COVID’s Cardiac Connection
Doctors say COVID-19’s effects on the heart could have consequences that last long after the pandemic has ended.
When the COVID pandemic first started, scientists were struggling to learn as fast as the virus was spreading. Inevitably, that meant that guidance changed as knowledge grew. They’re still learning – in December, for example, the Centers for Disease Control and Prevention (CDC) shortened the recommended quarantine period for someone exposed to COVID-19 from 14 days down to seven to 10 days.
Another fact they’ve learned over time: COVID is harmful to hearts, not just lungs. Although the magnitude and implications of COVID’s cardiac effects are not well understood, it’s becoming increasingly clear that it’s a risk to watch for.
Understanding the Link
Research and experience are showing that having heart disease can increase your risk of severe COVID and having COVID can increase your risk of heart disease.
“As the total number of cases of COVID has increased we have seen that folks with underlying cardiovascular disease – problems like congestive heart failure, a history of blockages in the arteries, heart or peripheral vasculature – may be at increased risk for worse outcomes with COVID,” says Dr. Adam Berman, a cardiologist with Augusta University Health.
A better understanding of that risk and who’s at greatest risk is the goal of more than $2.5 million in research being funded by the American Heart Association, says Dr. Divya Gupta, a member of the association’s board in Atlanta and medical director of advanced heart failure and transplantation at Emory Healthcare.
Emory is part of a nationwide registry created by the association to capture demographics of COVID patients, says Gupta. “We do know a couple of things,” she says. “About 70% of people hospitalized with COVID have hypertension, 25% have coronary disease and 40% have diabetes.”
At Augusta University, Berman and his colleagues are finding more evidence of a connection between the worst COVID outcome – fatality – and heart disease by looking at COVID death rates across Georgia’s 159 counties. They have found that the highest death rates are significantly associated with a county’s historical stroke rate. “We don’t know why, but [stroke rate] is probably a marker of cardiovascular disease,” he says. Their theory is that in Georgians with existing cardiovascular disease, COVID infection is more likely to lead to adverse outcomes including death.
Perhaps more alarming than the high rate of heart disease or risk factors among people hospitalized for COVID is the discovery of heart problems in COVID patients – even some healthy young athletes – who didn’t have them previously.
“I’ve seen quite a few patients who don’t have any heart issues at all and once they got COVID they developed a heart rhythm problem,” says Dr. Ugochukwu Egolum, a cardiologist with the Northeast Georgia Health System. Heart rhythm problems can be one result of COVID-related heart damage that may or may not heal over time.
“About 8 to 12% [of COVID patients] have some form of acute cardiac injury,” says Gupta. “Some of those patients might recover, but we don’t know long term what that is going to lead to. There are all kinds of injuries the heart muscle can sustain and then recover from, but the question is what [is] the downstream effect of that? Does it mean that later on down the road the heart muscle is more susceptible if it undergoes stress? We just don’t know right now.”
How Damage is Done
Even though COVID is a respiratory illness, doctors believe it can directly affect the heart muscle as well as causing other problems that indirectly impact the heart. “It can be a lot of stuff,” says Berman. One possibility, he says, is that fluid-filled lungs make it impossible for the heart to receive enough oxygen. “The lung involvement may be pressing a lot of strain on the heart.”
Another widely accepted explanation is that damage to the heart and blood vessels occurs due to inflammation created as part of the body’s immune response to the virus. Inflammation is a normal response to infection, but in COVID it can go into overdrive. Unchecked inflammation in the blood vessels can lead to clots that cause heart attacks. Inflammation of the heart muscle itself – called myocarditis – can lead to heart rhythm irregularities and potentially heart failure in the future, says Berman.
Although heart issues – chiefly myocarditis – can happen with other viral infections, in COVID they are far more common, says Berman. Why? “There is some hypothetical suspicion that it has to do with how the SARS-COVID-19 virus enters the body – through the interior lining of the blood vessels called the endothelium,” he says.
The virus’s interaction with the ACE2 receptor – a protein on the surface of many cells in the heart, lungs, blood vessels and other tissues – seems to be how it causes widespread vascular damage throughout the body, says Berman. “The reaction with this particular receptor seems to be unique, which would explain why COVID-19 affects the vascular system differently from what is seen with other viruses,” he says.
Experts say the implications of COVID’s propensity to cause heart damage go beyond the immediate consequences for patients who are sick with the virus.
Research shows that people don’t have to have COVID symptoms to be at risk of heart issues, says Gupta. “This disease creates so much inflammation,” she says. “Even if it is not causing an immediate effect there can be long-term consequences we have not identified at this time point.
“It is very possible that [COVID is] creating risk factors for downstream problems,” she notes. Just as diabetes and high blood pressure are known to be risk factors for cardiovascular disease, she says, “it is possible in the future we may be adding a history of COVID as one of those risk factors.”
Statistics show the numbers of deaths attributed to COVID, but they cannot tell what the long-term health consequences will be, says Gupta. “We really don’t know what the morbidity is. We have no idea what the issue will be a decade or two from now.”
As the future heart health for COVID patients is uncertain, so is the best treatment to control heart problems or prevent them and their consequences down the line.
One promising possibility lies in classes of drugs that suppress or alter the immune system. Although there has been concern such drugs might increase the risk of COVID or severe disease, research on people with inflammatory diseases for which such drugs are often used have not borne this out.
In fact, in November, the FDA issued an emergency use authorization for the rheumatoid arthritis medication baricitinib for the treatment of suspected or COVID-19 in patients requiring supplemental oxygen or mechanical ventilation. Baricitinib is a kind of medication called a JAK inhibitor. It works on the immune system to help reduce the processes that drive inflammation.
Another medication, dexamethasone, a corticosteroid used to treat a wide range of inflammatory conditions, is being used in COVID patients to limit the inflammation that damages the heart, blood vessels and other tissues. In a large multi-center trial of dexamethasone published in The Lancet medical journal, a moderate dose of the drug reduced deaths in hospitalized patients with COVID-19 and respiratory failure who needed supplemental oxygen.
Other studies – including trials taking place at several Georgia medical centers – are looking at the benefits of targeting the virus directly with the antiviral medication remdesivir or convalescent plasma – antibody-containing blood plasma taken from people who have recovered from COVID. “The reasoning is if you are able to control the infection or the inflammation doesn’t get out of control there is less damage to the heart,” says Egolum.
While heart monitoring is standard in patients hospitalized for COVID, it is not clear yet whether any type of routine monitoring or evaluation is needed for patients who are not sick enough to be hospitalized or who have already recovered from COVID. But Egolum notes if you have COVID you should discuss heart disease risk with your doctor and start treatment to address that risk if needed.
“From my perspective, when a patient has COVID I think it is an opportunity for the physician to do a risk assessment of the patient and if there is some risk for coronary disease and they have not been on, say, aspirin, this may be a time to get on it,” he says. “If the patient has high cholesterol and has not been treated previously, this may be the time to get them on those medications that may prevent issues related or unrelated to COVID.”
People who have had COVID and experience symptoms that could be indicative of heart involvement should talk to their doctors right away, adds Dr. Naga Kommuri, a cardiologist at the Heart Center of Northeast Georgia Medical Center in Braselton and Buford. “Chest pain, shortness of breath, the inability to breathe when lying flat will suggest a different spectrum of heart conditions, whether it is a blockage, weak heart function or a heart rhythm problem,” he says. “If you have these symptoms, that is when you have to seek early advice from your doctor, preferably a cardiologist, so we can diagnose things accordingly and treat accordingly.”
Ironically people with heart disease who don’t have COVID may be the ones who wind up having increased heart problems. Fear of catching COVID is keeping people from maintaining regular appointments for cardiovascular conditions or seeking care if they have a problem. Doctors fear this too will lead to more severe problems down the line.
“We have seen a huge drop-off in people coming in for heart attacks,” says Berman, “but we know that stuff is still happening.”
Similar observations have been made by Egolum and his colleagues with the Northeast Georgia Health System. In a study published in September in the Journal of Cardiac Failure, doctors compared the number of heart failure admissions in the system since the beginning of the COVID pandemic with those of the same period last year. “We saw a significant drop of 20 to 30% of patients coming in with heart failure,” he says. “We think a lot of this is fear of COVID. They’re staying home and not getting care as appropriate.”
His concern is that delayed care means worse outcomes. “Not only are patients delaying care, but one of the things I have seen is that the patients who do end up getting admitted are a lot sicker because they have waited so long,” says Egolum. “People have come in a week or two after having a heart attack.
“We are trying to get the message out that we still have all of the resources to take care of any problem patients have from a cardiovascular perspective and not to wait too long before coming in,” he says. “It’s a major issue we need to pay attention to.”
For patients who worry about seeking healthcare in person during the pandemic, doctors say telehealth is an alternative in some cases and most health systems and medical practices throughout the state are offering it.
“A lot of cardiac practices have adopted telehealth – ours has,” says Berman. “I am doing a ton of telehealth now and it allows me to keep in touch with my cardiac patients from the convenience of their home. That is something worth exploring if you have underlying cardiovascular disease.”
Prevention is the Priority
Doctors say when it comes to COVID and the heart the most important message is one of prevention. It’s another reason to follow safety guidelines to avoid being exposed to the virus, and it’s also a reason to adopt a heart-healthy lifestyle now.
Steps to prevent both COVID and heart problems are familiar to all of us, but bear repeating, says Gupta.
“Keep your hands clean, keep hand sanitizer with you all the time, social distance and wear your mask to minimize spreading or catching COVID,” she says.
Gupta says we should all be conscious of heart-healthy habits. “Exercising right, eating right, not smoking is probably the best way to try to take care of ourselves. I think we all know these things, I think we just have to do what we can do to take care of ourselves.”