Reviewing CVD and Acute Cardiovascular Complications

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CVD (cardiovascular disease):

  1. Pre-existing cardiovascular and metabolic disease are common in COVID-19 patients and they increase the risk of morbidity and mortality1. These comorbidities (hypertension, cardiovascular/cerebrovascular disease and diabetes) are associated with a greater risk of ICU hospitalisation2.
  2. Patients with CVD appear more susceptible to COVID-19–induced cardiac injury3.

 

Acute cardiovascular complications:

  1. Acute cardiac injury is frequent in hospitalised patients (7-17%) and it affects up to one quarter of ICU patients1,4. It is associated with major adverse clinical outcomes and it represents one independent risk factor for in-hospital mortality3,4. Patients with cardiac injury present with more severe acute illness, manifested by abnormal laboratory parameters (higher levels of NT-proBNP, creatinine and inflammatory markers such as C-reactive protein, procalcitonin and leukocytes), more prominent radiographic findings and a greater proportion requiring non-invasive and invasive ventilation3. The exact etiology of cardiac biomarkers elevation is likely heterogeneous. Some cases probably result from type 2 MI (myocardial infarction) in the context of supply-demand mismatch, but acute myocarditis and type 1 MI may also be potential causes. In fact, a direct viral attack of cardiomyocytes mediated via ACE2 (highly expressed in the heart) could very well be the predominant mechanism1,4.
  2. Myocarditis, including fulminant form5, has been described in several case reports. Excessively elevated cardiac biomarkers, new-onset cardiac arrhythmias and acute-onset heart failure symptoms in a COVID-19 patient should raise clinical suspicion for acute myocarditis4. No confirmatory pathological specimens showing viral inclusions have been reported thus far (at the time of publication).
  3. Cardiomyopathy could affect up to a third of ICU patients, according to recent data from the US6; however, pre-existing heart failure was highly prevalent (42,9%) and sample size was small (n=21) in the case series this data comes from. The degree to which de novo cardiomyopathy occurs in the absence of pre-existing heart failure, and whether it results from direct cardiac involvement rather than being stress-induced, remain unclear.
  4. Arrythmia is also frequent in hospitalised patients (16,7%), particularly in ICU patients (44,4%)4. Specifically, patients with acute cardiac injury present a considerably increased risk (17,3%) of malignant arrhythmias (sustained ventricular tachycardia/ventricular fibrillation)7.
  5. Acute heart failure is common in hospitalised patients (23%) and it is significantly more prevalent among non-survivors (52%); ACS, fulminant myocarditis, stress-induced cardiomyopathy and arrhythmia are potential precipitating factors4.

 

This information comes from multiple sources. Clerkin K. et al. (AHA Circulation) included 68 relevant articles published up to March 19 in their systematic literature review; its data mainly comes from Chinese retrospective cohort studies and meta-analyses of the initial outbreak in Wuhan, China. Li B. et al (Clin Res Cardiol) did a meta-analysis to evaluate the prevalence of cardiovascular and metabolic diseases in COVID-19 patients and compare the incidences of comorbidities in ICU and non-ICU patients; 6 studies were included in the meta-analysis, regrouping 1527 patients. Shi S. et al (JAMA Cardiology) present a retrospective cohort study, conducted in a single center at Renmin Hospital of Wuhan University from January 20 to February 10; all consecutive inpatients with laboratory-confirmed COVID-19 were included in this study and a total of 416 hospitalized patients were included in the final analysis. Cardiac injury was defined as blood levels of cardiac biomarkers (hs-TNI) above the 99th-percentile upper reference limit, regardless of new abnormalities in electrocardiography and echocardiography. Rali A.S. et al (USC) did a literature review from 37 articles (with input from Chinese data, mostly retrospective cohort studies from Wuhan) to summarize the available evidence on the cardiovascular manifestations of COVID-19. Zeng J.H et al (Infection) report the first official case of fulminant myocarditis; a 63-year-old Chinese man was admitted with confirmed COVID-19 pneumonia and cardiac symptoms, associated with elevated cardiac biomarkers and with diffuse myocardial dyskinesia and decreased left ventricular ejection fraction (LVEF) on echocardiography. Laboratory tests for viruses that cause myocarditis were all negative, and the patient conformed to the diagnostic criteria of the Chinese expert consensus statement for fulminant myocarditis; after receiving antiviral therapy and mechanical life support, laboratory parameters normalised and the LVEF of the patient recovered to 68%. The patient eventually died of aggravation of secondary infection on the 33rd day of hospitalization. Arentz M. et al (JAMA) provide the first description of critically ill COVID-19 patients in the US; in this case series, they present the clinical presentation, characteristics, and outcomes of 21 incident cases admitted to the intensive care unit (ICU) at Evergreen Hospital in Kirkland, Washington, where one of the first deaths in the USA was reported. Finally, Guo T. et al (JAMA Cardiology), in their single-center, retrospective, observational study, analyze comorbidities, laboratory findings and outcomes in 187 patients who were either treated and discharged or died during hospitalisation at the Seventh Hospital of Wuhan City, China.

 

Sources:

  1. Clerkin K., Fried J., Raikhelkar J., Sayer G., Griffin J., Masoumi A., Jain S., Burkhoff D., Kumaraiah D., Rabbani L., Schwartz A., and Uriel N. (March 21, 2020). Coronavirus Disease 2019 (COVID-19) and Cardiovascular Disease. Circulation AHA. https://doi.org/10.1161/CIRCULATIONAHA.120.046941
  2. Li, B., Yang, J., Zhao, F. et al (March 02, 2020). Prevalence and impact of cardiovascular metabolic diseases on COVID-19 in China. Clinical Research in Cardiology. https://doi.org/10.1007/s00392-020-01626-9
  3. Shi S., Qin M., Shen B. et al (March 25, 2020). Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. JAMA Cardiology. https://doi.org/10.1001/jamacardio.2020.0950
  4. Rali A.S., Sauer A.J. (March 21, 2020). COVID-19 Pandemic and Cardiovascular Disease. US Cardiology Review (USC). https://doi.org/10.15420/usc.2020.14
  5. Zeng J.H., Liu Y.X., Yuan J., Wang F.X., Wu W.B., Li J.X., Wang L.F., Gao H., Wang Y., Dong C.F., Li Y.J., Xie X.J., Feng C. and Liu L. (April 10, 2020). First case of COVID-19 complicated with fulminant myocarditis: a case report and insights. Infection. https://doi.org/10.1007/s15010-020-01424-5
  6. Arentz M., Yim E., Klaff L. et al (March 19, 2020). Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA. https://doi.org/10.1001/jama.2020.4326
  7. Guo T., Fan Y., Chen M. et al (March 27, 2020). Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19). JAMA Cardiology. https://doi.org/10.1001/jamacardio.2020.1017
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