Cardiology and COVID-19

Authors

• Prab R. Tumpati, MD, editor in chief and founder, WikiMD
• Anuradha Kolluru MD FACC , RPVI , editor in chief ( cardiology)

Editor-In-Chief of Cardiology: Anuradha Kolluru M.D.

Dr. Anuradha Kolluru is a leading board certified general cardiology physician with over 10 years of practice experience in treating patients for a variety of cardiovascular diseases. Dr Kolluru is board certified by the American Board of Internal Medicine (ABIM) in many specialties including internal medicine, cardiovascular disease, nuclear cardiology, echocardiography, cardiovascular CT and vascular interpretation (RPVI).

Areas of interest for Dr. Kolluru include women and heart disease, cardio-oncology, cardio-metabolic, cardiac imaging, heart failure and preventive cardiology. Learn more about Dr. Kolluru.

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A Novel virus goes viral: COVID-19

Heart of the Matter – Cardiovascular Care

Introduction

Coronaviruses are a family of related single stranded RNA viruses that cause diseases in mammals and birds.  So far seven strains of coronaviruses are known to cause diseases in humans , of which four produce mild symptoms of the common cold and three other which potentially can cause severe acute respiratory syndrome( SARS)  .They are Middle East respiratory syndrome related coronavirus (MERS-CoV) ,   Severe acute respiratory syndrome coronavirus  (SARS-CoV ) and more recently identified the novel coronavirus, severe acute respiratory syndrome coronavirus (SARS-CoV-2 ).

The Pandemic

COVID-19 Pandemic map

Towards the end of 2019 year ( around December), Wuhan, a city in the Hubei Province of China, has experienced an outbreak of this novel coronavirus related respiratory illnesses. It rapidly spread throughout out the world and currently is in pandemic phase. The current pandemic due to this novel coronavirus disease in 2019-2020 showed many similarities to the previous SARS outbreak and the viral agent identified as yet another strain of the SARS-related coronavirus .In February 2020, the World Health Organization designated the disease COVID-19, which stands for coronavirus disease 2019 [1]. The virus that causes COVID-19 is designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); previously, it was also referred to as 2019-nCoV.

As we are in this pandemic of COVID-19, knowledge and understanding regarding the direct and indirect cardiovascular effects of this virus and infection is evolving.  Preliminary data from China suggests that patients with pre-existing comorbidities, particularly cardiovascular disease (CVD) and cancer may be among those at highest risk of not just acquiring the infection but also having worse outcomes (2-4). This is due to associated multiple risk factors , comorbidities and immunosuppression noted in this population .This is extremely concerning and challenging  from a public health perspective since cancer and CVD are amongst the most prevalent diseases worldwide (5), and the impact of the current pandemic of coronavirus disease 2019 (COVID-19) is catastrophic.

Pathophysiology

SARS Cov-2 virus has spike proteins on them like their other family members of corona, hence the family name of corona meaning crown or halo in Latin).

Angiotensin converting enzyme-2 (ACE2) receptors in upper respiratory tract , lung and in heart serve as a cellular entry point into the human body.

Cardiac Injury can be ACE2 mediated direct damage, Hypoxia induced injury, physiological stress of COVID-19 (Systemic inflammatory response syndrome) or from systemic inflammatory cytokines release leading to cascade of events like atherosclerotic plaque rupture, induction of procoagulant factors, and hemodynamic changes, which predispose to ischemia and thrombosis.

Clinical Manifestation

Most ( 81% ) of the patients infected with this virus have mild symptoms ( like respiratory viral illness, e.g flu like symptoms) . Around 20% need hospitalization for moderate to severe symptoms . Mortality from this virus has been reported to be 1-3%, compared to seasonal influenza ( 0.1%) . Mortality estimated to be around 10.5% in patients with concomitant CV disease.

Retrospective cohort study of hospitalized patients from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020 with COVID-19 demonstrated an association of older age, higher sequential organ failure assessment (SOFA) score, and elevated d-Dimer at admission as risk factors for death in adult patients with COVID-19. A significant number of hospitalized patients had other medical comorbidities, and patients exhibited prolonged viral shedding (6)

Cardiac complications, including new or worsening heart failure, new or worsening arrhythmia, or myocardial infarction are common in patients with pneumonia. Cardiac arrest occurs in about 3% of inpatients with pneumonia (7). Mortality of patients with concomitant CV disease is estimated around 10%

Experts from china gave an update of cardiovascular symptoms they noticed in patients with virus. They suggested early warnings of myocarditis but with no signs of direct virus infiltration of the myocardium yet in an electron microscope specimen reviewed by Junbo Ge, MD, FACC, (governor of ACC's China chapter and president of the Chinese Cardiovascular Association) from Wuhan. Most histology demonstrates mononuclear infiltrates with endothelial shedding, inflammation and small vessel thrombosis. Elevation of troponin in patients with the virus, indicate myocardial injury, but not necessarily mean myocarditis. Their blood tests showed elevated C-reactive protein, CD4, CD8 and interleukin-6, pointing to an acute inflammatory response responsible for multiorgan damage, not only myocardial damage.

Currently, there are yet to be vaccines or specific antiviral drugs to prevent or treat human coronavirus infections.

ACC Clinical Guidance and Practice

SARS-CoV-2

• ACC Clinical Bulletin
• CardioSmart patient summary
• Telehealth: Rapid Implementation For Your Cardiology Clinic
• HFSA/ACC/AHA Statement Addresses Concerns Re: Using RAAS Antagonists in COVID-19
• CardioSmart patient summary
• ACC Interventional Council, SCAI Address Cath Lab Considerations During COVID-19
• Troponin and BNP Use in COVID-19
• Is There a Role For Statin Therapy in Acute Viral Infections?
• Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease 2019 (COVID-19) Pandemic NEW!
• COVID-19 Operational Considerations NEW.

Latest articles - Cardiology and COVID-19

• Most recent articles
• Ongoing trials

COVID vaccine development

WHO preventing coronavirus

Coronavirus: WHO declares COVID 19 a pandemic.

• Prevention
• FAQs on COVID
• Glossary of COVID

Treatments

The monoclonal antibodies treatments Bamlanivimab (made by Eli Lilly and Company) and the therapeutic cocktail Casirivimab/Imdevimab (made by Regeneron) called monoclonal antibodies that can be given to help treat patients with COVID-19.  

List of approved COVID-19 vaccinations in US

The following COVID-19 vaccines have received emergency use authorization from the U.S. Food and Drug Administration for the prevention of COVID-19:

• The Pfizer-BioNTech COVID-19 vaccine for use in persons 16 years of age and older.
• The Moderna COVID-19 vaccine for use in persons 18 years of age and older.
• The Johnson & Johnson (Janssen) COVID-19 vaccine for use in persons 18 years and older.

External links

• US HHS dashboard

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References

1. World Health Organization. Director-General's remarks at the media briefing on 2019-nCoV on 11 February 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-remarks-at-the-media-briefing-on-2019-ncov-on-11-february-2020 (Accessed on February 12, 2020).

2. Guan WJ, Ni ZY, Hu Y et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med 2020.

3. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). 16- 24 February 2020. Available at: https://wwwwhoint/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-reportpdf; Accessed March 9, 2020.

4. Chen N, Zhou M, Dong X et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020;395:507-513.

5. Mortality GBD, Causes of Death C. Global, regional, and national life expectancy, all- cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016;388:1459- 1544.

6. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30566-3/fulltext

7  Marrie T, J Shariatzadeh MR  Community-acquired pneumonia requiring admission to an intensive care unit: a descriptive study.Medicine (Baltimore). 2007; 86: 103-111