July 30, 2020

Covid-19 can cause heart problems, research shows. But is it permanent?

Daily Briefing

    Studies have shown that the novel coronavirus is associated with heart damage and cardiac problems in some patients, and research published Monday in JAMA Cardiology suggest those issues could last for months after patients recover from Covid-19—sparking concern among cardiologists that the heart complications could be permanent.

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    Could coronavirus heart damage last long term?

    Research has shown that people with heart conditions, including coronary artery disease and heart failure, have a higher risk of developing a severe case of Covid-19, the disease caused by the coronavirus, and of dying from the disease than healthy people. In addition, health care providers and researchers have reported finding elevated heart rates, heart attacks, heart damage, inflammation, and irregular heart rhythms in Covid-19 patients, even among patients who had no prior heart issues.

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    Researchers have set out to determine just how commonly heart issues among Covid-19 patients occur and whether the effects of the coronavirus on some patients' hearts could last long term.

    In one study published Monday in JAMA Cardiology, researchers analyzed autopsy reports from 39 patients in Germany who had tested positive for the coronavirus between April 8 and April 18. The patients ranged in age from 78 to 89 years, with a median age of 85, and pneumonia was the listed cause of death for 35 of the patients.

    The researchers found that 24 of the patients had some level of the novel coronavirus in the muscles surrounding their hearts, and 16 of those patients had high levels of the virus in those muscles. Further, those 16 patients showed evidence of elevated cytokine response—based on a panel of six proinflammatory genes—when compared with 15 patients with no detected levels of the coronavirus in their heart muscles, according to the study. However, the researchers wrote that although they observed a "response" to the coronavirus infection among patients with high levels of the virus in the muscles surrounding their hearts, "this was not associated with an influx of inflammatory cells."

    Dirk Westermann, a cardiologist at the University Heart and Vascular Centre, who was involved in the study, explained that he and his colleagues found "signs of viral replication" in patients who were "heavily infected" with the coronavirus, but he added that scientists still "don't know the long-term consequences of the changes in gene expression." Still, Westermann said, "I know from other diseases that it's obviously not good to have that increased level of inflammation."

    Separately, researchers in a second study published Monday in JAMA Cardiology analyzed cardiac MRIs from 100 people in Germany who recovered from Covid-19, as well as cardiac MRIs from 100 people who had not been infected with the coronavirus. The patients ranged in age from 45 to 53 years, with a median age of 49.

    The researchers found that the MRIs from many people in the group of recovered Covid-19 patients showed evidence of cardiac issues two months after the patients had recovered from the disease. Among that group, 78 patients experienced structural changes to their hearts, 76 showed evidence of a cardiac injury like those typically seen after a heart attack, and 60 had signs of inflammation of the heart. Overall, the researchers said MRIs from patients who had been infected with the coronavirus were more likely to show signs of heart problems than patients who hadn't been infected with the virus.

    Valentina Puntmann, the study's lead author, said none of the patients in the Covid-19 group knew that there was something wrong with their hearts. Most of the patients were relatively healthy otherwise, and two-thirds had recovered from Covid-19 at home, indicating that they had a comparatively mild case of the disease.

    "The fact that 78% of 'recovered' [Covid-19 patients] had evidence of ongoing heart involvement means that the heart is involved in a majority of patients, even if Covid-19 illness does not scream out with the classical heart symptoms, such as anginal chest pain," Puntmann said.

    The research wrote that the "findings indicate the need for ongoing investigation of the long-term cardiovascular consequences of Covid-19."

    Experts worry coronavirus heart damage could spark chronic conditions

    STAT News reports that, although it's "too soon to say if the [heart] damage in patients recovering from Covid-19 is transient or permanent … cardiologists are worried" that the damage could lead to serious and chronic conditions such as heart failure.

    Matthew Tomey, a cardiologist and assistant professor of medicine at the Icahn School of Medicine at Mount Sinai Health System, who was not involved with the studies, said the findings "suggest that being infected with Covid-19 carries a high likelihood of having some involvement of the heart." He added, "If not answering questions, [they] prompt important questions about what the cardiac aftermath is."

    Tomey said he and other doctors have tentatively linked cardiac problems in Covid-19 patients to some lingering symptoms of the disease. For instance, Tomey said some patients who had Covid-19 in March or April are still experiencing weakness and fatigue.

    "Patients come to my office saying, 'Hey, I'm a 31-year-old who used to run and be completely unlimited in my exercise, and now I get palpitations walking across the street. Or I get out of breath climbing up to my second-floor apartment,'" he said.

    But Tomey noted that more research is needed to fully understand how the coronavirus affects patients' hearts—and for how long.

    "The question now is how long these changes persist," Tomey said. "Are these going to become chronic effects upon the heart or are these—we hope—temporary effects on cardiac function that will gradually improve over time?"

    Clyde Yancy, a cardiologist at Northwestern's Feinberg School of Medicine, and Gregg Fonarow, a cardiologist at UCLA's Geffen School of Medicine, in an editorial accompanying the two studies wrote that, if research confirms the risk of chronic cardiac injury from the novel coronavirus, the world could be dealing with consequences of the viral pandemic for years to come. "[T]hen the crisis of Covid-19 will not abate but will instead shift to a new de novo incidence of heart failure and other chronic cardiovascular complications."

    Likewise, Marc Pfeffer, a cardiologist at Brigham and Women's Hospital, said, "We knew that this virus … doesn't spare the heart. We're going to get a lot of people through the acute phase [but] I think there's going to be a long-term price to pay" (Cooney, STAT News, 7/27; Guzman, "Changing America," The Hill, 7/27; Lou, Medpage Today, 7/27; Lindner et al., JAMA Cardiology, 7/27; Puntmann et al., JAMA Cardiology, 7/27).

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