Cardiovascular Vulnerability to COVID-19 in Cancer Survivors

Abstract

Coronavirus disease 2019 (COVID-19) has been declared a global pandemic by the World Health Organization on March 11, 2020. COVID-19 is caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-Cov-2). Although primarily a respiratory disease, cardiovascular complications of COVID-19 have been increasingly recognized. In addition, higher fatality has been reported in COVID-19 patients with underlying cardiovascular diseases. Cancer survivors have a considerably increased risk for premature cardiovascular diseases, mainly due to cardiotoxic cancer treatments. Therefore, it is foreseeable that cancer survivors will be more vulnerable to cardiovascular complications caused by COVID-19. In this review, three scenarios for increased cardiovascular complications of COVID-19 in cancer patients are proposed. In the first scenario, cardiotoxic cancer treatment and COVID-19 synergize to exacerbate direct myocardial damage. In the second scenario, cardiotoxic cancer treatment leads to a reduced cardiac reserve in cancer survivors, making them more vulnerable to COVID-19 in a “two-hit” model. The third scenario suggests that several shared risk factors may aggravate cardiovascular complications caused by both cancer treatment and COVID-19. Taken together, cancer survivors may be more vulnerable to cardiovascular complications when challenged by the COVID-19, and special cardiovascular care should be given to these patients.

Anti-cancer Therapy Leads to Increased Cardiovascular Susceptibility to COVID-19

“…Indeed, myocardial injury caused by COVID-19 infection can worsen the outcome consequences in patients with reduced cardiac reserve, leading to the development of severe cardiac complications in these patients. The cardiovascular complications from COVID-19 infection could provoke an acceleration of the myocardial injury resulting from anti-cancer treatment in a "two-hit" manner, as both COVID-19 infection and anti-cancer therapy can lead to myocardial injury (13). As mentioned previously, SARS-CoV-2 downregulates ACE2 expression by binding to ACE2 receptors (47), and ACE2 receptors are essential regulators of cardiac function (49).…”

“…The myocardial injury associated with COVID-19 could harm cancer survivors, who are already at high risk of suffering from an anti-cancer therapy-induced cardiac injury (13). The possible relation and overlap between the myocardial injury mechanism of COVID-19 and the anti-cancer therapy-induced cardiac injury is a major cause of concern in the clinic.…”

SARS-CoV-2 Infection and Cardioncology: From Cardiometabolic Risk Factors to Outcomes in Cancer Patients

“…Second, recent anticancer therapies have an impact on the prognosis of COVID-19 because, after adjusting for risk factors (age, smoking history) and other comorbidities, cancer patients treated with chemotherapy or surgery within 2 weeks of the viral infection have a poor prognosis compared to patients not recently treated. A very interesting review of Zordoky B [ 42 ] described the cardiovascular vulnerability of cancer survivors with three scenarios for increased cardiovascular outcomes of COVID-19 in cancer patients. Firstly, cardiotoxic cancer treatment and COVID-19 synergize to exacerbate direct myocardial damages, mainly through pro-oxidative, pro-apoptotic and pro-inflammatory effects.…”

“…In addition, nivolumab was recently associated to acute lymphocytic myocarditis in patients with lung cancer [ 71 ]. Therefore, it is speculated that cancer patients treated with immunotherapies could have a higher risk of myocarditis during COVID-19, which is in line with scenarios of Zordoky [ 42 ]; however, the risk of myocarditis should be compared to the possible beneficial effects of ICIs treatments due to their immune-stimulating effects [ 58 ]; therefore, more retrospective studies are needed to measure the index of fatal myocarditis in these patients and overall risk of mortality and prognosis.…”