Laboratory and Imaging Evaluation of Cardiac Involvement in Patients with Post-Acute COVID-19

Abstract

Background In the post-acute COVID-19 syndrome, many patients suffer from palpitations, effort-associated fatigue, and even sudden death. The mechanism of heart involvement in this syndrome is uncertain. The main purpose of the study was to identify possible cardiac involvement causes in patients with post-acute COVID-19 by using biomarkers such as NT-proBNP and nitric oxide (NO) and cardiac imaging modalities. Methods In this cross-sectional study, a total of 105 participants were included according to the existence of symptoms, and 40 of these participants were asymptomatic patients. The ages of the participants ranged from 20 to 50 years. All patients were healthy before COVID-19. The symptoms were defined as palpitations and/or fatigue association with exercise in post-acute COVID-19 term. The comparison of the two groups was made by using biochemical parameters (NT-proBNP, Troponin I, NO) and imaging techniques (echocardiography, cardiovascular magnetic resonance (CMR) and cardiac positron emission tomography (PET)). Results The symptomatic patients had higher NT-proBNP levels compared with asymptomatic patients (132.30±35.15; 76.86±16.79, respectively; p < 0.001). Interestingly, the symptomatic patients had lower NO levels than asymptomatic patients (9.20±3.08; 16.15±6.02, respectively; p < 0.001). Echocardiography and CMR were normal. However, we found regional increased 18F-FDG uptake on cardiac PET to be compatible with myocardial fatigue. Conclusion We found elevated NT-proNBP levels, low serum NO levels, and increased 18F-FDG uptake on cardiac PET in post-acute COVID syndrome. Cardiac PET could replace or be added to CMR for detecting subtle subacute/chronic myocarditis. The follow-up of patients with post-acute COVID-19 could target the possibility of risk of heart failure.

Reduced exercise capacity, chronotropic incompetence, and early systemic inflammation in cardiopulmonary phenotype Long COVID

“…49,[70][71][72] In heart failure, chronotropic incompetence during exercise is negatively correlated with copeptin (C-terminal portion of arginine) and norepinephrine levels. 73 FDG-PET studies suggest vascular inflammation 74 and cardiac inflammation 75 may be present in early PASC, consistent with findings of elevated inflammatory markers. Systemic inflammation in the setting of stress (as evidenced in the association between amygdalar activity and bone-marrow/arterial inflammation) 76 has been implicated in the pathophysiology of health disparities 77,78 and posttraumatic stress disorder.…”

2022 ACC Expert Consensus Decision Pathway on Cardiovascular Sequelae of COVID-19 in Adults: Myocarditis and Other Myocardial Involvement, Post-Acute Sequelae of SARS-CoV-2 Infection, and Return to Play

“… 111 , 151 , 152 , 153 Cardiac evaluation in these patients may also fail to identify a specific etiology for their reported symptoms. 154 , 155 , 156 , 157 , 158 Collectively, this can be a source of tremendous frustration for patients and clinicians alike and may lead to significant variation in care.…”

“…Although cardiac symptoms were approximately twice as common in individuals with abnormalities on FDG-PET, this was not statistically significant. Recognizing that different imaging studies may identify less overt forms of underlying myocardial involvement, 11 , 63 , 157 it is not always clear whether identified abnormalities relate to prior SARS-CoV-2 infection, a different disease process, or an incidental finding unrelated to the current presentation.…”

The Evaluation of Oxidative Stress in the Young Adults with COVID-19 mRNA Vaccines Induced Acute Pericarditis- Myopericarditis

“…COVID-19 associated oxidative stress has been shown in cardiovascular involvement. 9 The low levels of NO have been identified at the onset of the post COVID-19 cases. Additionally, the level difference of H2O2 in the COVID-19 patients has been shown to be associated with the lung damage and oxidation of key constituents of innate immunity.…”

“… 8 Moreover, oxidative stress has been known to contribute to cardiovascular problems in the patients with COVID-19. 9–11 Vascular nitric oxide (NO) abnormalities cause endothelial dysfunction occurring with various cardiovascular pathologies. The relationship between oxidative stress and COVID-19 vaccine-induced heart involvement (eg acute pericarditis-myopericarditis) is unknown.…”