Cardiovascular Involvement in COVID-19: What Sequelae Should We Expect?

Abstract

Several forms of cardiovascular involvement have been described in patients with Coronavirus disease 19 (COVID-19): myocardial injury, acute coronary syndrome, acute heart failure, myocarditis, pericardial diseases, arrhythmias, takotsubo syndrome, and arterial and venous atherothrombotic and thromboembolic events. Data on long-term outcome of these patients are still sparse, and the type and real incidence of cardiovascular sequelae are poorly known. It is plausible that myocardial injury may be the initiator of an inflammatory cascade, edema, and subsequent fibrosis, but also a consequence of systemic inflammation. The extent and distribution of ongoing inflammation may be the basis for ventricular dysfunction and malignant arrhythmias. Indeed, preliminary observational findings seem to emphasize the importance of close monitoring of COVID-19 patients with myocardial injury after discharge. Residual subclinical disease may be effectively investigated by using second-level imaging modalities such as cardiac magnetic resonance, which allows better characterization of the type and extension of myocardial damage, as well as of the ongoing inflammation after the acute phase. In patients with venous thromboembolism, a very common complication of COVID-19, the type and the duration of anticoagulation therapy after the acute phase should be tailored to the patient and based on the estimation of the individual thromboembolic and hemorrhagic risk. Large randomized clinical trials are ongoing to address this clinical question. Whether the severity of cardiovascular involvement, the type of treatments adopted during the acute phase, and the hemodynamic response, may influence the long-term outcome of patients recovered from COVID-19 is unknown. An etiological diagnosis of myocardial injury during the hospitalization is the first step for an appropriate follow-up in these patients. After discharge, the screening for residual left and right ventricular dysfunction, arrhythmias, residual thrombosis, and myocardial scar should be considered on a case-by-case basis, whereas an active clinical surveillance is mandatory in any patient.

Prognostic Implications of Right Ventricular Function and Pulmonary Pressures Assessed by Echocardiography in Hospitalized Patients with COVID-19

“…RV dysfunction can be attributed to different mechanisms: (1) systemic inflammation and hypoxemia inducing pulmonary vasoconstriction, (2) micro and/or macro thrombotic events affecting the pulmonary circulation, (3) the use of high-flow oxygen or mechanical ventilation therapy promoting increased RV afterload, (4) super-infection with other types of pneumonia, which should contribute to alteration of the pulmonary ventilo-perfusive unite, (5) the use of a-agonists (in case of hemodynamic instability), ( 6) elevated left atrial pressure, due to concomitant LV dysfunction and leading to elevated pulmonary pressures, (7) and a combination of the above. Regardless of its pathophysiology, the increase in RV afterload results in cardiac output reduction and hypotension, with consequent impaired coronary perfusion triggering a "snake biting its own tail" mechanism, for which RV dysfunction begets RV dysfunction [7,[24][25][26]. Additionally, non-physiological transeptal pressure gradient between RV and LV may determine septal bowing, resulting in abnormal orientation of helical myofibrils and further reduction in LV cardiac function.…”

Cardiovascular risk factors and clinical outcomes of patients hospitalized with COVID-19 pneumonia in Somalia

“…COVID-19 and CRF have negative bilateral interactions. 19 On one hand, patients with CRF are more likely to develop severe disease or die of COVID-19. 13 , 17 , 20 On the other hand, indirect and direct cardiovascular insults such as myocardial injury, acute coronary syndrome, acute heart failure, myocarditis, pericardial diseases, arrhythmias, takotsubo syndrome, and arterial and venous athero-thrombotic and thromboembolic events are more likely to occur in patients with COVID-19.…”

“… 13 , 17 , 20 On the other hand, indirect and direct cardiovascular insults such as myocardial injury, acute coronary syndrome, acute heart failure, myocarditis, pericardial diseases, arrhythmias, takotsubo syndrome, and arterial and venous athero-thrombotic and thromboembolic events are more likely to occur in patients with COVID-19. 19 Moreover, patients with COVID-19 are at an increased risk of developing diabetes due to the destructive effect of SARS-COV-2 on the pancreatic beta islets 21 and the hyperglycemic effect of glucocorticoids which are routinely used in the treatment of severe COVID-19. 22 …”

The Provision of Dental Care to COVID-19 Survivors: A Concise Review

“…Cardiac injury may develop in COVID-19 patients with or without an existing CVD 45 . They need close monitoring, even after discharge, as the ongoing systemic inflammation may lead to ventricular dysfunction and malignant arrythmia 46 . Persistent symptoms may include hypotension, tachycardia, palpitations, dyspnoea and arrhythmias 47 , 48 , 49 , 50 , with some requiring hospital readmission 51 .…”