Don’t Overlook COVID-19’s Cardiovascular Footprint, Say NYC Physicians
A case series from this United States hot spot shows the diversity of CV presentations and the care individual patients may require.
Cardiovascular risks sparked by COVID-19—and their diverse presentations—are becoming ever more apparent as the disease spreads worldwide. Clinicians are faced with developing unique diagnostic algorithms and treatment pathways to help these patients as patterns emerge.
A newly released case series from New York City, where COVID-19 cases have spiked in recent weeks, offers insight into four scenarios: chest pain and ST elevation but nonobstructive disease (aka, a “STEMI mimic”), cardiogenic shock, decompensated heart failure, and the special circumstance of heart transplantation.
“What we tried to do in this paper is just to give a little bit of the variety of what we see unfortunately now day-to-day with COVID-19 patients,” senior author Nir Uriel, MD (NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY), told TCTMD.
“COVID-19 is a viral disease that mainly manifests itself as a respiratory syndrome. However, there are going to be effects on other systems in our body and specifically the cardiovascular system, and people with cardiovascular disease who we care for on a daily basis are much more prone to more significant disease with COVID-19,” he pointed out.
Moreover, as lead author Justin A. Fried, MD (Columbia University Vagelos College of Physicians and Surgeons, New York, NY), and colleagues note in their paper, “discriminating between a cardiac or respiratory etiology of symptoms can be challenging since each may present predominantly with dyspnea. It is also critical to recognize when cardiac and pulmonary involvement coexist.”
As is the case with other viral diseases, cardiac issues aren’t rare in people infected with SARS-CoV-2. Studies out of Wuhan, China, first suggested that around 7% of COVID-19 patients showed signs of myocardial injury; more recent research has suggested the percentage might be as high as 20%, Uriel said.
“In this period of time, we need to be very cautious of just focusing on the respiratory system. Attention to cardiovascular symptoms is mandatory in every patient that we evaluate,” he advised, suggesting that COVID-19’s effects can be viewed as a “big umbrella.”
Fried, too, told TCTMD the purpose here was to “increase awareness.” Beyond complications caused by COVID-19, there are also “a number of patients with underlying cardiac disease who are at higher risk for decompensation even in the setting of a primary respiratory illness,” he explained.
Mary Norine Walsh, MD (St. Vincent Hospital and Heart Center, Indianapolis, IN), past president of the American College of Cardiology, described the Circulation-published case series as “really informative.”
“The four cases highlight the different types of presentations and then the different considerations that need to be taken when evaluating and testing and treating these patients. It’s a great paper,” she commented to TCTMD.
Across a Spectrum
One patient presented with “persistent chest pressure for 2 days.” Though she lacked common COVID-19 symptoms like cough, fever, and diarrhea, she ultimately tested positive for the disease. ECG findings showed diffuse ST elevations and elevated cardiac enzymes. Diagnostic angiography showed nonobstructive disease. In the end, her diagnosis was myopericarditis and cardiac amyloidosis.
Another, a 38-year-old man with a history of type 2 diabetes, experienced hypoxemic respiratory failure. After other solutions were tried, he underwent first venovenous extracorporeal membrane oxygenation (ECMO) and then veno-arterial-venous. After a week, he no longer needed ECMO and “is hemodynamically stable, although he remains on mechanical ventilation,” the physicians report.
The third patient had nonischemic cardiomyopathy with recent normalization of LVEF as well as A-fib, hypertension, and diabetes. After numerous treatments, they write, “she remains intubated on day 9 of her hospitalization due to agitation with ventilator-weaning attempts.”
And finally, the paper describes a man who’d undergone heart transplantation in 2007 and renal transplantation in 2010. His outpatient regimen of immunosuppressive drugs complicated his care. Still, he remained clinically stable and was discharged after 7 days.
For Walsh, as a transplant cardiologist, the latter case is noteworthy. “The risk-benefit ratio of cardiac transplantation now is very different than prior to the pandemic,” she explained. Physicians worry about taking a patient from home to a hospital setting where they might be exposed to COVID-19, Walsh continued. “That is one of the considerations that all of us at transplant centers are thinking about now: how sick should a patient be on the transplant list before we would want to take the increased risk of the operation?”
There’s also the potential that organ donors could be infected with SARS-CoV-2, she added. “Although all donors are currently being tested for COVID, just like they are for other communicable diseases, we all know that there is a significant false negative rate to some of the testing.”
Dealing With Limited Data
A common thread in COVID-19 care is uncertainty.
In this series, all but the patient with decompensated heart failure, who had prolonged QT on ECG, were given hydroxychloroquine. The long-used antimalarial lacks evidence when it comes to its potential role in COVID-19, and it is known to lengthen QT interval. Still, many in the medical community are hopeful that hydroxychloroquine could prove beneficial, and some aren’t waiting for the data to come in.
Asked about this controversial area, Fried replied: “I think we’re leaning heavily on our infectious disease colleagues to help guide this. Certainly in patients with severe disease, we’re strongly considering it in [those] with appropriate QT intervals. At this point, I think it’s changing almost day by day. New therapies are emerging or we’re reutilizing older therapies.” Right now, he added, there aren’t “sufficient data to recommend necessarily one drug over another, but we are using some of these drugs, hydroxychloroquine being one of them, quite a lot. Because again, in the absence of high-quality evidence, we still try to treat our patients the best way we see fit.”
Uriel emphasized that their center has a protocol for measuring QT duration and monitoring for adverse events in every patient who receives hydroxychloroquine.
“That being said, we are waiting for more meaningful data to guide which medication is really the right medication,” he commented, predicting that this information will arrive quickly.
A big unknown is COVID-19’s long-term cardiac implications for patients who experience heart problems and recover from them. It’s also unknown whether, even without these complications, COVID-19 might put patients at higher CV risk over their lifetimes. Uriel said the 2002 SARS outbreak offers some clues, with researchers finding that some people developed metabolic abnormalities over time.
“We’re going to have hundreds of thousands of people in the United States, and probably millions across the world, that recover from COVID-19 disease. If it changes their CV risk profile is something that only time will tell, but we need to be prepared to answer that question with cohort studies designed to do that,” Uriel said.
More immediate is the worry that patients are possibly avoiding medical care in the COVID-19 era, as evidenced by the noticeable drop in STEMI cases.
With limits on outpatient visits, telemedicine has moved to the forefront of patient care. “It’s important to consider checking in with your patients—particularly your cardiac patients—relatively frequently, not only to see how they’re doing with their underlying cardiac disease but also to provide advice in these circumstances on how to handle it if they do end up getting sick. A lot of patients out there are fearful of seeking medical care in [these circumstances] and that can be dangerous as well,” Fried observed.
Walsh agreed. “A big message to patients has to be: if they’re having cardiac symptoms to not be afraid of going to the emergency room. That’s one of our biggest concerns as a profession right now,” she stressed. It’s a topic that Walsh said she brings up in every telehealth appointment with her own patients.
Fried JA, Ramasubbu K, Bhatt R, et al. The variety of cardiovascular presentations of COVID-19. Circulation. 2020;Epub ahead of print.
- Fried, Uriel, and Walsh report no relevant conflicts of interest.