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The RV was dysfunctional in 12.1% and RV infection: impact on management and prognosis strain was reduced in 17.7% of the patients. There were no significant differences between a normal or an abnormal TTE study Ecocardiografı´a en la fase aguda de la infección por COVID-19: and the presence of elevated high-sensitivity troponin I (hs-cTnI), impacto en el tratamiento clı́nico y pronóstico N-terminal pro-B-type natriuretic peptide (NT-proBNP), or D-dimer levels (P > .3 for all parameters). LV performance assessed by GLS showed a significant association with hs-cTnI (r = -0.556, P = .039), To the Editor, as well as global myocardial work index (GWI) (r = 0.900, Although coronavirus disease 2019 (COVID-19) is a systemic P = .037). An abnormal TTE was one of the steps that impacted the viral infection leading to severe acute respiratory syndromes, an clinical decision-making process in 60 patients: 28 treatment increasing number of reports suggest that myocardial involvement changes, 22 discharges from intensive care, and 10 titrations of is common and is associated with higher mortality.1 It has been hemodynamic support. The median length of hospital stay was observed that left (LV) and right ventricular (RV) abnormalities 34 (interquartile range [IQR], 16-49) days, and in-hospital death may not be uncommon, raising concern for systemic inflamma- did not significantly differ between a normal or abnormal TTE tion.2 However, there are few data on the performance of result. transthoracic echocardiography (TTE) to understand whether To our knowledge, this is the first prospective report on a myocardial injury is a bystander phenomenon or a contributor cohort of selected patients with COVID-19 infection admitted to to severe damage. Thus, this study aimed to define abnormalities a tertiary referral center undergoing TTE at the physician’s on advanced TTE analysis in acute COVID-19 infection and to discretion. The main findings are: a) more than half of the patients determine their implications in management and prognosis. with COVID-19 had an abnormal TTE study and the most prevalent We performed a prospective cohort study including abnormality was diastolic dysfunction, with only less than 12% of 200 patients admitted with COVID-19 and undergoing a TTE at the patients showing RV or LV dysfunction; b) patients with an the discretion of the clinician between March 1 and May 25, 2020. abnormal TTE study were older and had more cardiovascular risk Due to the lack of familiarity with COVID-19, imaging was limited factors than patients with a normal TTE; c) there were no to patients who were expected to derive a benefit from its significant differences between TTE result and cardiac biomark- findings.3 Exclusion criteria were as follows: absence of confirmed ers; d) the most common indications were concerns about a SARS-CoV-2, age < 18 years, handheld echocardiograms, and systemic condition and the TTE result directly modified manage- lack of quality. Each patient’s chart was reviewed following ment in most cases, being one of the analytic steps in the TTE assessment to evaluate changes in management: treatment treatment decision-making process. changes (antibiotics, diuretics, anticoagulation), hemodynamic Recent studies showing troponins to be associated with higher support titration, facilitating decisions regarding patient care level, C-reactive protein, cytokines and NT-proBNP levels in SARS-CoV-2 and no changes. Echocardiographic assessment, 2D-strain imaging, infection have suggested a link between myocardial injury, and myocardial work analysis was performed. Approval for the inflammation, and ventricular dysfunction1; however, these study was obtained from the center’s Institutional Review Board. studied lack imaging findings. In our study, despite biological All patients included in the study signed the consent form prior to cardiac injury, LV systolic dysfunction and wall motion abnormal- inclusion. ities were uncommon, suggesting it may be related to the Sixty-six studies were included in the final analysis after inflammatory syndrome. LV GLS has been described to be reduced exclusion of 134 patients (handheld echocardiograms, not in 52% to 70% of COVID-19 patients, emerging as a strong predictor following quality protocols). No differences regarding demo- of mortality4 and, in our data, myocardial work analysis was also graphics and clinical characteristics were found between patients significantly associated with hs-cTnI levels. Therefore, the most included and excluded in the analysis (P > .05). The median age prevalent findings were subclinical changes, reinforcing evidence was 62 years [IQR, 55-70] and 59.1% of patients were males from other cohort studies, that cardiac involvement is high but (Table 1). Median time between hospital admission and TTE was mainly subclinical4,5 (reduced GLS and persistent myocardial 14 days [IQR, 6–22]. Indication for TTE was: 50% systemic inflammation on cardiovascular magnetic resonance). In our conditions concern (endocarditis, pulmonary embolism), 30.3% cohort, strain and myocardial work analysis were not considered hemodynamic assessment (shock, heart failure), 19.7% cardiac as surrogate markers of LV dysfunction in COVID-19 patients with conditions (elevated biomarkers, chest pain). Patients with an a normal echocardiogram and did not influence the decision- abnormal TTE were older and presented more cardiovascular risk making process. It remains unknown whether clinical decisions factors compared with patients with a normal TTE. Overall, based on these parameters result in a better outcome. Further 36 patients (54.5%) had an abnormal TTE study (Table 2). The most multimodality imaging and large-scale biomarker studies are frequent abnormality was diastolic dysfunction (defined according necessary to understand the pathophysiology. In previous reports, to the 2016 ASE/EACVI guidelines) (33.3%), followed by RV a major cardiovascular event was the main factors indicating TTE2; dysfunction (12.1%), LV dysfunction (6.1%), and severe valvular however, in our study, the most frequent indicator was a systemic heart disease or endocarditis (3%). 2-dimensional strain imaging condition, because myocardial injury was carefully interpreted and myocardial work analysis were performed only in 33 and with integration of symptoms, electrocardiographic changes, and 16 patients, respectively, due to the required high-resolution the likelihood of coronary disease. Based on our results and in image quality. LV global longitudinal strain (GLS) was reduced in agreement with previous publications,6 an echocardiographic 48.5% of the patients and myocardial work performance were all study should be limited to patients with a primary concern about a reduced in patients with an abnormal TTE, although differences systemic condition, to rule out long-term intensive care unit https://doi.org/10.1016/j.rec.2021.11.012 1885-5857/ C 2021 Sociedad Española de Cardiologı́a. Published by Elsevier España, S.L.U. All rights reserved. Please cite this article in press as: González-Del-Hoyo M, et al. Echocardiography in the acute phase of COVID-19 infection: impact on management and prognosis. Rev Esp Cardiol. 2021. https://doi.org/10.1016/j.rec.2021.11.012 G Model REC-101791; No. of Pages 4 2 Scientific letter / Rev Esp Cardiol. 2021;xx(x):xxx–xxx Table 1 Demographic and clinical characteristics of patients with and without a normal echocardiogram. Variables Overall (n = 66) Normal echocardiogram (n = 30) Abnormal echocardiogram (n = 36) P Demographics and risk factors Age, y 62 [55-70] 58 [51-65] 65 [58-71] .015 Female sex 27 (40.9) 15 (50) 12 (33.3) .131 BSA, kg/m2 2 [1.9-2.1] 2 [1.9-2.1] 2 [1.8-2.1] .585 Current or previous smoker 20 (30.3) 3 (10) 17 (47.2) .001 Diabetes mellitus 18 (27.3) 7 (23.3) 11 (30.6) .354 Hypertension 31 (47.0) 9 (30) 22 (61.1) .011 Hypercholesterolemia 19 (28.8) 7 (23.3) 12 (33.3) .269 Chronic kidney disease 11 (16.7) 5 (16.7) 6 (16.7) .627 Atrial fibrillation 6 (9.1) 0 6 (16.7) .021 Ischemic heart disease 3 (4.6) 0 3 (8.3) .156 Chronic obstructive pulmonary disease 5 (7.9) 0 5 (13.9) .042 Previous organ transplant 7 (10.6) 4 (13.3) 3 (8.3) .397 Heart failure 4 (6.1) 1 (3.3) 3 (8.3) .379 Severe valvular heart disease 5 (7.6) 1 (3.3) 4 (11.1) .257 Charlson comorbidity index 2 (1-4) 1 (0-2) 3.5 (1-5) .004 Baseline treatment ACEI 6 (9.1) 2 (6.7) 4 (11.1) .413 ARB 16 (24.2) 5 (16.7) 11 (30.5) .155 Beta-blocker 14 (21.2) 5 (16.7) 9 (26.0) .306 Loop diuretics 3 (4.8) 2 (6.7) 1 (2.8) .429 Insulin therapy 8 (12.7) 3 (10) 5 (13.9) .488 Anticoagulant therapy 8 (12.7) 0 8 (22.2) .006 Cause of admission Respiratory 40 (67.8) 18 (66.7) 22 (68.8) .542 Fever 52 (88.1) 26 (96.3) 26 (81.25) .082 Gastrointestinal 13 (22.0) 8 (29.6) 5 (15.6) .164 Asymptomatic 7 (10.6) 3 (10) 4 (11.1) .603 Laboratory findings Elevated hs-cTnI levels 22 (57.9) 11 (57.9) 11 (57.9) .628 hs-cTnI, ng/L 50 [12-188] 74 [9-296] 48 [12-188] .930 Elevated NT-proBNP levels 24 (72.7) 12 (75.0) 12 (70.1) .543 NT-proBNP, pg/mL 1429 [198-5849] 1272 [267-4101] 1429 [198-5849] .943 Elevated D-dimer levels 52 (85.3) 24 (85.7) 28 (84.9) .607 D-Dimer, ng/mL 3251 [1489-7763] 3362 [1638-7262] 3251 [1246-12 192] .965 Management Intensive care level 39 (59.1) 22 (73.3) 17 (47.2) .028 Noninvasive ventilation or high flow oxygen therapy 8 (12.1) 0 8 (22.2) .005 Invasive mechanical ventilation 33 (50.0) 22 (73.3) 11 (30.6) .001 PEEP, mmHg 10 (8-12) 10 (8-12) 10 (8-14) .457 Vasopressor requirement 24 (36.4) 13 (42.2) 11 (30.6) .207 In-hospital outcomes Venous thromboembolism 20 (32.3) 10 (33.3) 10 (27.8) .412 Pulmonary embolism 9 (14.5) 3 (10) 6 (16.7) .339 Stroke 5 (7.6) 2 (6.7) 3 (8.3) .587 Acute coronary syndrome 1 (1.5) 1 (3.3) 0 .455 In-hospital mortality 7 (10.6) 2 (6.7) 5 (13.9) .296 ACEI, angiotensin-converting-enzyme inhibitors; ARB, angiotensin II receptor blockers; BSA, body surface area; hs-cTnI; high-sensitivity cardiac-specific troponin I; NT- proBNP, N-terminal pro-B-type natriuretic peptide; PEEP, positive end-expiratory pressure. Categorical values are expressed as No. (%) and continuous values as median [interquartile range] complications, or to evaluate causes of hemodynamic instability Second, the single site and small sample size may have led to type II and facilitate the decision-making process regarding patient care errors. However, the study was performed in a tertiary center level and de-escalation of medical treatments. representative of a large suburban area admitting 2025 patients This study has the limitations of selection bias, as echocardiog- with COVID-19 during the first wave of the pandemic. Third, it is raphy and biomarker testing were left to the physician’s decision. unknown whether imaging abnormalities (diastolic dysfunction) Please cite this article in press as: González-Del-Hoyo M, et al. Echocardiography in the acute phase of COVID-19 infection: impact on management and prognosis. Rev Esp Cardiol. 2021. https://doi.org/10.1016/j.rec.2021.11.012 G Model REC-101791; No. of Pages 4 Scientific letter / Rev Esp Cardiol. 2021;xx(x):xxx–xxx 3 Table 2 Echocardiographic findings in patients with a normal and abnormal echocardiographic study and COVID-19. Variables Normal echocardiogram (n = 30) Abnormal echocardiogram (n = 36) P Left ventricle LV dysfunction 0 7 (19.4) .011 LV end-diastolic dimension, mm 44 (40-50) 45 (41-50) .775 LV end-systolic dimension, mm 27 (23-31) 29 (24-33) .314 LV ejection fraction 4Ch, % 63 (60-66) 57 (52-65) .032 LV GLS, % 18.2 [ 14.2-22.7] 17.1 [ 12.3-22.2] .649 Reduced LV GLS 7 (50) 9 (47.4) .580 Regional motion abnormalities 0 5 (13.9) .042 Right ventricle RV dysfunction 0 8 (22.2) .006 TAPSE, mm 22 [20-24] 19 (18-22) .031 Reduced TAPSE 0 8 (22.2) .021 S’ wave, cm/s 14.7 [12-17] 13.8 [12-15.5] .452 RV fractional area change % 50 [43-59] 45 [41-54] .157 Reduced RV fractional area change 0 5 (19.2) .158 RVFWLS % 25 [ 23.5-27.2] 23 [-21-29] .955 Reduced RVFWLS 0 3 (23.1) .421 Myocardial work (available for 16 patients) Reduced GWI 0 3 (30) .250 GWI, mmHg% 2010 [1780-2138] 1908 [1474-2362] Reduced GCW 1 (16.7) 3 (30) .999 GCW, mmHg% 2211 [1966-2374] 2185 [1513-2650] Elevated GWW 0 4 (40) .234 GWW, mmHg% 68 [49-73] 124 [80-142] Reduced GWE 0 4 (40) .234 GWE, % 96 [95-97] 93 [89-96] Diastolic function LV diastolic dysfunction 0 (0) 28 (77.8) .001 Types of diastolic dysfunction .001 Diastolic dysfunction type I 0 (0) 23 (63.9) Diastolic dysfunction type II 0 (0) 2 (5.6) Diastolic dysfunction type III 0 (0) 3 (8.3) E/A ratio 1.1 [0.9-1.2] 0.7 [0.6-1.0] .002 Mitral valve deceleration time, ms 219 [202-233] 207 [275-250] .414 E/e’ ratio 9 [7-10] 9 [7-11] .947 Elevated E/e’ ratio 0 3 (15) .244 Mitral regurgitation None 17 (73.9) 22 (61.1) .305 Mild-moderate 6 (26.1) 13 (36.1) .402 Severe 0 1 (2.8) .610 Tricuspid regurgitation None 10 (50) 19 (52.8) .531 Mild-moderate 10 (50) 15 (41.7) .586 Severe 0 2 (5.6) .532 Severe valvular heart disease 0 5 (13.9) .034 Pulmonary hypertension (RVSP  35 mm Hg) 2 (6.8) 9 (25.0) .047 FAC, fraction area change; GCW, global constructive work; GLS, global longitudinal strain; GWE, global work efficiency; GWI, global work index; GWW, global wasted work; LV, left ventricle; RV, right ventricle; RVFWLS, right ventricle free wall longitudinal strain; RVSP, right ventricle systolic pressure. Data are expressed as no. (%) or median [interquartile range]. were previously present and were thus unrelated to the infection. In conclusion, severe echocardiographic abnormalities are Finally, our results should be interpreted in light of the low uncommon in hospitalized patients with COVID-19 infection, mortality of our population and the absence of a short-term impact who show mostly subclinical myocardial changes. However, in does not allow conclusions to be drawn on the absence of long- these patients echocardiographic study is useful to guide the term consequences. treatment and clinical decision-making process. Please cite this article in press as: González-Del-Hoyo M, et al. Echocardiography in the acute phase of COVID-19 infection: impact on management and prognosis. Rev Esp Cardiol. 2021. https://doi.org/10.1016/j.rec.2021.11.012 G Model REC-101791; No. of Pages 4 4 Scientific letter / Rev Esp Cardiol. 2021;xx(x):xxx–xxx c FUNDING Consorcio de Investigación Biomédica en Red de Epidemiologı´a y Salud Pública (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain There are no funding sources for this article for any author. * Corresponding author: E-mail addresses: jfrodrig@vhebron.net (J. Rodrı́guez-Palomares), AUTHORS’ CONTRIBUTIONS iferreir@vhebron.net (I. Ferreira-González). All authors had access to the data and participated in the preparation of this manuscript. All authors have contributed to the conceptualization of the study, data curation, formal analysis, REFERENCES investigation, methodology, validation, writing, and reviewing. 1. Shi S, Qin M, Shen B, et al. Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan China. JAMA Cardiol. 2020;5: CONFLICTS OF INTEREST 802–810. 2. 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