Cardiac Complications of COVID-19 in Low-Risk Patients

Abstract

The coronavirus disease 2019 (COVID-19) pandemic has resulted in over 6 million deaths and significant morbidity across the globe. Alongside common respiratory symptoms, COVID-19 is associated with a variety of cardiovascular complications in the acute and post-acute phases of infection. The suggested pathophysiological mechanisms that underlie these complications include direct viral infection of the myocardium via the angiotensin-converting enzyme 2 (ACE2) protein and a cytokine release syndrome that results in indirect inflammatory damage to the heart. Patients with pre-existing cardiovascular disease and co-morbidities are generally more susceptible to the cardiac manifestations of COVID-19. However, studies have identified a variety of complications in low-risk individuals, including young adults and children. Myocarditis and paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS) are among the adverse events reported in the acute phase of infection. Furthermore, patients have reported cardiac symptoms persisting beyond the acute phase in post-COVID syndrome. This review summarises the acute and chronic cardiac consequences of COVID-19 in low-risk patients, explores the pathophysiology behind them, and discusses new predictive factors for poor outcomes.

Keywords: COVID-19; PIMS; SARS-CoV-2; cardiovascular disease; post-COVID syndrome.

Figure 1

An illustration of the potential mechanisms underlying COVID-19 complications in the heart. A schematic of direct and indirect mechanisms through which COVID-19 causes cardiac complications. The COVID-19 virus (shown at the top of the figure) may directly bind to cardiomyocytes and endothelial cells (left) to cause direct cardiac infection and cardiotoxicity. Indirect damage may also occur (right), with downstream inflammatory and hypoxaemic mechanisms. In the lower figure, we show the consequent cardiac complications that may result. ACE2 = angiotensin-converting enzyme 2. Created with BioRender.com with permission.