Getting to the Heart of the Matter: Myocardial Injury, Coagulopathy, and Other Potential Cardiovascular Implications of COVID-19

Abstract

COVID-19 was primarily identified as a respiratory illness, but reports of patients presenting initially with cardiovascular complaints are rapidly emerging. Many patients also develop cardiovascular complications during and after COVID-19 infection. Underlying cardiovascular disease increases the severity of COVID-19 infection; however, it is unclear if COVID-19 increases the risk of or causes cardiovascular complications in patients without preexisting cardiovascular disease. The review is aimed at informing the primary care physicians of the potential cardiovascular complications, especially in patients without underlying cardiovascular disease. A comprehensive literature review was performed on cardiac and vascular complications of COVID-19. The primary cardiac and vascular complications include myocarditis, acute coronary syndrome, myocardial injury, arrhythmia, heart failure, shock, multisystem inflammatory syndrome, venous and arterial thrombotic events, stroke, and coagulopathy. A detailed analysis of the pathogenesis revealed six possible mechanisms: direct cardiac damage, hypoxia-induced injury, inflammation, a dysfunctional endothelial response, coagulopathy, and the catecholamine stress response. Autopsy reports from studies show cardiomegaly, hypertrophy, ventricular dilation, infarction, and fibrosis. A wide range of cardiac and vascular complications should be considered when treating patients with confirmed or suspected COVID-19 infection. Elevated troponin and natriuretic peptides indicate an early cardiac involvement in COVID-19. Continuous monitoring of coagulation by measuring serum D-dimer can potentially prevent vascular complications. A long-term screening protocol to follow-up the patients in the primary care settings is needed to follow-up with the patients who recovered from COVID cardiovascular complications.

Emerging Role of Platelet-Endothelium Interactions in the Pathogenesis of Severe SARS-CoV-2 Infection-Associated Myocardial Injury

“…The cardiac manifestations that may occur during COVID-19 infection include acute cardiac injury, myocarditis, acute myocardial infarction (AMI), heart failure, arrhythmia, cardiomyopathy, hypotension, shock, and cardiac arrest (18,23,24). An echocardiographic study of patients with COVID-19 documented pre-existing abnormalities, which prompted the authors to suggest caution with regard to attributing such abnormalities to acute COVID-19 infection (25).…”

“…An echocardiographic study of patients with COVID-19 documented pre-existing abnormalities, which prompted the authors to suggest caution with regard to attributing such abnormalities to acute COVID-19 infection (25). Among the vascular complications documented are venous and arterial thrombotic events, which are associated with greater need for respiratory support, vasopressors, and hemodialysis, and a longer hospital stay (24,26). Autopsy studies from patients who died from COVID-19 infection have demonstrated a range of cardiac abnormalities including cardiac hypertrophy and/or enlargement, ventricular dilatation, infarction, and fibrosis (24).…”

“…Among the vascular complications documented are venous and arterial thrombotic events, which are associated with greater need for respiratory support, vasopressors, and hemodialysis, and a longer hospital stay (24,26). Autopsy studies from patients who died from COVID-19 infection have demonstrated a range of cardiac abnormalities including cardiac hypertrophy and/or enlargement, ventricular dilatation, infarction, and fibrosis (24).…”

“…A number of investigators have shown the potential value of a range of cardiac biomarkers, including high sensitivity troponins (Tn; TnT and TnI), creatinine kinase isoenzyme-MB (CK-MB) and N-terminal pro-brain-type natriuretic peptide (BNP; NT-proBNP), either as early indicators of cardiac involvement in COVID-19 infections and/or as markers of disease prognosis (27)(28)(29)(30)(31)(32)(33)(34), while measurement of D-dimers is thought to be potentially important in preventing, diagnosing and managing vascular complications (24).…”

Effect of diabetes on short-term mortality and incidence of first hospitalizations for cardiovascular events after recovery from SARS-CoV-2 infection

“…Coronavirus 19 disease 2019 (COVID-19), associated with SARS-CoV-2 virus pandemic, leads to a significant increase in the risk of death, mainly affecting elderly people with chronic diseases including diabetes [1] , [2] , [3] , [4] , [5] . Moreover, COVID-19 shares with diabetes an increased risk of thrombotic or thromboembolic events leading to acute cardiovascular events [6] , [7] , [8] , [9] , [10] . In addition, mortality linked to diabetes or to incident myocardial infarctions are significantly augmented during COVID-19 acute manifestations [11] , [12] .…”