The coronavirus disease is wreaking havoc on the health of communities throughout the world and may have lasting cardiac effects on those who have recovered from the virus. Early observations show that up to a third of patients who have been hospitalized with COVID-19 have evidence of heart involvement.
In an article published online on June 26 in the journal Heart Rhythm, lead author Raul Mitrani, M.D., and co-authors with the University of Miami Miller School of Medicine's Division of Cardiovascular Medicine, examine the varied cardiovascular injuries and complications that patients who have recovered from the acute COVID-19 infection may experience largely based on evidence from other viral infections or inflammatory injury to the heart. The authors also recommend developing screening and tracking measures to detect cardiac injury and potentially mitigate long-term impact.
Our manuscript focused on potential mid- and long-term cardiovascular effects among patients who recovered from acute COVID-9 infection. There is concern for patients having subtle or overt cardiovascular abnormalities in heart function or in cardiac rhythm disturbances."
Dr. Raul Mitrani, professor of clinical medicine and director of clinical cardiac electrophysiology
Titled "COVID-19 Cardiac Injury: Implications for Long-Term Surveillance and Outcomes in Survivors," the article notes that acute cardiac injury in patients hospitalized with COVID-19 is associated with higher morbidity and mortality, myocarditis from other viral pathogens can evolve into overt or subclinical myocardial dysfunction, and sudden death has been described in the convalescent phase of viral myocarditis.
"Myocarditis, inflammation of the heart from a virus, can recover without sequelae or can be associated with some degree of heart damage," said co-author Jeffrey Goldberger, M.D., M.B.A., professor of medicine and chief of the Cardiovascular Division. "Even small amounts of heart damage can predispose to heart rhythm problems, some of which may be lethal. How shall we best prepare for this possibility?"
The article builds on UM's existing COVID-19 cardiac research into how the virus impacts the heart and the university's unique COVID-19 Heart Program to address the cardiac needs of COVID-19 patients post infection and the larger patient population who had significant cardiac symptoms during the pandemic but did not seek treatment because of concerns about COVID-19.
Linking COVID-19 and cardiac injury
In the article, the authors note that the spike protein that causes COVID-19 enters the body's cells through the ACE2 receptor. The ACE2 is a protein that is attached to many cells in the body, including those of the heart. This may explain why up to a third of patients hospitalized with COVID-19 show evidence of myocardial injury (injury to the muscle tissues of the heart) and elevated levels of troponin (proteins that release when the heart is damaged).
In the short term, cardiac injury can worsen a COVID-19 patient's prognosis, increase the need for mechanical ventilation and increase the risk of death. However, the long-term effects are still unknown.
Since there is no study about the long-term cardiovascular effects of COVID-19, the authors reviewed data from a large number of studies relating to other types of virus-related myocardial injury. For instance, in one study, patients with viral myocarditis (inflammation of the heart muscle) had an increased prevalence of atrial and ventricular arrhythmias. When evaluated alongside other data, this information may shed light on the possible long-term effects of COVID-19 cardiac injury.
Analyzing data is just the first step. As the report emphasizes, there is a need to start planning for ongoing clinical trials that screen patients during their recovery phase. With so many unknowns related to COVID-19, implementing this surveillance is easier said than done. Nothing seems standard with this virus. Symptoms differ from patient to patient. Severity is mild to severe. Treatments are experimental and evolving. This can lead to diverse responses.
To ensure optimal monitoring, the authors suggest defining the highest-risk population. One model would identify this group as patients with COVID-19 who also have elevated levels of troponin or BNP. This population is already providing short-term prognostic information about COVID-19.
Envisioning what a clinical study will look like
Long-term surveillance will help determine the best course of action for patients with COVID-19 cardiac injury. In the meantime, Dr. Mitrani and co-authors recommend using standard ECG and echocardiograms from two to six months after recovery. If this testing shows abnormalities, advanced imaging, such as MRI with gadolinium enhancement, may be necessary.
Now is the time to plan for the long-term effects of COVID-19 cardiac injury. By using existing data, identifying high-risk patients, and planning for long-term clinical studies, researchers can potentially mitigate the long-term effects of COVID-19 cardiac injury.
"One of the key features of the COVID-19 illness is that it clearly has unique and novel aspects associated with it," said Dr. Goldberger, who co-authored the editorial along with UM cardiology fellow Nikita Dabas, M.D., M.P.H.
"Because it is novel, we simply do not know what to expect. Our medical system is getting trained very quickly on the treatment for the acute illness, but we should also begin to focus on the long-lasting effects."
Mitrani, R.D., et al. (2020) COVID-19 Cardiac Injury: Implications for Long-Term Surveillance and Outcomes in Survivors. Heart Rhythm. doi.org/10.1016/j.hrthm.2020.06.026.