COVID-19 can cause heart problems for survivors: Cardiologist

People with chronic cardiac conditions are at significantly elevated risk of dying during the acute phase of COVID-19, the disease caused by the SARS-CoV-2 virus.
 
But there is emerging evidence that the disease can cause chronic cardiac issues, according to interventional cardiologist Dion Stub, an associate professor at Monash University.
 
‘The cardiac issues associated with coronavirus are real,’ Associate Professor Stub said.
 
‘Many of the mortalities are a combination of cardiac and respiratory involvement, while a number of patients will have significant cardiac involvement with little respiratory involvement.’
 
Associate Professor Stub’s assessment is supported by a study in Nature, which found the virus is ‘thought to infect host cells through ACE2 to cause COVID-19, while also causing damage to the myocardium’.
 
Associate Professor Stub said the pathophysiology of the virus has plenty of mechanisms that are able to cause myocardial injury separate to respiratory issues, even though the heart-lung system was interdependent.
 
Cardiac injuries during the acute phase of the disease
‘Reports both locally and internationally show that of patients who developed COVID-19, 15–30% had associated myocardial injury as part of the virus,’ Associate Professor Stub told newsGP.
 
‘For those who do get that [injury], there are significantly increased risks of poorer outcomes.’
 
Almost one in five patients hospitalised with COVID-19 had heart damage in a JAMA Cardiology cohort study of 416 patients from Wuhan, China with associated risks of mortality. 
 
Associate Professor Stub said myocardial injuries are emerging later in the course of the disease, occurring between days 10 and 20 after the onset of symptoms, with a median of 15 days. 
 
‘There’s a whole spectrum of potential myocardial injury,’ he said. ‘One of the feared ones is when you get myocardial injury due to the cytokine storm, which can lead to a profound cardiac failure.
 
‘Cytokine surges can cause cardiac failure and circulatory collapse.’
 
Other direct consequences can include a stress-related response mimicking takotsubo syndrome, the formation of microthrombi, or a myocardial infarction.
 
An additional danger is that any myocardial injury can increase the risk of cardiac arrhythmia.
 
For Associate Professor Stubs, that is cause for real concern given the attention around the proposed use of hydroxychloroquine as a treatment for COVID-19.
 
‘Some international leaders said “what’s the harm, why isn’t everyone taking it?” We know that there are very real risks of developing long QT syndrome or arrhythmia,’ he said.
 
‘There were promising early reports that hydroxychloroquine and azithromycin [could help]. But more recent reports show no significant benefits.’
 
That could mean the use of the drug could pose particular risks to patients who have incurred a myocardial injury or who have pre-existing cardiac issues.
 
Potential chronic cardiac effects
Patients who have had COVID-19 may have a slightly elevated risk of developing heart conditions as a result.
 
While there is as yet no evidence base of chronic effects on the heart, Associate Professor Stub said based on the impact influenza has on the heart, it is likely a small proportion could develop chronic myocardial fibrosis or myocarditis.
 
‘It’s likely to be a small risk, but a real one,’ he said.
 
‘For anyone who ends up with viral-related cardiac injury, ongoing monitoring of cardiac function with simple tests is recommended.’  
 
Yale cardiologist Dr Joseph Brennan has predicted the disease will have long-term sequelae.
 
‘I don’t know that for real,’ he told the Los Angeles Times.
 
But the disease was ‘so overwhelming’ that it is likely chronic conditions would be an outcome, he said.  
 
The RACGP has more information on coronavirus available on its website.
 
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