CVD and COVID-19
Patients with preexisting CVD are at increased risk for severe COVID-19 infection and death.7,8 The mortality rate for patients with CVD is around 11% compared with a 2% overall mortality rate.8 The reasons are unclear but may be related to a generally poorer health status, changes in ACE2 receptors as a result of medical treatment, or underlying immune dysfunction as a result of the CVD.7,9,10 Patients with preexisting CVD are also at risk for developing a critical illness.7,9,10 In addition, patients with comorbidities such as diabetes, chronic kidney disease, and chronic obstructive pulmonary disease (COPD) are at increased risk of cardiac involvement during a COVID-19 infection.7,9,10
Acute myocardial injury and arrhythmias (bradycardia and tachycardia) are the most common manifestations of COVID-19 cardiac involvement.10 Acute cardiac injury has been reported in 8% to 12% of patients, defined as elevated high-sensitivity cardiac troponin I (hs-cTnI).7 Higher hs-cTnI levels, and progressively increasing levels, are associated with mortality.7
Potential pathogenic mechanisms of acute cardiac injury include direct effects of the virus on heart muscle via ACE2, systemic inflammation, increased myocardial demand, plaque rupture and coronary artery thrombosis, electrolyte imbalance, and the effect of therapies for COVID-19 infection.7
Overall, myocardial injury is significantly associated with fatal outcomes of COVID-19 infections; however, patients with underlying CVD but without myocardial injury have a relatively favorable prognosis.9
In addition, microvascular effects such as microvascular thrombosis may be involved in hypoxemic respiratory failure in some patients with COVID-19.11 While its prevalence in COVID-19 is unknown, a study has reported thromboembolism resulting in the need for amputation.12 The American Society of Hematology recommends all hospitalized patients with COVID-19 receive pharmacologic thromboprophylaxis with LMWH or fondaparinux and that healthcare providers consider continuing anticoagulation treatment after patients are discharged.11
Reports are indicating that children and infants may rarely develop a multi-system inflammatory syndrome, related or similar to Kawasaki disease.13,14 The condition includes cardiac inflammation and elevated levels of hs-cTnI and brain natriuretic peptide (BNP).13,14