Since March 11, 2020, when the WHO declared COVID-19 as a pandemic, this disease grabbed media attention globally. New information on the disease has been flooding the mainstream medical journals monthly and weekly, if not daily. Reader fatigue has already set in. However, conscientious health specialists and journalists must disseminate information quickly now to benefit everyone, especially the public and the health care community.
A paper titled “Cardiovascular complications in COVID-19” published in The American Journal of Emergency Medicine by a team of researchers which included Dr William Brady, University of Virginia at Charlottesville highlighted the urgency for quick, uninterrupted and updated interdisciplinary communication.
Is there a need for public to know such details? It may help public and physicians to arrive at shared decisions. The public will appreciate how physicians take decisions in spite of the challenges they face from an unknown enemy. Shared knowledge and mutual respect shall moderate unjustified expectations.
Dr Brady and colleagues searched Pub Med and Google Scholar for articles using 15 keywords including “COVID-19”, “SARS-CoV-2”, “and heart”, “cardiac”, “myocardial injury”, “acute myocardial infarction”, “acute coronary syndrome”, “heart failure”, etc. It was a commendable job. They included case reports, retrospective and prospective studies, systematic reviews and meta-analyses, clinical guidelines, and narrative reviews focusing on COVID-19 and cardiovascular effects and complications. They critically examined the articles and included in the review, 45 of them, by consensus.
Researchers noted that COVID-19 can cause serious cardiovascular complications including, heart failure, heart attacks and blood clots that can lead to strokes. They also warned that COVID-19 treatments can interact with medicines used to manage patients’ existing cardiovascular conditions.
Their paper aims to serve as a guide for emergency-medicine doctors treating patients who may have or are known to have COVID-19. The authors clarified that specialists paid more attention to the pulmonary (breathing) complications of COVID-19, and less to cardiovascular complications that can lead to death or lasting impairment.
“In writing this article, we hope to increase emergency physicians’ knowledge and awareness of this new pathogen and its impact on the cardiovascular system,” a press release from the University quoted Dr William Brady,
“As we encounter more and more patients with COVID-19-related illness, we are increasing our understanding of its impact on the body in general and the cardiovascular system in particular. The rate of learning on this area is amazingly rapid. Information continues to change weekly, if not daily.” He clarified.
COVID-19 and Heart Failure, Stroke
Heart failure is a particular concern in patients with COVID-19. In one study, authors found that 24% of the patients were suffering acute heart failure when physicians first diagnosed them with the coronavirus. The researchers clarified that this doesn’t mean that 24% of all COVID-19 patients will suffer heart failure. The authors stated that it remained unclear if the heart failure was the result of COVID-19 specifically or if the virus was worsening undiagnosed heart failure.
Of the patients with heart failure, nearly half were not known to have high blood pressure or cardiovascular disease (CVD)
The authors also found the following:
- A meta-analysis of 1527 patients with COVID-19 found that 17.1% had hypertension and 16.4% had cardiac disease, and that these patients were more likely to require critical care.
- Another study of 44,672 patients with COVID-19 found that a history of CVD was associated with nearly five-fold increase in fatality rate when compared with patients without CVD (10.5% vs. 2.3%).
- Other studies suggest similar findings with increased risk of mortality in patients with prior CVD.
COVID-19, and other diseases that cause severe inflammation throughout the body, increase the risk that fatty plaque built up in the blood vessels will rupture, leading to heart attacks and stroke. The authors stated that influenza and certain other viruses have been associated with increased risk of plaque ruptures within the first week after the disease was diagnosed.
Potential drug reactions
The authors described the potential drug interactions in COVID-19 patients. For example, they found that the highly publicized malaria drug hydroxychloroquine (HCQ) can interact with medications designed to regulate heart rhythm, in addition to causing heart damage and worsening cardiomyopathy. The Indian Council of Medical Research (ICMR) knew this and stipulated stringent conditions in their second advisory while prescribing HCQ for prophylaxis.
Remdesivir, an antiviral COVID-19 treatment authorized by the FDA, can cause low blood pressure and abnormal heart rhythm. Doctors must bear these interactions in mind when treating patients with COVID-19, the authors cautioned.
“As we gain more experience with this new pathogen, we realize that its adverse impact extends beyond the respiratory system,” Brady said. “We will continue to learn more about COVID-19 and the most optimal means of managing its many presentations.”
Reviewers reproduced a very useful list of drugs, their mechanism of action and cardio vascular effects and medication interactions from a paper titled “Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems during the COVID-19 Pandemic” in the J Am Coll Cadiol March 18, 2020
Limitations of the study
The researchers conceded that the current literature evaluating cardiovascular complications and effects associated with COVID-19 suffers from several limitations, including significant heterogeneity in patient selection, outcomes, comparators, and study design, as well as low numbers of included patients and high risk of bias. They clarified that with the current pandemic, a significant number of papers is published in preprint form; they did not complete full peer review. We need more data on the discussed cardiovascular complications and COVID-19.
COVID-19 is associated with many cardiovascular complications, including myocardial injury and myocarditis, heart failure etc. Some of the medications utilized to treat COVID-19 also have potential cardiac complications. The emergency clinicians must be aware of these complications when treating the COVID-19 patient.
It appears that the impact of COVID-19 on children was not expected. The authors did not cover it. The reviewers did a commendable job as the first effort. A wider analysis which included later developments is called for. When the dust settles down and tranquillity prevails, the authors must revisit the article and develop the review as a guide add additional information, if any, and preferably get it examined by a professional association such as the American Heart Association before final release.