What is Cardiac Manifestations of Coronavirus (COVID-19) (COVID Affecting the Heart)?
Coronaviruses are a large group of viruses that have a layer of fat, or an envelope, around them. They contain a single strand of genetic information and can infect many different kinds of animals. They are split into types based on how much harm they can cause. The types that are very harmful to humans include SARS-CoV, MERS-CoV, and the current SARS-CoV2 viruses.
In December 2019, infections from the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) were identified for the first time. This disease was called COVID-19 and by March 2020, was declared a global pandemic by the World Health Organization (WHO).
Although COVID-19 primarily affects the respiratory system – namely the lungs, it has been linked to many heart-related problems. Damage to the heart is regarded as one of the most common complications of the disease. Heart-related conditions that may develop after a person recovers include coronary artery disease (narrowing of the arteries that supply blood to the heart), heart failure, irregular heart rhythms, and inflammation of the heart muscle known as myocarditis.
Studies consistently show that if a patient with COVID-19 also has a pre-existing heart condition, and/or if they develop heart damage as a result of the illness, they usually have worse health outcomes. This summary looks at the heart-related symptoms of COVID-19 and gives an overview of the recommended checks and treatments related to these complications.
What Causes Cardiac Manifestations of Coronavirus (COVID-19) (COVID Affecting the Heart)?
Coronaviruses are a family of viruses, including four types: Alphacoronavirus, Betacoronavirus, Bammacoronavirus, and Deltacoronavirus. These viruses are common in birds and mammals, and are usually found to cause mild cold-like symptoms in humans. They are typically spread through the tiny droplets spread from an infected person’s sneeze or cough.
The virus that caused the COVID-19 outbreak is known as SARS-CoV-2, and it is a type of Betacoronavirus. It’s quite similar to the SARS-CoV virus, which caused the SARS outbreak in 2003.
This coronavirus, in particular, is an RNA virus, and its structure includes several different proteins. One of the key proteins, called a spike protein, allows the virus to get into human cells by binding to a type of human receptor known as ACE-2.
While these viruses typically target the respiratory system, because ACE-2 receptors can be found in other parts of the body, including the intestines, blood vessels, and brain, the virus can cause damage in these places too. For example, the virus can even directly harm heart cells, leading to heart inflammation.
However, it should be noted that the virus’s impact isn’t only through direct invasion. The virus can also cause severe ‘body-wide’ inflammation, increased oxygen demand, blood clotting issues, and heart rhythm problems. This is particularly worrisome for people with pre-existing heart disease, as they already have a lower tolerance for such stress.
It has been observed that patients with pre-existing heart conditions are more likely to become severely ill if they contract COVID-19. Studies have established a significant link between pre-existing heart disease (such as high blood pressure and coronary artery disease) and the risk of severe COVID-19 illness. However, the exact reasons for this are not yet fully understood.
Numerous studies have also shown that people with pre-existing heart conditions who get COVID-19 have a higher risk of death from the disease. According to the U.S. Center for Disease Control (CDC), diseases like heart failure and coronary artery disease substantially increase the risk for severe COVID-19 and poor health outcomes. Lastly, age is an important risk factor to consider ; older adults are at a higher risk of heart damage if they contract the SARS-CoV-2 virus.
Risk Factors and Frequency for Cardiac Manifestations of Coronavirus (COVID-19) (COVID Affecting the Heart)
Since the start of the pandemic, cardiovascular problems have been noticed in patients with COVID-19. These problems can range from heart injuries to the onset of heart failure, heart inflammation, and pericardial effusion (fluid around the heart). A 2021 study found that around 22% of all COVID-19 patients in hospital showed heart injury. This number increased to 28% in severe cases and went up to 30% in patients over the age of 60.
Common heart complications due to COVID-19 include heart conditions like acute coronary syndrome and irregular heartbeats or arrhythmias. These are found more frequently in older patients already at risk due to high blood pressure, diabetes, and heart disease. Heart attacks have been seen in around 1.3% of COVID-19 patients, a figure that climbs to 4.9% among those who unfortunately died from the disease.
- Irregular heartbeats, particularly atrial fibrillation, are common, occurring in up to 10.4% of patients with moderate to severe COVID-19.
- Congestive heart failure has been reported in 2.8% of COVID-19 patients, increasing to 24% in fatal cases.
- Younger patients have more frequently reported acute myopericarditis (inflammation of the heart muscle and the sac surrounding the heart), although heart complications are generally low in this group.
- Acute myocarditis (heart inflammation) associated with COVID-19 appears in around 2 to 4 out of every 1,000 hospitalizations, and can occur with or without a related lung infection (pneumonia).
Despite these numbers being relatively low, if a patient shows signs of cardiac injury, it requires immediate medical attention due to the potential risk of death.
Signs and Symptoms of Cardiac Manifestations of Coronavirus (COVID-19) (COVID Affecting the Heart)
For patients who have acute COVID-19, cardiac complications can be an issue. These patients can have a range of symptoms. Most have typical COVID-19 symptoms like a cough, fever, and difficulty breathing. However, some may not have symptoms. Few may have symptoms that suggest they have heart disease.
Research shows that only a small number of patients initially show symptoms of heart disease due to COVID-19. One study found that 7.3% of the patients experienced heart palpitations, and another found that only 2% had chest pain. The vast majority have typical COVID-19 symptoms, including:
- Cough
- Fever
- Muscle aches
- Headache
Patients in critical condition need monitoring of their cardiac status. However, these patients may show signs of heart damage more as a result of their severe illness rather than due to a heart condition like an acute coronary syndrome. For example, a study from November 2020 found that serious COVID-19 patients had similar rates of heart injury as patients with serious non-COVID related lung distress.
The study also found that the heart injury seen in critical COVID-19 patients reflected their existing health risks and conditions, as well as the impact of their other organ system failures due to their severe illness. Among the COVID-19 patients in critical condition who needed mechanical ventilation, 50% showed signs of heart injury based on blood tests. But, heart injury was also common in cases of critical illness not related to COVID-19. So, the study concluded that the heart injury in serious COVID-19 was similar to that seen in patients with serious lung distress generally.
COVID-19 patients who experience heart conditions such as arrhythmias, acute coronary syndrome, or heart inflammation show typical signs for these conditions, not unique ones related to COVID-19. Acute heart failure has been reported in about 23% of COVID-19 patients. Most of these patients also show increased levels of a marker in the blood that indicates heart damage. A small number may have a condition known as Takotsubo syndrome.
Testing for Cardiac Manifestations of Coronavirus (COVID-19) (COVID Affecting the Heart)
Patients with COVID-19 often show elevated levels of specific heart health indicators known as cardiac biomarkers, such as troponin and B-type natriuretic peptide (BNP). If these are high, it can indicate heart damage related to the illness, even if there aren’t any symptoms. An electrocardiogram (a test that checks your heart’s rhythm and electrical activity) and echocardiography (an ultrasound of the heart) can be beneficial in these cases to tell whether the heart damage was caused by a blockage of the blood supply to the heart or by an increased demand on the heart.
Patients who continue to have symptoms like fatigue, muscle pain, and shortness of breath after recovering from COVID-19 may benefit from heart tests to see if they need rehab exercises to strengthen their heart and lungs. Studies found these patients tend to have lower levels of oxygen during exercise tests.
Patients with serious illness need careful interpretation of their heart test results to avoid misdiagnosis. A recent study showed that out of over 2000 patients with a high level of troponin, less than half actually had heart problems. But people with heart issues had a higher death rate (28%) compared to those with high troponin levels from non-heart problems (16%). Patients without an elevated troponin level had a death rate of 3.4%.
Hospitalized patients, particularly those with possible heart injuries from infections, should have an electrocardiogram. The most common findings in patients with COVID-19 include a faster than normal heart rate and a rapid heartbeat.
Echocardiography can reveal major problems in the heart, especially in patients with heart injuries from acute COVID-19 illness. Common findings include abnormalities in the heart’s left side (left ventricular) wall movement and the heart’s overall function, the right side (right ventricular) of the heart’s function, and fluid around the heart.
However, having high levels of heart biomarkers isn’t always linked to abnormal echocardiography results. For example, a study reported that most patients with high troponin levels during hospitalization due to acute COVID-19 illness still had a normal “ejection fraction” (the percentage of blood leaving your heart each time it contracts). If there are echocardiography irregularities, however, a higher mortality rate could be anticipated.
Usually, a diagnosis of myocarditis (heart muscle inflammation) requires a small sample of heart tissue to be analyzed. Although imaging with techniques like cardiac MRI suggests that a high number of patients have ongoing heart inflammation after a COVID-19 infection, the exact incidence can only be confirmed by examining heart tissue after death. Interestingly, this evaluation suggests that standard clinical methods of diagnosing myocarditis, like electrocardiograms and cardiac biomarkers tests, overestimate the true occurrence of myocarditis.
Treatment Options for Cardiac Manifestations of Coronavirus (COVID-19) (COVID Affecting the Heart)
When caring for COVID-19 patients, it’s important to focus on early detection and treatment of heart complications. We must also prioritize reducing their exposure to the virus where possible.
The best treatment for heart injuries in patients with COVID-19 is not yet clearly defined. Until we have specific guidelines, doctors usually treat patients showing signs of reduced blood flow to the heart or symptoms suggesting heart inflammation with supportive care. This type of care often includes maintaining proper fluid balance and controlling symptoms. Patients who have heart failure related to COVID-19 or who show signs of the heart muscle not pumping well after infection should receive standard therapies for heart failure. Those with heart rhythm problems should receive medications or potential medical interventions based on their specific heart rhythm abnormality.
In 2020, there was some debate over the safety of using certain blood pressure drugs, known as ACE inhibitors and angiotensin receptor blockers, in patients with COVID-19. However, the current consensus is that these medications are safe to continue using. A clinical trial found no major differences in outcomes or length of hospital stays between COVID-19 patients who continued taking these drugs and those who temporarily stopped.
According to guidelines from the US National Institutes of Health, doctors should continue administering these blood pressure drugs to COVID-19 patients unless they have an immediate health condition, such as kidney failure, that requires them to stop. The American Heart Association, the Heart Failure Society of America, and the American College of Cardiology all agree that the use of these drugs should not change based solely on a COVID-19 diagnosis.
Ultimately, whether or not to continue these medications should be based on an individual’s overall health condition. If the patient is already taking these drugs for underlying heart or blood vessel conditions, they should continue as prescribed.
Patients with lingering heart or lung symptoms after recovering from COVID-19 should consider physical or occupational therapy and gradually increasing exercise programs. Supervised exercise in specialized heart and lung rehabilitation programs is preferred in the early stages.
What else can Cardiac Manifestations of Coronavirus (COVID-19) (COVID Affecting the Heart) be?
When someone gets infected with COVID-19, they could experience heart problems. The specific term for this is an acute myocardial injury. However, this can be caused by several conditions. These are:
- Long-lasting Troponin increase (chronic troponin elevation)
- Blood clot in lungs (Pulmonary embolism)
- Shock caused by issues other than the heart (Noncardiogenic shock)
- Overwhelming infection in the body (Sepsis)
- Failure of the kidneys (Renal failure)
Understanding these possibilities can help doctors to figure out what’s really going on.
What to expect with Cardiac Manifestations of Coronavirus (COVID-19) (COVID Affecting the Heart)
If a patient with acute COVID-19, which is a term for a sudden and severe onset of the disease, also has a heart injury, they are more likely to pass away from any cause. On top of that, patients who test positive for certain heart-related markers (substances in the bloodstream that signal heart damage), even if the cause isn’t primarily heart-related, have a higher chance of dying (16%) compared to those without any increase in these markers (3.4%).
The impact of conditions like heart disease on the chance of survival has been well demonstrated. In a group of 191 patients, 30% had high blood pressure, making up 48% of the patients who did not survive. Furthermore, 8% had heart disease, which comprised 13% of the non-survivors.
In another report on 44,672 confirmed COVID-19 cases from the Chinese Center for Disease Control and Prevention, the overall fatality rate was 2.3%. However, it was significantly higher for patients who suffered from high blood pressure (6%), diabetes (7%), or heart disease (11%).
COVID-19 associated acute myocarditis (inflammation of the heart muscle) often resulted in shock (a life-threatening condition that requires immediate medical treatment) in 38.9% of cases. Yet, patients who only had myocarditis had a better chance of survival compared to those who also had pneumonia (a lung infection) as a result of COVID-19.
Possible Complications When Diagnosed with Cardiac Manifestations of Coronavirus (COVID-19) (COVID Affecting the Heart)
A study within the United States Department of Veterans Affairs database showed several heart conditions become more frequent after a COVID-19 infection. These illnesses, such as strokes, irregular heartbeats, heart ischemia, heart failure, and blood clots, were seen more often not just among severe COVID-19 patients, but in all infected parties. However, the folks most affected by these heart problems were those needing intensive care. Atrial fibrillation and heart failure were the primary causes and occurred in an extra 10 people for every 1,000 persons.
Even a year after their initial bout with COVID-19, 2% of patients developed new health conditions like high blood pressure and heart failure. Heart failure on the right side of the heart, excluding patients with high blood pressure or left-side heart failure, was noticed in 2.7% of these individuals.
Further, damage to the heart muscle (myocardial injury) during the initial infection stage is connected to prolonged symptoms and higher hospital readmission rate, even a year later. This is likely due to the fact that the heart muscle continues to be impaired after the initial infection. In fact, a short-term follow-up (2-3 months post infection) showed that 78% of patients had heart abnormalities as seen in cardiac magnetic resonance imaging (CMR) results. In contrast, functional heart tests did not reveal any major dysfunction in the right ventricle of the heart in 42% of recovered patients.
Common Health Complications:
- Strokes
- Irregular heartbeats
- Ischemia (Reduced blood flow to the heart)
- Heart failure
- Blood clots
- New-onset high blood pressure and heart failure
- Right-sided heart failure (excluding those with high blood pressure or left heart failure)
- Prolonged symptoms a year after infection
- Increased hospital readmission rate
- Abnormalities in heart structure
Preventing Cardiac Manifestations of Coronavirus (COVID-19) (COVID Affecting the Heart)
The best way to avoid heart-related issues caused by COVID-19 is to prevent the infection itself. Vaccines for COVID-19 have been shown to be very effective in reducing the number of people who need to be hospitalized, relocated to the intensive care unit, or visit the emergency department because of the virus.
Even though these vaccines might not work as well for older people or those with many health conditions, they are still very effective at protecting these individuals from severe forms of the disease and even death. It’s also important to note that adults who haven’t been vaccinated are more likely to end up in the hospital compared to those who have received the vaccine.
