Prevalence and impact of the cardiac injury on COVID‐19: A systematic review and meta‐analysis

Abstract

Background: The exact prevalence and impact of cardiac injury in hospitalized patients with coronavirus disease 2019 (COVID-19) is still controversial. Hence, we aim to investigate prevalence of cardiac injury and its impact on the outcomes in patients with COVID-19.

Hypothesis: Cardiac injury is common and associated with higher risk of death.

Methods: We searched the Cochrane Library, PubMed, MedRxiv, and EMBASE databases from December 2019 to July 15, 2020 for studies that evaluated the prevalence and impact of cardiac injury on COVID-19. This study has been registered with PROSPERO (International prospective register of systematic reviews)-registration number-CRD-42020186120.

Results: Twenty-one studies including 6297 participants were identified. The proportions of cardiac injury were 22%, 28% among hospitalized patients with COVID-19 or severe COVID-19 patients, respectively. The incidences of cardiac injury in advance age (>60 years) (30%) was about two-fold than young patients (<60 years) (15%) with COVID-19. Severe cases (42%) have seven-fold prevalence cardiac injury than in their non- severe counterparts (6%). Furthermore, cardiac injury is associated with an increased risk of all-cause mortality in patients with COVID-19 (OR 10.11, 95% CI 4.49-22.77). In patients with severe COVID-19, cardiac injury is associated with an increased risk of all-cause mortality (OR: 16.79, 95% CI: 5.52-51.02).

Conclusions: This was the first meta-analysis exploring the prevalence and impact of cardiac injury on COVID-19. Cardiac injury is common in hospitalized patients and advanced age and severe COVID-19 patients prone to experience more risk of cardiac injury. Furthermore, cardiac injury is associated with increased risk of all-cause mortality.

Full text

CLINICAL INVESTIGATIONS
Prevalence and impact of cardiac injury on COVID-19: A
systematic review and meta-analysis
Linghua Fu M.D.
1
| Xiao Liu M.D., Ph.D.
1
| Yuhao Su M.D.
1
|
Jianyong Ma M.D., Ph.D.
1
| Kui Hong M.D., Ph.D.
1,2
1
Cardiology Department, The Second
Affiliated Hospital of Nanchang University,
Nanchang, Jiangxi, China
2
Jiangxi Key Laboratory of Molecular
Medicine, Nanchang, Jiangxi, China
Correspondence
Kui Hong, M.D., Ph.D., Cardiology
Department, the Second Affiliated Hospital of
Nanchang University, Nanchang City, Jiangxi
330006, China.
Email: hongkui88@163.com
Funding information
National Natural Science Foundation of China,
Grant/Award Number: 81530013;
Postgraduate Innovation Foundation of
Nanchang University, Grant/Award Number:
CX-2017198; Scientific and Technical
Innovation Group of Jiangxi Province, Grant/
Award Number: 20181BCB24012
Abstract
Background: The exact prevalence and impact of cardiac injury in hospitalized
patients with coronavirus disease 2019 (COVID-19) is still controversial. Hence, we
aim to investigate prevalence of cardiac injury and its impact on the outcomes in
patients with COVID-19.
Hypothesis: Cardiac injury is common and associated with higher risk of death.
Methods: We searched the Cochrane Library, PubMed, MedRxiv, and EMBASE data-
bases from December 2019 to July 15, 2020 for studies that evaluated the preva-
lence and impact of cardiac injury on COVID-19. This study has been registered with
PROSPERO (International prospective register of systematic reviews)-registration
number-CRD-42020186120.
Results: Twenty-one studies including 6297 participants were identified. The propor-
tions of cardiac injury were 22%, 28% among hospitalized patients with COVID-19
or severe COVID-19 patients, respectively. The incidences of cardiac injury in
advance age (>60 years) (30%) was about two-fold than young patients (<60 years)
(15%) with COVID-19. Severe cases (42%) have seven-fold prevalence cardiac injury
than in their non- severe counterparts (6%). Furthermore, cardiac injury is associated
with an increased risk of all-cause mortality in patients with COVID-19 (OR 10.11,
95% CI 4.49–22.77). In patients with severe COVID-19, cardiac injury is associated
with an increased risk of all-cause mortality (OR: 16.79, 95% CI: 5.52–51.02).
Conclusions: This was the first meta-analysis exploring the prevalence and impact of
cardiac injury on COVID-19. Cardiac injury is common in hospitalized patients and
advanced age and severe COVID-19 patients prone to experience more risk of car-
diac injury. Furthermore, cardiac injury is associated with increased risk of all-cause
mortality.
KEYWORDS
cardiac injury, coronavirus disease 2019, death, intensive care unit
Linghua Fu, Xiao Liu, and Yuhao Su contributed equally to the study.
Received: 26 September 2020 Revised: 19 December 2020 Accepted: 21 December 2020
DOI: 10.1002/clc.23540
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2020 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.
276 Clin Cardiol. 2021;44:276–283.wileyonlinelibrary.com/journal/clc

1|INTRODUCTION
Coronavirus disease 2019 (COVID-19) pandemic is an ongoing global
public health emergency, caused by severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2). As of July 11, 2020, there are 12 322 395
confirmed cases with 556 335 deaths reported in 216 countries.
1
COVID-19 is associated with an increased risk of acute respiratory dis-
tress syndrome and has adverse effects on other organ systems, includ-
ing the heart, kidney, and liver.
2
Cardiovascular disease is a common
comorbidity in patients with COVID-19.
3
COVID-19 also lead to many
cardiovascular diseases, such as cardiac arrhythmias, myocardial infarc-
tion, cardiomyopathy, shock, and cardiac arrest.
4
Cardiac injury is defined as the level of serum troponin with at
least one value was above the 99th percentile upper reference
according to latest guideline.
5
Recently, a body of the literatures
4,6-18
shown that acute cardiac injury occurs in patients with COVID-19.
However, the reported prevalence of cardiac injury on COVID-19 var-
ies from one to another. In a cohort of 138 hospitalized patients with
COVID-19 from Wuhan,
4
cardiac injury was reported in 11.2% of hos-
pitalized patients and 22% of intensive care unit (ICU) patients.
Another study from New York City has reported the existence of car-
diac injury in 36% of patients hospitalized with COVID-19.
14
The
exact prevalence of cardiac injury in hospitalized patients with
COVID-19 is still not clear.
Moreover, accumulating evidence
3,4,6-24
supports the notion that
acute cardiac injury leads to other poor outcomes patients with car-
diac injury had a significantly higher mortality risk than those without
cardiac injury. We therefore conducted a systematic review and
meta-analysis to investigate the reported prevalence and impact of
cardiac injury on COVID-19.
2|METHODS
This meta-analysis was performed based on the Preferred Reporting
Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines
for studies that evaluate healthcare interventions (http://www.
prisma- statement.org).
25
This study has been registered with PROS-
PERO (International prospective register of systematic reviews)-
registration number-CRD 42018090474. Severe COVID-19 patients
is defined as patients with COVID-19 who are admitted to an ICU
patients, while the non-severe COVID-19 patients is defined as hospi-
tal patients with COVID-19 who are not admitted to an ICU. Ethical
approval is not applicable for this study.
2.1 |Literature search
We conducted computerized searches of the Cochrane Library,
PubMed, MedRxiv (https://www.medrxiv.org/), and Embase data-
bases from December 2019 to July 2020 (Table S1 in Supplemental
material). To identify studies involving relevant COVID-19, we per-
formed the search using the following terms: 2019-novel coronavirus,
SARS-CoV-2, COVID-19, and 2019-nCoV. To identify studies involv-
ing outcomes, we performed the search using the following terms:
cardiac injury, myocardial injury, and cardiac troponin. The definition
of cardiac injury was those adopted by the original studies (Table S2
in Supplemental material).
Two groups of keywords were combined using the Boolean oper-
ator “and.”No language restrictions were applied for the literature
search. We also reviewed reference lists, relevant journals, and con-
ference abstracts to identify relevant studies. Additionally, we
searched ClinicalTrial.gov (https://www.clinicaltrials.gov/) to obtain
information on studies that were terminated before being published.
2.2 |Study selection
Studies were considered eligible if they (1) were cohort or nested
case–control studies; (2) reported the prevalence of cardiac injury;
(3) reported the association between cardiac injury and outcomes
(e.g. all-cause death) in this illness. Certain publication types
(e.g., reviews, editorials, and animal studies) or studies with insuffi-
cient data were excluded from this analysis.
2.3 |Data extraction and quality assessment
Two researchers (Linghua Fu and Yuhao Su) extracted the basic char-
acteristics, including the first author, publication year, geographical
location, study type, participants (sex, age, and sample size), and dura-
tion of follow-up. For multiple reports using the same data, we
included the articles with the longest follow-up or the largest numbers
of participants. The quality of all prevalence studies was indepen-
dently assessed by the Joanna Briggs Institute critical appraisal check-
list. In addition, we assessing the quality of included studies involved
with the impact of cardiac injury by Newcastle–Ottawa quality scale
(NOS), which entailed evaluations of the selection of cohorts, the
comparability of cohorts, and the assessment of outcome. In this
meta-analysis, we defined studies with an NOS of ≥6 stars as moder-
ate to high-quality studies; studies which lower scores were defined
as low-quality studies.
26,27
Two researchers discussed the topics dur-
ing several face-to-face and web-based meetings.
2.4 |Statistical analyses
Statistical analysis was performed using Stata 15.0 (StataCorp, College
Station, Texas, https://www.stata.com/stata15/) and Review
Manager Version 5.3 (the Nordic Cochrane Center, Rigshospitalet,
Denmark; http://ims.cochrane.org/revman). Meta-analyses involved
with the prevalence of cardiac injury were performed by Stata soft-
ware. The exact binomial (Clopper–Pearson) method was used to cal-
culate 95% confidence intervals (CIs). Estimates were normalized
using the Freeman–Tukey double arcsine transformation. We selected
a random effects model to evaluate summary prevalence. The effect
FU ET AL.277

measurement estimate of mortality risk chosen was the odds ratio
(ORs) in our study. Risk ratio and hazard ratio in other studies were
considered to be OR, as OR was shown to be a more effective mea-
sure.
28
If not available, the ORs were calculated by events and total
numbers of patients in two groups. The natural logarithm of the OR
(log [OR]) and its standard error (SElog [OR]) were calculated and then
pooled using statistical software. Cochran's chi-square test and I
2
sta-
tistic were used to evaluate the heterogeneity among the included
studies. I
2
values of 25%, 50%, and 75% were considered to represent
low, moderate, and high heterogeneity, respectively.
29,30
The statisti-
cal significance threshold was set at p< .05.
3|RESULTS
3.1 |Study selection
We screened 811 potentially relevant articles in the Cochrane Library
(n= 19), PubMed (n= 393), MedRxiv (n= 286), and Embase (n= 113)
databases (Figure S1 in Supplemental Material). We excluded 91 stud-
ies after screening the titles and abstracts, and the full texts of the
remaining 720 studies were reviewed. After a quick screening of the
full-text articles, 30 records were received full-test review, and
9 excluded for the following reasons: (1) seven studies did not have
relevant results, and (2) two studies
31,32
were based on same popula-
tion. Finally, 21 studies
3,4,6-24
were included in the present meta-
analysis.
3.2 |Study characteristics and quality
The study characteristics were shown in Table 1. All included studies
were published in 2020. The sample sizes of the included studies
ranged from 16 to 2736, with a total of 6297 individuals. Most
patients were male (56.1%). Among the 21 articles, 4
6,8,9,14
were con-
ducted in the USA, 1
7
was conducted in South Korea, and
16
3,4,10-13,15-24
were conducted in China. Majority of stud-
ies
3,4,6-9,11,13,14,16-24
were retrospective observational (case–control)
TABLE 1 Clinical characteristics of the 21 included studies
Studies Country Study type
Number,
N
Age,
years
Male,
N
Comorbidity, N
Cardiac
injury,
NHTN Diabetes CHD CKD
Chronic
lung
diseases Malignancy
Zhou F
3
China Retrospective 191 56 119 58 36 15 2 6 2 33
Wang
D
4,31
China Retrospective 138 56 75 43 14 NA 4 4 10 10
Latif F
6
USA Retrospective 28 64 22 20 17 NA 10 10 5 13
Hong KS
7
South
Korea
Retrospective 98 55.4 38 30 9 NA NA 3 4 11
Arentz
M
8
USA Retrospective 21 70 11 NA 7 NA 10 7 NA 3
Aggarwal
S
9
USA Retrospective 16 67 12 9 5 3 6 2 3 3
Yu Y
10
China Prospective 226 64 139 96 47 22 8 15 10 61
Yang F
11
China Retrospective 92 69.8 49 51 13 NA 2 1 4 31
Wei JF
12
China Prospective 101 49 54 21 14 5 NA 1 NA 16
Li X
13
China Retrospective 548 60 279 166 83 34 10 17 24 119
Lala A
14
USA Retrospective 2736 66.4 1630 1065 719 453 NA 273 195 985
Huang
C
15
China Prospective 41 49 30 6 8 NA NA 1 1 5
Han H
16
China Retrospective 273 58.86 97 NA NA NA NA NA NA 27
Deng Q
17
China Retrospective 112 65 57 36 19 15 NA 4 NA 42
Yang R
18
China Retrospective 212 55.6 107 NA NA NA NA NA NA 7
Yang X
19
China Retrospective 52 59.7 35 NA 9 NA NA 4 2 12
Shi S
20
China Retrospective 416 64 205 127 60 44 14 12 9 82
Nie SF
21
China Retrospective 311 63 190 NA NA NA NA NA NA 103
Guo T
22
China Retrospective 187 58.5 91 61 28 21 6 4 13 52
Deng Y
23
China Retrospective 225 54 124 58 26 NA NA 25 8 66
Chen T
24
China Retrospective 274 62 171 93 47 NA 4 18 7 89
Abbreviations: CHD, coronary heart disease; CKD, chronic kidney disease; HTN, hypertension; N, number; NA, not available.
278 FU ET AL.

studies, and three
10,12,15
were prospective observational (cohort)
studies.
As shown in Supplementary Table 3, those 21 studies were
critically appraised for quality using the Joanna Briggs Institute
Critical Appraisal Checklist for reporting prevalence data. All stud-
ies were evaluated on the basis of data relevance and methodo-
logical rigor, and papers that met a minimum of six of the nine
criteria.
The quality of the included studies we assessing the quality of
included studies involved with the impact of cardiac injury was
assessed and summarized in Supplementary Table 4. According to the
NOS, all of the included studies were considered to be high quality,
with a score range of 6–9.
3.3 |The prevalence of cardiac injury in
hospitalized patients with COVID-19
As presented in Figure 1, a total of 20 studies
3,4,6-23
comprising 6130
hospitalized patients with COVID-19 were included in the meta-anal-
ysis, resulting a pooled cardiac injury prevalence of 22% (95% CI: 16%
to 28%), with a high heterogeneity (I
2
= 97.0%).
There were 11 studies reported the incidence of cardiac injury in
severe COVID-19 and non-severe COVID-19 patients, with 1781 or
914 subjects, respectively. The overall incidence of cardiac injury ranges
from 10.2% to 69.2% and 1.0% to 9.0% in severe and non-severe
COVID-19 patients, respectively. Thepooledprevalenceofcardiacinjury
was 42.0% (95% CI: 29% to 54%, I
2
= 97%) among severe patients with
COVID-19 and 6% (95% CI: 3% to 9%, I
2
= 77%) among non-severe
patients with COVID-19 with a high heterogeneity (Figure 2).
In further subgroup analysis defined by age, there was a signifi-
cant increased incidence of cardiac injury in older COVID-19 patients
(≥60 years) (ES: 15%, 95% CI: 10% to 21%, I
2
= 92%) compared with
young COVID-19 patients (ES: 30%, 95% CI: 25% to 36%, I
2
= 92%)
(< 60 years) (Figure S2). There was no significant difference in cardiac
injury in patients with COVID-19 among the region subgroup (China
and USA) (Figure S3).
3.4 |The impact of cardiac injury on all-cause
death in hospitalized patients with COVID-19
There were 10 publications
3,4,12,13,19-24
reported the association
between cardiac injury and death. As shown in Figure 3, cardiac injury
FIGURE 1 Meta-analysis for the proportion of cardiac injury in patients hospitalized with COVID-19
FU ET AL.279

is associated with an increased risk of all-cause mortality in patients
with COVID-19 (OR: 10.11, 95% CI: 4.49–22.77; I
2
= 89%). For three
studies
13,20,21
that provided risk estimates adjusted for clinical con-
founding, the result did not change, with summary OR for 2.43 (95%
CI: 1.71–3.46, I
2
= 40%).
3.5 |The impact of cardiac injury on all-cause
death in hospitalized patients with severe COVID-19
There were two studies
4,7,12,15
reported the association between car-
diac injury and death in patients with severe COVID-19. None of
FIGURE 2 Meta-analysis for the proportion of cardiac injury in patients hospitalized with severe and non-severe COVID-19
FIGURE 3 Meta-analysis for association between cardiac injury and all-cause death in patients hospitalized with COVID-19
280 FU ET AL.

included studies reported the adjusted results, thus, forced us to per-
form a univariate analysis. As presented in Figure 4, cardiac injury is
associated with an increased risk of all-cause mortality in patients
with severe COVID-19 (OR: 16.79, 95% CI: 5.52–51.02; I
2
= 43%).
4|DISCUSSION
To our knowledge, this was the first meta-analysis exploring the prev-
alence and impact of cardiac injury on COVID-19. A total of 21 stud-
ies
3,4,6-24
including 7076 COVID-19 patients were selected and
assessed. Our analysis indicated that cardiac injury is commonly
observed in hospitalized patients with COVID-19, especially in severe
patients. Moreover, cardiac injury was associated with higher risk of
all-cause mortality in hospitalized patients with COVID-19.
COVID-19 is a systemic illness characterized by hyper-
inflammation and cytokine storm. The close association between
COVID-19 and cardiovascular disease has been observed in many
studies. Cardiovascular disease, such as hypertension, hyperlipidemia,
and coronary heart disease, are the common comorbidity in patients
with COVID-19. Those patients with cardiovascular comorbidity are
at increased risk of morbidity and mortality. Those cardiovascular co-
morbidities may be related to cardiac injury in COVID-19. Recent evi-
dence
33
also showed that COVID-19 can damage the heart directly.
Consistently, our multivariable analyses showed that elevated tropo-
nin release is independently predicted all-cause death after adjusted
for clinical confounding, including cardiac cardiovascular co-morbidity.
Cardiovascular manifestations, such as myocarditis, heart failure,
arrhythmia, may occur with COVID-19. More recently, there is
increasing awareness of the cardiac injury in patients with COVID-19
disease.
As we found, up to 23% of hospitalized patients with COVID-19
have cardiac injury. The exact mechanisms of cardiac injury in COVID-19
are not fully understood. Several potential pathogenic mechanisms
appear to be involved. One potential mechanism is directly involves viral
infiltration into myocardial tissue, resulting in cardiomyocyte death and
inflammation.
34
Another proposed mechanisms of COVID-19–related
cardiac injury include a cytokine storm manifested by elevated levels of
interleukin-6, ferritin, lactate dehydrogenase, and D-dimer, which
mediated by an imbalanced response by type 1 and type 2T helper cell.
3
Increasedcytokinesandchemokineshavebeenreportedinpatientswith
COVID-19 who are admitted to an ICU as compared to non-ICU
patients,
15
which may explain the higher cardiac injury in patients requir-
ing intensive care unit care. Other suggested mechanisms include cardiac
myocyte apoptosis due to hypoxia-induced excessive intracellular cal-
cium and cardiac stress lead by respiratory failure and hypoxemia.
35
Age have been identified as an important risk factor for poor
prognosis in patients with covid-19. Our results also showed advance
older patients (>60 years) with COVID-19 have a higher prevalence
rate of cardiac damage compared with young people. This founding
was not surprising, as we all known, advance age higher rates of
underlying CVD and other comorbid conditions, including hyperten-
sion, coronary heart disease, cardiomyopathy. Thus, these patients
might more prone to have elevated TnT levels and experience myo-
cardial injury during the course of COVID-19. Sex was also a Lala
study reported myocardial injury was more frequent compared to
reports from China. We demonstrate that myocardial injury was not
difference between the China and USA. However, the studies in USA
is limited, the extract prevalence of cardiac injury in USA need further
investigated. There might be a sex difference in the prevalence of car-
diac injury in COVID-19. Sex is a common modified factor in the risk
and outcomes of CVDs
36
. Some evidence also showed that there
might be a sex predisposition to COVID-19, with men more prone to
being affected.
37
However, there were limited studies assessed
whether there is a sex difference in the prevalence of cardiac injury in
COVID-19. Guo’cohort
22
showed male was more prone to experi-
ence an elevated TnT level (p= .005). In contract, another study from
china did not find the sex difference (p= .39). Therefore, the sex dif-
ference in the risk of cardiac injury in COVID-19 is still not clear and
needed further studied.
Moreover, severe COVID-19 patients (42%) have up to seven-
fold prevalence cardiac injury compared with the non-severe COVID-19
patients (6%). These results suggested COVID-19 patients with cardiac
injury might experience a worse prognosis. This hypothesis was further
supported by our prognosis analysis, that elevated serum troponin is
associated with an increased risk of severity and all-cause mortality in
patients with COVID-19. Similarly, our results also showed that cardiac
injury is associated with poor prognosis. Myocardial injury are common
and associated with higher risk of all-cause mortality in hospitalized
patients with COVID-19. Moreover, it was notable that a few studies
FIGURE 4 Meta-analysis for association between cardiac injury and all-cause death in patients hospitalized with severe COVID-19 cases
FU ET AL.281

reported that a proportion of patients with underlying CVD but with nor-
mal TnT levels had a relatively favorable outcome. Therefore, the uses of
serum troponin testing may be a potential tool to facilitate risk stratifica-
tion, help make decisions among hospitalized COVID-19 patients. These
results might call out the patients with induction of cardiac injury, more
attention, prioritized treatment and even more aggressive treatment
strategies should be reasonable. Although up to date, until now, no spe-
cific antiviral drugs have been recommended for COVID-19, Dexametha-
sone
38
and Remdesivir
39
might be applied. The dexamethasone was
reported be able to reduce the death
38
and the Remdesivir was showed
to reduce the length of hospital stay.
39
Elevated serum troponin concentrations are the hallmark of car-
diac injury, including but not limited to myocardial infarction.
5
The
high prevalence of cardiac injury may increase the need for cardiology
consultation. Interpretation of cardiac injury requires cautiously. In
patients with COVID-19, the phenotypes of myocardial injury in
COVID-19 include viral myocarditis, stress cardiomyopathy, tachyar-
rhythmia, coronary microvascular ischemia, pulmonary embolism, type
1 myocardial infarction, and type 2 myocardial infarction.
40
The phe-
notypes of cardiac injury must be elucidated according to clinical sce-
narios. According to latest guideline, minority of patients with cardiac
injury is diagnosed with acute myocardial infarction. In a case series of
18 patients with confirmed COVID-19 who had ST-segment elevation
on electrocardiography, 10 patients underwent coronary angiography,
of whom two thirds had nonobstructive disease.
41
Hence, we need to
take together with clinical information, electrocardiogram, cardiac
echocardiography, coronary angiography, and cardiac MRI to assess
the cause of cardiac injury.
4.1 |Study limitations
Some limitations may influence the validity of this meta-analysis. First,
all the included studies were observational studies and some studies
did not adjust for the clinical confounding in the outcome of death
and these biases might influence on our results. For example, ACEI/
ARB, as we describe previously, was showed be associated with
decreased risk of death in COVID-19
42
. However, although with num-
ber changes, the positive association between cardiac injury and
death was still persisted when excluding the unadjusted studies,
which showed the robustness of our conclusion. Second, the defini-
tion of the cardiac injury differed across the included trials and poten-
tially affected the findings. Third, the majority of studies are from
China, the studies involved with the prevalence and impact of cardiac
injury on COVID-19 is needing to confirm this conclusion. Fourth,
high heterogeneity existed across studies in some comparisons, limit-
ing the interpreting on the results, however, we attempted to account
for this by using a random effect model to make our results more con-
servable. The precise number for the type of cardiac injury is lacking,
therefore, we cannot evaluate the association between type of car-
diac involvement and adverse prognosis. Finally, lots of studies did
not provide the adjusted results, thus, further studies with well-
designed are needed to confirm our results.
5|CONCLUSIONS
This was the first meta-analysis exploring the prevalence and impact
of cardiac injury on COVID-19. Cardiac injury is common in hospital-
ized patients and advanced age and severe COVID-19 patients prone
to experience more risk of cardiac injury. Furthermore, cardiac injury
is associated with increased risk of all-cause mortality.
CONFLICT OF INTEREST
All authors have no conflicts of interest that might be relevant to the
contents of this manuscript.
ORCID
Xiao Liu https://orcid.org/0000-0002-5570-289X
Kui Hong https://orcid.org/0000-0002-0875-0557
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SUPPORTING INFORMATION
Additional supporting information may be found online in the
Supporting Information section at the end of this article.
How to cite this article: Fu L, Liu X, Su Y, Ma J, Hong K.
Prevalence and impact of cardiac injury on COVID-19: A
systematic review and meta-analysis. Clin Cardiol. 2021;44:
276–283. https://doi.org/10.1002/clc.23540
FU ET AL.283