-6736(20)30183-5Search in Google Scholar

12. MALIK P, PATEL U, PATEL NH, SOMI S, SINGH J. Elevated cardiac troponin I as a predictor of outcomes in COVID-19 hospitalizations: a meta-analysis. Infez Med. 2020;28(4):500–506.Search in Google Scholar

13. BAGATE F, MASI P, D’HUMIÈRES T, AL-ASSAAD L, CHAKRA LA, RAZAZI K, et al. Advanced echocardiographic phenotyping of critically ill patients with coronavirus-19 sepsis: a prospective cohort study. J Intensive Care. 2021;9(1):12.10.1186/s40560-020-00516-6Search in Google Scholar

14. LI X, PAN X, LI Y, AN N, XING Y, YANG F, et al. Cardiac injury associated with severe disease or ICU admission and death in hospitalized patients with COVID-19: a meta-analysis and systematic review. Crit Care. 2020;24(1):468.10.1186/s13054-020-03183-zSearch in Google Scholar

15. GIUSTINO G, CROFT LB, STEFANINI GG, BRAGATO R, SILBIGER JJ, VICENZI M, et al. Characterization of Myocardial Injury in Patients With COVID-19. J Am Coll Cardiol. 2020;76(18):2043–2055.10.1016/j.jacc.2020.08.069Search in Google Scholar

16. PEIRÓ ÓM, CARRASQUER A, SÁNCHEZ-GIMENEZ R, LAL-TREHAN N, DEL-MORAL-RONDA V, BONET G, et al. Biomarkers and short-term prognosis in COVID-19. Biomarkers. 2021;26(2):119–126.10.1080/1354750X.2021.1874052Search in Google Scholar

17. SHOAR S, HOSSEINI F, NADERAN M, MEHTA JL. Meta-analysis of Cardiovascular Events and Related Biomarkers Comparing Survivors Versus Non-survivors in Patients With COVID-19. Am J Cardiol. 2020;135:50–61.10.1016/j.amjcard.2020.08.044Search in Google Scholar

18. LI J, ZHANG Y, WANG F, LIU B, LI H, TANG Z, et al. Cardiac damage in patients with the severe type of coronavirus disease 2019 (COVID-19). BMC Cardiovasc Disord. 2020;20(1):479.10.1186/s12872-020-01758-wSearch in Google Scholar

19. MU S, WEI W, JIN C, PU N, YU K, GU G, et al. Risk factors for COVID-19 patients with cardiac injury: pulmonary ventilation dysfunction and oxygen inhalation insufficiency are not the direct causes. Aging (Albany NY). 2020;12(23):23464–23477.10.18632/aging.104148Search in Google Scholar

20. SHAH P, DOSHI R, CHENNA A, OWENS R, COBB A, IVEY H, et al. Prognostic Value of Elevated Cardiac Troponin I in Hospitalized Covid-19 Patients. Am J Cardiol. 2020;135:150–153.10.1016/j.amjcard.2020.08.041Search in Google Scholar

21. ÖZYILMAZ S, ERGÜN ALIŞ E, ERMIŞ E, ALLAHVERDIYEV S, UÇAR H. Assessment of the Relationship between Mortality and Troponin I Levels in Hospitalized Patients with the Novel Coronavirus (COVID-19). Medicina (Kaunas). 2020;56(12):693.10.3390/medicina56120693Search in Google Scholar

22. MEDETALIBEYOGLU A, EMET S, SENKAL N, AYDOGAN M, KOSE M, TUKEK T. Cardiovascular view of intermediate and high-risk COVID-19 patients: single-centre experience with low mortality and intensive care hospitalisation rates. Cardiovasc J Afr. 2021;32(2):79–86.Search in Google Scholar

23. ARCARI L, LUCIANI M, CACCIOTTI L, MUSUMECI MB, SPUNTARELLI V, PISTELLA E, et al. Incidence and determinants of high-sensitivity troponin and natriuretic peptides elevation at admission in hospitalized COVID-19 pneumonia patients. Intern Emerg Med. 2020;15(8):1467–1476.10.1007/s11739-020-02498-7Search in Google Scholar

24. STEFANINI GG, CHIARITO M, FERRANTE G, CANNATA F, AZZOLINI E, VIGGIANI G, et al. Early detection of elevated cardiac biomarkers to optimise risk stratification in patients with COVID-19. Heart. 2020;106(19):1512–1518.10.1136/heartjnl-2020-317322Search in Google Scholar

25. QIN JJ, CHENG X, ZHOU F, LEI F, AKOLKAR G, CAI J, et al. Redefining Cardiac Biomarkers in Predicting Mortality of Inpatients With COVID-19. Hypertension. 2020;76(4):1104–1112.10.1161/HYPERTENSIONAHA.120.15528Search in Google Scholar

26. SALVATICI M, BARBIERI B, CIOFFI SMG, MORENGHI E, LEONE FP, MAURA F, et al. Association between cardiac troponin I and mortality in patients with COVID-19. Biomarkers. 2020;25(8):634–640.10.1080/1354750X.2020.1831609Search in Google Scholar

27. CAO J, ZHENG Y, LUO Z, MEI Z, YAO Y, LIU Z, et al. Myocardial injury and COVID-19: Serum hs-cTnI level in risk stratification and the prediction of 30-day fatality in COVID-19 patients with no prior cardiovascular disease. Theranostics. 2020;10(21):9663–9673.10.7150/thno.47980Search in Google Scholar

28. HODGES G, PALLISGAARD J, SCHJERNING OLSEN AM, MCGETTIGAN P, ANDERSEN M, KROGAGER M, et al. Association between biomarkers and COVID-19 severity and mortality: a nationwide Danish cohort study. BMJ Open. 2020;10(12):e041295.10.1136/bmjopen-2020-041295Search in Google Scholar

29. RAAD M, DABBAGH M, GORGIS S, YAN J, CHEHAB O, DAGHER C, et al. Cardiac Injury Patterns and Inpatient Outcomes Among Patients Admitted With COVID-19. Am J Cardiol. 2020;133:154–161.10.1016/j.amjcard.2020.07.040Search in Google Scholar

30. TORAIH EA, ELSHAZLI RM, HUSSEIN MH, ELGAML A, AMIN M, EL-MOWAFY M, et al. Association of cardiac biomarkers and comorbidities with increased mortality, severity, and cardiac injury in COVID-19 patients: A meta-regression and decision tree analysis. J Med Virol. 2020;92(11):2473–2488.10.1002/jmv.26166Search in Google Scholar

31. HE X, WANG L, WANG H, XIE Y, YU Y, SUN J, et al. Factors associated with acute cardiac injury and their effects on mortality in patients with COVID-19. Sci Rep. 2020;10(1):20452.10.1038/s41598-020-77172-1Search in Google Scholar

32. YAO Q, NI J, HU TT, CAI ZL, ZHAO JH, XIE QW, et al. Clinical characteristics and outcomes in coronavirus disease 2019 (COVID-19) patients with and without hypertension: a retrospective study. Rev Cardiovasc Med. 2020;21(4):615–625.10.31083/j.rcm.2020.04.113Search in Google Scholar

33. ALOISIO E, CHIBIREVA M, SERAFINI L, PASQUALETTI S, FALVELLA FS, DOLCI A, et al. A Comprehensive Appraisal of Laboratory Biochemistry Tests as Major Predictors of COVID-19 Severity. Arch Pathol Lab Med. 2020;144(12):1457–1464.10.5858/arpa.2020-0389-SASearch in Google Scholar

34. SINGH N, ANCHAN RK, BESSER SA, BELKIN MN, CRUZ MD, LEE L, et al. High sensitivity Troponin-T for prediction of adverse events in patients with COVID-19. Biomarkers. 2020;25(8):626–633.10.1080/1354750X.2020.1829056Search in Google Scholar

35. LI C, JIANG J, WANG F, ZHOU N, VERONESE G, MOSLEHI JJ, et al. Longitudinal correlation of biomarkers of cardiac injury, inflammation, and coagulation to outcome in hospitalized COVID-19 patients. J Mol Cell Cardiol. 2020;147:74–87.10.1016/j.yjmcc.2020.08.008Search in Google Scholar

36. POTERUCHA TJ, ELIAS P, JAIN SS, SAYER G, REDFORS B, BURKHOFF D, et al. Admission Cardiac Diagnostic Testing with Electrocardiography and Troponin Measurement Prognosticates Increased 30-Day Mortality in COVID-19. J Am Heart Assoc. 2021;10(1):e018476.10.1161/JAHA.120.018476Search in Google Scholar

37. SI D, DU B, NI L, YANG B, SUN H, JIANG N, et al. Death, discharge and arrhythmias among patients with COVID-19 and cardiac injury. CMAJ. 2020;192(28):E791–E798.10.1503/cmaj.200879Search in Google Scholar

38. ZHOU M, WONG CK, UN KC, LAU YM, LEE JC, TAM FC et al. Cardiovascular sequalae in uncomplicated COVID-19 survivors. PLoS One. 2021;16(2):e0246732.10.1371/journal.pone.0246732Search in Google Scholar

39. GHIO S, BALDI E, VICENTINI A, LENTI MV, DI SABATINO A, DI MATTEO A, et al. Cardiac involvement at presentation in patients hospitalized with COVID-19 and their outcome in a tertiary referral hospital in Northern Italy. Intern Emerg Med. 2020;15(8):1457–1465.10.1007/s11739-020-02493-ySearch in Google Scholar

40. LI J, GUO T, DONG D, ZHANG X, CHEN X, FENG Y, et al. Defining heart disease risk for death in COVID-19 infection. QJM. 2020;113(12):876–882.10.1093/qjmed/hcaa246Search in Google Scholar

41. BELARTE-TORNERO LC, VALDIVIELSO-MORÉ S, VICENTE ELCANO M, SOLÉ-GONZÁLEZ E, RUÍZ-BUSTILLO S, CALVO-FERNÁNDEZ A, et al. Prognostic Implications of Chronic Heart Failure and Utility of NT-proBNP Levels in Heart Failure Patients with SARS-CoV-2 Infection. J Clin Med. 2021;10(2):323.10.3390/jcm10020323Search in Google Scholar

42. ZYLLA MM, MERLE U, VEY JA, KOROSOGLOU G, HOFMANN E, MÜLLER M, et al. Predictors and Prognostic Implications of Cardiac Arrhythmias in Patients Hospitalized for COVID-19. J Clin Med. 2021;10(1):133.10.3390/jcm10010133Search in Google Scholar

43. MANOCHA KK, KIRZNER J, YING X, YEO I, PELTZER B, ANG B, et al. Troponin and Other Biomarker Levels and Outcomes Among Patients Hospitalized With COVID-19: Derivation and Validation of the HA2T2 COVID-19 Mortality Risk Score. J Am Heart Assoc. 2021;10(6):e018477.10.1161/JAHA.120.018477Search in Google Scholar

44. MAHMOUD-ELSAYED HM, MOODY WE, BRADLOW WM, KHAN-KHEIL AM, SENIOR J, HUDSMITH LE, et al. Echocardiographic Findings in Patients With COVID-19 Pneumonia. Can J Cardiol. 2020;36(8):1203–1207.10.1016/j.cjca.2020.05.030Search in Google Scholar

45. CHEN LQ, BURDOWSKI J, MARFATIA R, WEBER J, GLIGANIC K, DIAZ N, et al. Reduced cardiac function is associated with cardiac injury and mortality risk in hospitalized COVID-19 Patients. Clin Cardiol. 2020;43(12):1547–1554.10.1002/clc.23479Search in Google Scholar

46. VAN DEN HEUVEL FMA, VOS JL, KOOP Y, VAN DIJK APJ, DUIJNHOUWER AL, DE MAST Q, et al. Cardiac function in relation to myocardial injury in hospitalised patients with COVID-19. Neth Heart J. 2020;28(7-8):410–417.10.1007/s12471-020-01458-2Search in Google Scholar

47. LAZZERI C, BONIZZOLI M, BATACCHI S, CIANCHI G, FRANCI A, FULCERI GE, et al. Cardiac Involvment in COVID-19-Related Acute Respiratory Distress Syndrome. Am J Cardiol. 2020;132:147–149.10.1016/j.amjcard.2020.07.010Search in Google Scholar

48. GHIO S, BALDI E, VICENTINI A, LENTI MV, DI SABATINO A, DI MATTEO A, et al. Cardiac involvement at presentation in patients hospitalized with COVID-19 and their outcome in a tertiary referral hospital in Northern Italy. Intern Emerg Med. 2020;15(8):1457–1465.10.1007/s11739-020-02493-ySearch in Google Scholar

49. SONSOZ MR, ONCUL A, CEVIK E, ORTA H, YILMAZ M, AYDUK GOVDELI E, et al. Wide QRS Complex and Lateral ST-T Segment Abnormality Are Associated With Worse Clinical Outcomes in COVID-19 Patients. Am J Med Sci. 2021;361(5):591–597.10.1016/j.amjms.2020.12.012Search in Google Scholar

50. SANGHVI SK, SCHWARZMAN LS, NAZIR NT. Cardiac MRI and Myocardial Injury in COVID-19: Diagnosis, Risk Stratification and Prognosis. Diagnostics (Basel). 2021;11(1):130.10.3390/diagnostics11010130Search in Google Scholar

51. KNIGHT DS, KOTECHA T, RAZVI Y, CHACKO L, BROWN JT, JEETLEY PS, et al. COVID-19: Myocardial Injury in Survivors. Circulation. 2020;142(11):1120–1122.10.1161/CIRCULATIONAHA.120.049252Search in Google Scholar

52. LAI CC, SUNG MI, HO CH, LIU HH, CHEN CM, CHIANG SR, et al. The prognostic value of N-terminal proB-type natriuretic peptide in patients with acute respiratory distress syndrome. Sci Rep. 2017;7:44784.10.1038/srep44784Search in Google Scholar

53. UELAND T, HEGGELUND L, LIND A, HOLTEN AR, TONBY K, MICHELSEN AE, et al. Elevated plasma sTIM-3 levels in patients with severe COVID-19. J Allergy Clin Immunol. 2021;147(1):92–98.10.1016/j.jaci.2020.09.007Search in Google Scholar

54. BANSAL A, KUMAR A, PATEL D, PURI R, KALRA A, KAPADIA SR, et al. Meta-analysis Comparing Outcomes in Patients With and Without Cardiac Injury and Coronavirus Disease 2019 (COVID 19). Am J Cardiol. 2021;141:140–146.10.1016/j.amjcard.2020.11.009Search in Google Scholar

55. PRANATA R, HUANG I, LUKITO AA, RAHARJO SB. Elevated N-terminal pro-brain natriuretic peptide is associated with increased mortality in patients with COVID-19: systematic review and meta-analysis. Postgrad Med J. 2020;96(1137):387–391.10.1136/postgradmedj-2020-137884Search in Google Scholar

56. GAO L, JIANG D, WEN XS, CHENG XC, SUN M, HE B, et al. Prognostic value of NT-proBNP in patients with severe COVID-19. Respir Res. 2020;21(1):83.10.1186/s12931-020-01352-wSearch in Google Scholar

57. ABDEEN Y, KAAKO A, ALNABULSI M, OKEH A, MENG W, MILLER R. The prognostic effect of brain natriuretic peptide levels on outcomes of hospitalized patients with COVID-19. Avicenna J Med. 2021;11(1):20–26.10.4103/ajm.ajm_169_20Search in Google Scholar

58. ALMEIDA JUNIOR GLG, BRAGA F, JORGE JK, NOBRE GF, KALICHSZTEIN M, FARIA PMP, et al. Prognostic Value of Troponin-T and B-Type Natriuretic Peptide in Patients Hospitalized for COVID-19. Valor Prognóstico da Troponina T e do Peptídeo Natriurético Tipo B em Pacientes Internados por COVID-19. Arq Bras Cardiol. 2020;115(4):660–666.10.36660/abc.20200385Search in Google Scholar

59. MYHRE PL, PREBENSEN C, STRAND H, RØYSLAND R, JONASSEN CM, RANGBERG A, et al. Growth Differentiation Factor 15 Provides Prognostic Information Superior to Established Cardiovascular and Inflammatory Biomarkers in Unselected Patients Hospitalized With COVID-19. Circulation. 2020;142(22):2128–213710.1161/CIRCULATIONAHA.120.050360Search in Google Scholar

Recommended articles from Trend MD

Plan your remote conference with Sciendo