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FACULDADE DA SAÚDE E ECOLOGIA HUMANA PREVALÊNCIA DE COMORBIDADES EM PACIENTES INTERNADOS COM COVID-19 QUE TIVERAM LESÃO AGUDA DO MIOCÁRDIO: uma revisão bibliográfica Vespasiano 2022 ANNA LAURA FRANÇA GONTIJO MENDES ISADORA TEIXEIRA ISSA KARENN TAVARES KIEPPER TAMARA ARAÚJO PEREIRA CAMPOS PREVALÊNCIA DE COMORBIDADES EM PACIENTES INTERNADOS COM COVID-19 QUE TIVERAM LESÃO AGUDA DO MIOCÁRDIO: uma revisão bibliográfica Trabalho de Conclusão de Curso apresentado à Faculdade da Saúde e Ecologia Humana, como requisito parcial para obtenção do título de Bacharel em Medicina Orientador(a): Profa. Jacqueline de Castro Laranjo Vespasiano 2022 FICHA CATALOGRÁFICA P944 Prevalência de comorbidades em pacientes internados com covid-19 que tiveram lesão aguda do miocárdio: uma revisão bibliográfica. / Anna Laura França Gontijo Mendes... [et al.]. – Vespasiano, 2022. 39 f. Orientadora: Jacqueline de Castro Laranjo. Trabalho de conclusão de curso (Medicina) – Faculdade da Saúde e Ecologia Humana – FASEH, 2022. Outros autores: Isadora Teixeira Issa, Karenn Kiepper Tavares, Tamara Araújo Pereira Campos. 1. Covid-19. 2. Lesão cardíaca aguda. 3. Comorbidade. 4. Prevalência. I. Mendes, Anna Laura França Gontijo. II. Issa, Isadora Teixeira. III. Tavares, Karenn Kiepper. IV. Campos, Tamara Araújo Pereira. V. Faculdade da Saúde e Ecologia Humana. VI. Título. CDD 616.2414 Figura 1: Ficha catalográfica elaborada por Flávio José dos Santos – Bibliotecário CRB 6/3168 FOLHA DE APROVAÇÃO ANNA LAURA FRANÇA GONTIJO MENDES ISADORA TEIXEIRA ISSA KARENN TAVARES KIEPPER TAMARA ARAÚJO PEREIRA CAMPOS PREVALÊNCIA DE COMORBIDADES EM PACIENTES INTERNADOS COM COVID-19 QUE TIVERAM LESÃO AGUDA DO MIOCÁRDIO: uma revisão bibliográfica Trabalho de Conclusão de Curso apresentado à Faculdade da Saúde e Ecologia Humana como requisito para obtenção do título de Bacharel em Medicina. FASEH (2022) Vespasiano (2022) ______________________________________ Prof. Jaqueline de Castro Laranjo – FASEH ( Orientador) ______________________________________ Prof. – INSTITUIÇÃO _______________________________________ Prof. – INSTITUIÇÃO AGRADECIMENTO O desenvolvimento deste trabalho de conclusão de curso contou com a ajuda de diversas pessoas, dentre as quais agradecemos: Aos professores orientadores, que durante 18 meses nos acompanharam pontualmente, dando todo auxílio necessário para a elaboração do projeto. Em especial, a Professora Jacqueline por ter aceitado ser a orientadora deste trabalho. Aos professores do curso de medicina, que através de seus ensinamentos permitiram que nós pudéssemos concluir este trabalho. Aos nossos amigos da turma, pelos anos de convivência que serão lembrados para sempre. EPÍGRAFE “A menos que modifiquemos a nossa maneira de pensar, não seremos capazes de resolver os problemas causados pela forma como nos acostumamos a ver o mundo”. (Albert Einstein) RESUMO Os primeiros casos de infecção causada pelo COVID-19 surgiram em dezembro de 2019, na China. Em março de 2020, a Organização Mundial de Saúde (OMS), diante dos elevados índices de disseminação do COVID-19, declarou pandemia. Além de manifestações multissistêmicas, tem-se observado que a infecção pelo COVID-19 pode levar à formação de injúrias cardíacas agudas ou ao agravo de patologias cardiovasculares pré-existentes, sobretudo em pacientes internados. Para a elaboração desta revisão narrativa, foram selecionados 157 artigos. Desses, 27 estudos preencheram os critérios de inclusão. Foram avaliadas as características clínicas, os achados laboratoriais e o desfecho de pacientes com teste de PCR positivo para SARS-Cov-2 que apresentaram elevação de troponina acima do percentil 99 e, consequentemente, lesão cardíaca aguda. A idade avançada, acima de 66 anos, sexo masculino e a presença de Hipertensão Arterial Sistêmica (HAS) , Diabetes Mellitus (DM) e dislipidemia se mostraram como variantes prevalentes nos artigos. É importante ressaltar que como resultado obtivemos que, a 41,27% dos pacientes vieram a óbito Ademais, a fim de se elucidar os mecanismos de lesão miocárdica em pacientes com condições agudas e avançar no desenvolvimento de estratégias para amenizar o mau prognóstico associado, faz-se necessário a elaboração de estudos futuros. Palavras-Chave: COVID-19. Lesão cardíaca aguda. Comorbidade. Prevalência. SARS-Cov-2. ABSTRACT The first cases of infection caused by COVID-19 appeared in December 2019 in China. In March 2020, the World Health Organization (WHO), faced with the high rates of spread of COVID-19, declared a pandemic. In addition to multisystemic manifestations, it has been observed that COVID-19 infection can lead to the formation of acute cardiac injuries or the aggravation of pre-existing cardiovascular pathologies, especially in hospitalized patients. For the elaboration of these narrative reviews, 157 articles were selected. Of these, 27 studies met the inclusion criteria. Clinical characteristics, laboratory findings and outcome of patients with a positive PCR test for SARS-Cov-2 who presented an elevation of troponin above the 99th percentile and, consequently, acute cardiac injury, were evaluated. Advanced age, above 66 years old, male and the presence of systemic arterial hypertension,diabetes mellitus and dyslipidemia shown to be prevalent variants in the articles. It is important to emphasize that as a result, we obtained that 41.27% of the patients died. Furthermore, in order to elucidate the mechanisms of myocardial injury in patients with acute conditions and advance in the development of strategies to alleviate the associated poor prognosis, it is necessary to carry out future studies. Key-Words: COVID- 19. Myocardial injury. Comorbidity. Prevalence. SARS-Cov-2. LISTA DE ILUSTRAÇÕES FIGURA 1 – PRISMA (itens de relatório preferidos para revisões sistemáticas e meta análises) fluxograma de inclusões e exclusões de estudos …………………..………10 LISTA DE TABELAS TABELA 1 - Síntese e análise de dados …................................................................10 TABELA 2 - Prevalência de comorbidades …...........................................................17 LISTA DE SIGLAS BRA - Bloqueador de Renina Angiotensina BVS - Biblioteca Virtual de Saúde CD4 - Linfócito do grupamento de diferenciação 4 CD8 - Linfócito do grupamento de diferenciação 8 CK-MB - Creatinofosfoquinase isoenzima MB COVID-19 - Doença do Coronavírus 2019 DAC – Doença Arterial Coronariana DCV - Doença Cerebrovascular DM - Diabetes Mellitus DPOC - Doença Pulmonar Obstrutiva Crônica DRC - Doença Renal Crônica ECA2- Enzima Conversora de Angiotensina 2 EUA - Estados Unidos da América HAS - Hipertensão Arterial Sistêmica IAM - Infarto Agudo do Miocárdio IECA - Inibidores da Enzima Conversora de Angiotensina IMC - Índice de Massa Corporal LAM - Lesão aguda do miocárdio LCA - Lesão Cardíaca Aguda NT BNP- Peptídeo Natriurético Cerebral PCR - Proteína C Reativa SARS-CoV-2 - “severe acute respiratory syndrome coronavirus 2 ” - Síndrome Respiratória Aguda Grave Coronavírus 2 SDRA - Síndrome da Angústia Respiratória T2MI - Infarto do Miocárdio Tipo 2 UTI - Unidade de Terapia Intensiva SUMÁRIO INTRODUÇÃO 6 OBJETIVO 7 MATERIAL E MÉTODOS 8 Estratégia de pesquisa 8 Seleção de estudos 8 Extração de dados 9 RESULTADOS 9 DISCUSSÃO 19 CONCLUSÃO 27 REFERÊNCIAS 27 4 PREVALÊNCIA DE COMORBIDADES EM PACIENTES INTERNADOS COM COVID-19 QUE TIVERAM LESÃO AGUDA DO MIOCÁRDIO: Uma revisão bibliográfica ● Anna Laura França Gontijo MendesI; Isadora Teixeira IssaI; Karenn Tavares KiepperI; Tamara Araújo Pereira CamposI; Jacqueline de Castro Laranjo II; I Acadêmicas de Medicina da FASEH, Vespasiano, MG, Brasil II Doutora em Educação professora da FASEH, Vespasiano, MG, Brasil RESUMO Os primeiros casos de infecção causada pelo COVID-19 surgiram em dezembro de 2019, na China. Em março de 2020, a Organização Mundial de Saúde (OMS), diante dos elevadosíndices de disseminação do COVID-19, declarou pandemia. Além de manifestações multissistêmicas, tem-se observado que a infecção pelo COVID-19 pode levar à formação de injúrias cardíacas agudas ou ao agravo de patologias cardiovasculares pré-existentes, sobretudo em pacientes internados. Para a elaboração dessaa revisão narrativa, foram selecionados 157 artigos. Desses, 27 estudos preencheram os critérios de inclusão. Foram avaliadas as características clínicas, os achados laboratoriais e o desfecho de pacientes com teste de PCR positivo para SARS-Cov-2 que apresentaram elevação de troponina acima do percentil 99 e, consequentemente, lesão cardíaca aguda. A idade avançada, acima de 66 anos, sexo masculino e a presença de Hipertensão Arterial Sistêmica (HAS) , Diabetes Mellitus (DM) e dislipidemia se mostraram como variantes prevalentes nos artigos. É importante ressaltar que como resultado obtivemos que, a 41,27% dos pacientes vieram a óbito Ademais, a fim de se elucidar os mecanismos de lesão miocárdica em pacientes com condições agudas e avançar no desenvolvimento de estratégias para amenizar o mau prognóstico associado, faz-se necessário a elaboração de estudos futuros. Palavras-Chave: COVID-19. Lesão cardíaca aguda. Comorbidade. Prevalência. SARS-Cov-2. 5 ABSTRACT The first cases of infection caused by COVID-19 appeared in December 2019 in China. In March 2020, the World Health Organization (WHO), faced with the high rates of spread of COVID-19, declared a pandemic. In addition to multisystemic manifestations, it has been observed that COVID-19 infection can lead to the formation of acute cardiac injuries or the aggravation of pre-existing cardiovascular pathologies, especially in hospitalized patients. For the elaboration of these narrative reviews, 157 articles were selected. Of these, 27 studies met the inclusion criteria. Clinical characteristics, laboratory findings and outcome of patients with a positive PCR test for SARS-Cov-2 who presented an elevation of troponin above the 99th percentile and, consequently, acute cardiac injury, were evaluated. Advanced age, above 66 years old, male and the presence of systemic arterial hypertension,diabetes mellitus and dyslipidemia shown to be prevalent variants in the articles. It is important to emphasize that as a result, we obtained that 41.27% of the patients died. Furthermore, in order to elucidate the mechanisms of myocardial injury in patients with acute conditions and advance in the development of strategies to alleviate the associated poor prognosis, it is necessary to carry out future studies. Key-Words: COVID-19. Myocardial injury. Comorbidity. Prevalence. SARS-Cov-2. 6 INTRODUÇÃO A pandemia causada pelo COVID-19 surgiu inicialmente em dezembro de 2019, na cidade de Wuhan, província de Hubei, na China e sendo o agente etiológico o novo coronavírus denominado “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2) (ROMANO,2021). No Brasil, o primeiro caso de COVID-19 foi confirmado no final de fevereiro de 2020. Em maio de 2022 o número de casos passa de 30.594.388 e de óbitos confirmados de 664.390.RAS (BRASIL, 2021). O SARS-CoV-2 vírus possui alta transmissibilidade e tempo de incubação entre 4 e 8 dias. A transmissão se dá, sobretudo, pelo contato direto e indireto com gotículas respiratórias. Os sintomas mais frequentes incluem febre, fadiga, tosse seca, mialgia, congestão das vias aéreas superiores, dor abdominal, anosmia e ageusia (MARTINS et al, 2020). Além dos sintomas supracitados, assemelhando-se a outras infecções respiratórias, fatores de risco e comorbidades pré-existentes podem agravar a COVID-19, resultando em um possível agravamento das doenças cardiovasculares crônicas, bem como ao aparecimento agudo de novas complicações cardíacas (WU, 2020). É importante destacar que dentre as complicações cardíacas evidenciam sobretudo a lesão cardíaca aguda, que pode estar presente em aproximadamente 16% dos pacientes internados por COVID-19, e leva a manifestações mais graves da doença. (WEI, at. al, 2020) . Além disso, a COVID-19 apresenta manifestações multissistêmicas, sendo as injúrias cardíacas agudas uma que merece destaque, visto que, pacientes com lesão miocárdica internaram mais na unidade de terapia intensiva (UTI) (22,2% vs. 2,0%) e apresentaram maior taxa de óbito (59% vs. 1%) sendo, por isso, importante verificar a literatura para elucidar a ocorrência de lesões cardíacas agudas e as variáveis associadas a sua ocorrência (COSTA, 2020). 7 OBJETIVO O objetivo desta revisão narrativa é avaliar a prevalência fatores (comorbidades, idade, sexo e alguns biomarcadores), que podem estar relacionados a pacientes que desenvolvem lesão cardíaca aguda (LCA) associada a infecção pelo SARS-Cov-2. 8 MATERIAL E MÉTODOS Estratégia de pesquisa Realizamos pesquisas bibliográficas estruturadas nas bases científicas no PubMed, no Cochrane Central Register of Controlled Trials e na Biblioteca Virtual em Saúde (BVS), com os seguintes descritores: “adults”, “myocardial injury”, “risk factor” “COVID-19”. As buscas abrangeram o período desde a data de criação de cada banco de dados até 20 de março de 2022. Foram aplicados os filtros de artigos que continham resumo, texto completo grátis, artigos que estavam disponíveis em inglês ou português ou espanhol. Não foi aplicado nenhum desenho de estudo específico. Com objetivo de identificar artigos que poderiam ter sido perdidos nas buscas, a lista de referências de cada estudo selecionado foi revisada. Seleção de estudos Duas revisoras de forma independente e em duplicata, selecionaram os estudos a partir de uma triagem realizada pelo título do estudo e do seu resumo. Os revisores resolveram as divergências por discussão. Incluímos estudos que apresentaram características de pacientes internados com COVID-19 que apresentaram lesão aguda do miocárdio (LAM), caracterizada pelo aumento da troponina acima do percentil 99. Discriminadamente, compreendemos estudos que avaliaram pacientes com teste de PCR positivo para SARS-CoV-2 que apresentaram elevação de troponina acima do percentil 99 e, portanto, apresentaram LAM, que estavam internados em centros de saúde e apresentavam dados relativos a comorbidades, achados laboratoriais e mortalidade nestes pacientes. Excluímos estudos que não abordavam as comorbidades dos pacientes, ou seja, abordavam somente taxa de mortalidade ou achados laboratoriais. Quando o estudo apresentava as características dos pacientes a partir da elevação do nível de troponina, usamos os dados referentes a elevação acima do percentil 99. Selecionamos os seguintes biomarcadores como 9 alvo da nossa revisão: PCR, procalcitonina, D-dímero, CK-MB e NT-BNP, pois são marcadores relacionados à lesão cardíaca aguda e infecção. Em pacientes internados no hospital, os biomarcadores de estresse ou de lesão cardíaca e inflamação são frequentemente anormais. Essa alteração parece se dar tanto pelo dano miocárdico viral direto quanto pelo aumento do risco para ocorrência de doenças cardiovasculares (PELLICORI, et al, 2021). Em vista, de não haver padronização internacional de medidas, optamos por usar apenas biomarcadores que tiveram aumento. Extração de dados Os estudos selecionados foram divididos entre dois pares de revisoras, independentes que coletaram os seguintes elementos sobre as características do estudo (ano de publicação, país, tipo de estudo e período de tempo que o estudo foi realizado); características da população (tamanho da amostra, idade, comorbidades); descrição dos achados laboratoriais e desfecho. RESULTADOS A Figura 1, ilustra o diagrama de fluxo de itens de relatório preferidos para revisões sistemáticas e meta-análises (PRISMA). Nossa busca identificou 157 artigos, dos quais incluímos 51 estudos para avaliação de texto completo. 27 estudos preencheram os critérios de inclusão (apresentar comorbidades, definição de LCA como troponina acima dopercentil 99 ou níveis de troponinas acima do percentil 99). Esses 27 estudos, com amostras de 9 a 3219, envolveram um total de 8.215 pacientes e foram conduzidos em 7 países diferentes (China, EUA, Itália, Inglaterra, Brasil, Espanha e Turquia), o primeiro o sendo avaliando pacientes em janeiro 2020 e o último terminado em janeiro de 2021. 10 Figura 1 - PRISMA (itens de relatório preferidos para revisões sistemáticas e meta análises) fluxograma de inclusões e exclusões de estudos Tabela 1 - Síntese e análise de dados Número Autor Título Base de dados /Periódico Periódico País/ idioma Ano de publicação 1 Bardají, et al Prognostic implications of myocardial injury in patients with and without COVID-19 infection treated in a university hospital. 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http://portal.revistas.bvs.br/transf.php?xsl=xsl/titles.xsl&xml=http://catserver.bireme.br/cgi-bin/wxis1660.exe/?IsisScript=../cgi-bin/catrevistas/catrevistas.xis%7Cdatabase_name=TITLES%7Clist_type=title%7Ccat_name=ALL%7Cfrom=1%7Ccount=50&lang=pt&comefrom=home&home=false&task=show_magazines&request_made_adv_search=false&lang=pt&show_adv_search=false&help_file=/help_pt.htm&connector=ET&search_exp=Rev%20Esp%20Cardiol%20(Engl%20Ed) 11 injury in COVID-19 patients with and without coronary artery disease. 359-366 3 Briscoe, et al Clinical significance of coronavirus disease 2019 in hospitalized patients with myocardial injury Pubmed Clinical cardiology 2021; 44(3): 332–339 Inglaterr a/ Inglês 2021 4 Cao, 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 cardiovascul ar disease. BVS/ MEDLINE Theranostics 2020; 10(21): 9663-9673 China/ Inglês 2020 5 Deng, et al The diagnostic and prognostic role of myocardial injury biomarkers in hospitalized patients with COVID-19. Pubmed Clinica chimica acta 2020; 510 : 186-190 China/ inglês 2020 6 Efros, et al Myocardial injury in hospitalized patients with COVID-19 infection-Ris k factors and outcomes. 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Itália/ Inglês 2020 8 Galea, et al T2-mapping increase is the prevalent imaging biomarker of myocardial involvement in active COVID-19: a Cardiovascul ar Magnetic Resonance study Pubmed Journal of cardiovascul ar magnetic resonance 2021; 23(1): 68. Italia/ Inglês 2021 9 Guo, et al. Cardiovascul ar Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19) Pubmed JAMA Cardiol 2020;5(7):81 1-818 China/ Inglês 2020 10 He, et al Key factors leading to fatal outcomes in COVID-19 patients with cardiac injury Pubmed Scientific reports 2021; 11(1): 4144 China/ Inglês 2021 11 Huang, et al A novel risk score to predict cardiovascul ar complication s in patients with BVS Imun Inflamm Dis. 2020; 8(4): 638-649. 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of Myocardial Injury in Patients Hospitalized With COVID-19 Infection. BVS/ MEDLINE J Am Coll Cardiol 2020 ; 76(5): 533-546, Estados Unidos / Inglês 2020 13 Lombardi, et al Association of Troponin Levels With Mortality in Italian Patients Hospitalized With Coronavirus Disease 2019: Results of a Multicenter Study Pubmed JAMA cardiology 2020;5(11):1 274–1280. Itália/ Inglês 2020 14 Lorente-Ros, et al Myocardial injury determinatio n improves risk stratification and predicts mortality in COVID-19 patients. BVS Cardiol J 2020 ; 27(5): 489-496 Espanha / Espanho l 2020 15 Majure, et al Usefulness of Elevated Troponin to Predict Death in Patients With COVID-19 and Myocardial Pubmed The American journal of cardiology 2021; 138: 100–106 Estados Unidos/ Inglês 2021 http://portal.revistas.bvs.br/transf.php?xsl=xsl/titles.xsl&xml=http://catserver.bireme.br/cgi-bin/wxis1660.exe/?IsisScript=../cgi-bin/catrevistas/catrevistas.xis%7Cdatabase_name=TITLES%7Clist_type=title%7Ccat_name=ALL%7Cfrom=1%7Ccount=50&lang=pt&comefrom=home&home=false&task=show_magazines&request_made_adv_search=false&lang=pt&show_adv_search=false&help_file=/help_pt.htm&connector=ET&search_exp=J%20Am%20Coll%20Cardiol 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Using high sensitivity cardiac troponin values in patients with SARS-CoV-2 infection (COVID-19): The Padova experience Pubmed Clinical biochemistry 2021; 90: 8–14. Italia/ Inglês 2021 18 Michieli, et al High-Sensiti vity Cardiac Troponin T for the Detection of Myocardial Injury and Risk Stratification in COVID-19. Pubmed Clinical chemistry 2021; 67(8): 1080–1089. Estados Unidos / Inglês 2021 19 Nascimento, et al COVID-19 and Myocardial Injury in a Brazilian ICU: High Incidence and Higher Risk of In-Hospital Mortality. / COVID-19 e Injúria Miocárdica em UTI Brasileira: Alta Incidência e BVS Arq Bras Cardiol 2021 ; 116(2): 275-282 Brasil/ portuguê s 2021 https://nam12.safelinks.protection.outlook.com/?url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F33058800%2F&data=04%7C01%7C%7Cf37af74f90784e3704fe08da119a573c%7C84df9e7fe9f640afb435aaaaaaaaaaaa%7C1%7C0%7C637841651892083294%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=Xwhns4FhuwRpCTPwZ6LfQeik30A6bKEwhOTdP30%2Bbh4%3D&reserved=0 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