Heart Disease in COVID-19 Survivors.

Although COVID-19 is largely a respiratory illness, it does not limit itself to the respiratory system. This new virus can affect multiple organs and we’re learning that the virus can affect the heart in important ways both directly and indirectly.

Besides its most commonly recognized symptoms (fever, shortness of breath, cough, headache, gastrointestinal distress and loss of taste and smell), some coronavirus patients have presented with chest pain and palpitations, an early clue that the virus has the ability to impact the heart.

At the time of publication, well over a quarter million Americans have already died from symptoms related directly to the virus. And a number of areas hard-hit by the virus have seen an alarming spike in the number of patients succumbing to cardiovascular conditions, out of fear of visiting a hospital during the pandemic. Many of those deaths were undoubtedly preventable if these patients had received medical intervention early enough.

Coronavirus and the Heart

How might the coronavirus itself potentially affect the heart muscle? The answer is that fighting the disease puts a serious strain on a patient’s cardiovascular system. It can injure or inflame the heart directly, as well as triggering a number of reactive problems:

• Clotting, a notable coronavirus symptom, may trigger heart attack if clots affect the heart arteries.
• In patients with existing arterial disease, inflammation from the virus can destabilize plaque in the arteries and cause the plaque to rupture, causing a heart artery blockage, another path to heart attack.
• The disease can put tremendous metabolic strain on the body, leading to stress cardiomyopathy—muscle weakness that can cause heart failure. It can also cause a buildup of fluid around the heart, interfering with its proper function.
• Unlike other muscles, the heart is an engine that never quits. It requires oxygen around the clock. The body’s demand for oxygen rises as it fights the virus, but the supply of oxygen decreases as the virus replicates in the lungs. This creates significant stress on the heart which can lead to heart injury. It can also cause irregular heart rhythms, some of which can be life threatening.
• At its worst, the disease can trigger a cytokine storm, putting the immune system into overdrive. After the body has battled respiratory symptoms for weeks, it can experience a sudden and severe loss of heart function, practically overnight. This scenario can occur even as the coronavirus patient is starting to improve. It’s where we see the most frequent incidence of sudden death related to loss of cardiac function.

What Research Shows

In the past, we have seen similar viruses have a negative impact on heart function. For example, among the small studies of autopsies of patients who died during the SARS-CoV-1 epidemic of 2002, 35% showed viral invasion of the heart cells.

So, it was not surprising to learn that COVID-19 might affect the heart as well. The earliest data came from China, Italy and New York City, and was focused on the sickest patients. On average, 20%–35% of that population showed elevated heart enzymes, an indication of heart muscle injury.

Since then, we’ve seen additional, concerning results: heart injury might occur even when COVID-19 symptoms had been less severe and the patient appears to be fully recovered.

In a highly publicized study of 100 German patients—with an average age of 49 and a typical distribution of underlying conditions like high blood pressure and diabetes—60% recovered at home and never went to the hospital. Half had mild symptoms, and 18 had none at all. Yet alarmingly, MRI results showed significant cardiac inflammation in 78% of them.

Another study, reported in the Journal of the American Medical Association (JAMA), involved 26 collegiate athletes who’d contracted COVID-19. Despite normal echocardiogram results, 15% showed acute cardiac inflammation on an MRI. This study was a big motivator for the temporary shutdown of college sports last spring.

It’s important to note that all of these research studies evaluated small groups, and we do see many coronavirus patients with low levels of these harmful cardiac enzymes without any evidence of long-term cardiac damage. Nonetheless, the findings have raised concerns in the medical and scientific community.

Can a mild coronavirus infection carry risk higher than originally believed? How should we evaluate the cases of COVID-19 patients who were not sick enough to be hospitalized? These are difficult questions—especially with young people, who often fare well in spite of a COVID-19 infection. The appropriate standard of care to evaluate these patients is still evolving.  Guidelines using the different types of testing that are available—from EKG, echocardiogram, cardiac MRI and lab tests such as cardiac troponin, B-type natriuretic peptide and d-dimer—are not yet available.

The challenge will be developing these standards with limited data. For example, young elite athletes do not typically undergo cardiac MRI, so we don’t have very good control data indicating what is “normal” for that population. And pandemics don’t occur very often, so that data is limited, too. We know that various viruses can also affect the heart, including influenza, but we have very few cardiac MRI studies of patients with viral infections which might contribute clues about novel viruses. In a sense, we’re fixing the airplane as we fly it. But, with time, our available data will increase and the plan will gain clarity.

What You Can Do

Everyone, of course, should be ever-vigilant of any symptoms that may affect heart health.

Today, this is especially critical for patients who have recovered from COVID-19. A few words of advice:

• Keep taking your prescribed medicines. Early in the pandemic, fear developed around ACE medications, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ARBs). The virus gains entry through ACE2 receptors, proteins on the surface of cells. Since these drugs can increase the number of ACE2 receptors, there was speculation that they might give the virus an easier pathway into a patient’s system. But we now have data to show there is no reason to stop these medications. They may even provide some protection against the virus by blocking these receptors, but that research is ongoing.
• Stay in touch with your doctor. Some underlying conditions, including existing heart issues, can complicate recovery from the virus. And if you were infected with the virus and have recovered, it’s important to report any symptoms or lingering effects. Chest pain and palpitations have been reported by patients well after their recovery.
• Live healthy. Keep yourself as healthy as possible, particularly when new bugs surface. Get regular exercise. Include plant-based foods, which are anti-inflammatory, in your diet. Moderate consumption of sodium and alcohol, avoid tobacco and get enough sleep.
• Talk to your doctor before strenuous exercise. This is especially important for young athletes who may be harboring heart issues post–COVID-19. It is critical to return to the playing field safely. If moderate exercise brings unusual fatigue, chest pains, palpitations, light-headedness or shortness of breath, let your healthcare provider know.

Our Commitment to COVID-19 Recovery

MedStar Washington Hospital Center has a significant footprint in the Mid-Atlantic region when it comes to cardiac care. Our ongoing commitment is to provide access to all the care you need, at a location convenient to you.

The current pandemic hasn’t changed that. We are staffed and equipped to provide all levels of care, from basic services to complex cardiac care such as interventional cardiology and cardiac surgery. Our patients have immediate access to a high level of subspecialty expertise and the most advanced technology.

New vaccines are, of course, coming to fight COVID-19. We are also embracing emerging therapies such as recombinant antibody infusion which, when given early in the course of the infection, may reduce symptoms and lessen the need for hospitalization. This could enable some high-risk patients to begin fighting the virus after a single, one-hour infusion session. The agents have just received emergency-use authorization from the FDA and infusions have begun in our DC hospitals, with plans to expand to other sites, and potentially even directly to a patient’s home through visiting nurses.

In summary, remember: when it comes to your heart, don’t delay care. Heart trouble can rapidly become irreversible and life-threatening, and it won’t wait for the pandemic to recede.

At MedStar Washington Hospital Center, we are safe and ready to care for you. Contact us immediately if you or someone you love has the following cardiac symptoms (especially if you have recovered from COVID-19):

• Chest pain or pressure that lasts more than a few minutes
• Shortness of breath, which can happen without chest discomfort
• Pain or discomfort in one or both arms, the back, neck, jaw or stomach
• A cold sweat, nausea or light-headedness