Cardiac complications during the active phase of COVID-19: review of the current evidence

Abstract

Growing reports since the beginning of the pandemic and till date describe increased rates of cardiac complications (CC) in the active phase of coronavirus disease 2019 (COVID-19). CC commonly observed include myocarditis/myocardial injury, arrhythmias and heart failure, with an incidence reaching about a quarter of hospitalized patients in some reports. The increased incidence of CC raise questions about the possible heightened susceptibility of patients with cardiac disease to develop severe COVID-19, and whether the virus itself is involved in the pathogenesis of CC. The wide array of CC seems to stem from multiple mechanisms, including the ability of the virus to directly enter cardiomyocytes, and to indirectly damage the heart through systemic hyperinflammatory and hypercoagulable states, endothelial injury of the coronary arteries and hypoxemia. The induced CC seem to dramatically impact the prognosis of COVID-19, with some studies suggesting over 50% mortality rates with myocardial damage, up from ~ 5% overall mortality of COVID-19 alone. Thus, it is particularly important to investigate the relation between COVID-19 and heart disease, given the major effect on morbidity and mortality, aiming at early detection and improving patient care and outcomes. In this article, we review the growing body of published data on the topic to provide the reader with a comprehensive and robust description of the available evidence and its implication for clinical practice.

Keywords: COVID-19; Cardiac complications; Heart disease; Pathophysiology; SARS-CoV-2.

Fig. 1

Major pathophysiological pathways linking COVID-19 to heart disease. Ang-II Angiontensin-II, ACE2 angiotensin-converting enzyme 2, IL interleukin, TF tissue factor, TNF tumour necrosis factor. Sources: Sarscov2: "Coronavirus" by Yu. Samoilov is licensed under CC BY 2.0, https://www.flickr.com/photos/yusamoilov/49678500083/in/photostream/. Endothelial Injury: Normal vs. Partially-Blocked Vessel by BruceBlaus, https://commons.wikimedia.org/wiki/File:Blausen_0052_Artery_NormalvPartially-BlockedVessel.png. Inflammation: "Fig. 1 from 'Sex Differences in Inflammation During Atherosclerosis'" by Libertas Academica is licensed under CC BY 2.0, https://search.creativecommons.org/photos/7991b0ee-963d-42bc-bc85-fa2f19396da8. Hypoxia: Exercise/Contraction/Hypoxia, Indolences, https://commons.wikimedia.org/wiki/File:Muscle_pathways.svg. Viral attachment: The coronavirus replication cycle, Crenim at English Wikipedia, edited. https://commons.wikimedia.org/wiki/File:Coronavirus_replication.png

Fig. 2

Commonly reported risk factors associated with both heart disease and severe COVID-19

Fig. 3

Common cardiac complications associated with COVID-19