COVID-19 cardiac injury: Implications for long-term surveillance and outcomes in survivors

Abstract

Up to 20%-30% of patients hospitalized with coronavirus disease 2019 (COVID-19) have evidence of myocardial involvement. Acute cardiac injury in patients hospitalized with COVID-19 is associated with higher morbidity and mortality. There are no data on how acute treatment of COVID-19 may affect the convalescent phase or long-term cardiac recovery and function. Myocarditis from other viral pathogens can evolve into overt or subclinical myocardial dysfunction, and sudden death has been described in the convalescent phase of viral myocarditis. This raises concerns for patients recovering from COVID-19. Some patients will have subclinical and possibly overt cardiovascular abnormalities. Patients with ostensibly recovered cardiac function may still be at risk of cardiomyopathy and cardiac arrhythmias. Screening for residual cardiac involvement in the convalescent phase for patients recovered from COVID-19-associated cardiac injury is needed. The type of testing and therapies for post COVID-19 myocardial dysfunction will need to be determined. Therefore, now is the time to plan for appropriate registries and clinical trials to properly assess these issues and prepare for long-term sequelae of "post-COVID-19 cardiac syndrome."

Keywords: Arrhythmia; COVID-19; Cardiac injury; Cardiomyopathy; Myocarditis.

Figure 1

Flowchart demonstrating the pathophysiology and various mechanisms of cardiac injury during acute coronavirus disease 2019 infection. Possible sequelae after recovery are then demonstrated. EAT = epicardial adipose tissue; MI = myocardial infarction; PVC = premature ventricular complex; SCD = sudden cardiac disease; STEMI = ST-segment elevation myocardial infarction; VT = ventricular tachycardia.

Figure 2

Flowchart with recommendations to identify patients with cardiac injury during the acute phase- obtain troponin and brain natriuretic peptide (BNP). After the identification of patients with potential cardiac injury, the recommendation is to screen patients with an electrocardiogram (ECG) and echocardiogram (ECHO). Depending on symptoms, a cardiac monitor may be considered. Further testing and treatment would be guided by the patient’s symptoms, cardiac risk factors, and findings from initial testing. COVID-19 = coronavirus disease 2019; COVID-19+ = patients who test positive for COVID-19; ICM = ischemic cardiomyopathy; LGE = late gadolinium enhancement; MRI = magnetic resonance imaging; NICM = nonischemic cardiomyopathy; STEMI = ST-segment elevation myocardial infarction.