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Up to 20 percent of patients with COVID-19 may have heart injury due to the new coronavirus. Getty Images
  • Early evidence suggests that up to 1 in 5 patients with COVID-19 have signs of heart injury, regardless of whether or not they had respiratory symptoms.
  • The high incidence of cardiac problems in patients who contract the new coronavirus had perplexed medical experts.
  • One of the key problems associated with COVID-19 is the amount of inflammation the infection causes; this may affect heart health.

Despite the fact that COVID-19 is considered an illness of the lungs, many patients who contract the new coronavirus experience cardiac issues.

Early evidence suggests that up to 1 in 5 patients with COVID-19 have signs of heart injury, regardless of whether or not they had respiratory symptoms.

Though a good portion of these patients already had underlying health issues involving the heart, like heart disease or high blood pressure, many otherwise healthy patients have also developed heart problems, including blood vessel injuries, blood clots, arrhythmia, strokes, and heart attacks.

The high incidence of cardiac problems in patients who contract the coronavirus has had physicians stumped: How could a respiratory infection inflict so much damage on the heart?

Recent research suggests it boils down to a few factors: the widespread inflammation the infection causes, the possibility that the virus directly infects and injures the cardiovascular system, and the overall stress the infection puts on preexisting heart conditions.

A new study, published in the Journal of Emergency Medicine mid-May, evaluated 45 recent reports pertaining to COVID-19 and cardiovascular complications and found that the coronavirus can cause lasting heart impairments.

In addition, the experimental drugs used to treat COVID-19 — like hydroxychloroquine and remdesivir — may cause heart damage in some patients and worsen preexisting heart issues in others.

Researchers hope the new findings will inform how emergency physicians screen and treat patients diagnosed with COVID-19.

Still, more research is needed to confirm exactly how the coronavirus affects heart function, and which patients with COVID-19 are most at risk for running into heart troubles.

One of the key problems associated with COVID-19 is the amount of inflammation the infection causes.

According to health experts, this level of inflammation occurs due to a phenomenon called a “cytokine storm,” in which the immune system produces too big of a response against a virus.

Instead of solely attacking the virus, the immune cells injure healthy cells, too, spurring inflammation.

A big inflammatory response can put a lot of stress on the heart, making the heart work harder to pump blood throughout the body as the body fights off the infection.

“In terms of the heart, when there is a cytokine storm, the excess of cytokines can lead to fulminant myocarditis (inflammation of the heart), with heart muscle cell necrosis or death,” said Dr. Joyce M. Oen-Hsiao, the director of clinical cardiology at Yale Medicine, adding that this can lead to problems with heart function and heart failure.

According to research published in late April in the journal Frontiers in Cardiovascular Medicine, there are a variety of reasons why a respiratory infection can inflict so much damage on the heart, including the widespread inflammation the infection causes, the possibility that the virus directly infects and injures the cardiovascular system, and the overall stress the infection puts on preexisting heart conditions.

Those who have a more intense inflammatory response seem more likely to develop serious heart troubles and have a higher risk of dying from COVID-19, the study’s lead author Shuyang Zhang, a cardiology professor at Peking Union Medical College Hospital Beijing, China, said in a statement.

The virus may also directly infect cells in the cardiovascular system.

The coronavirus infects the body via a receptor called the angiotensin converting enzyme 2, or ACE2.

ACE2 receptors are prevalent in the lungs, hence the respiratory symptoms, but they’re in the heart and blood vessels, too.

According to Dr. Jack Wolfson, a board certified cardiologist and a fellow of the American College of Cardiology, the coronavirus appears to enter and infect the heart cells though these ACE2 receptors.

“Once inside the heart cell, damage to the cellular machinery directly from the virus and the human immune cell response leads to cell dysfunction and cellular death,” Wolfson said.

Researchers observed this with SARS (severe acute respiratory syndrome), a coronavirus that struck back in 2002. The SARS virus also attached to ACE2 receptors, and autopsies revealed that viral genetic material was present in heart samples from patients with SARS.

Many patients who develop severe COVID-19 complications already have underlying heart issues.

One study looking at over 72,000 patients with COVID-19 found that about 22 percent of patients who died had cardiovascular comorbidities.

The study also found that the fatality rate amongst patients with heart diseases (10.5 percent) was higher than patients with other chronic health conditions (7.3 percent for diabetes, 6.3 percent for chronic respiratory disease, and 5.6 percent for cancer).

“A person with preexisting coronary artery disease is more likely to experience cardiac complications since they already have compromised blood flow to their heart and diminished blood vessel function,” Wolfson said.

If the heart has an even harder time pumping blood to its cells due to COVID-19, the heart cells may become damaged and a person could potentially suffer from a heart attack, said Oen-Hsiao.

On top of the three mechanisms above, the medications used to treat the infection can increase a person’s risk.

According to Zhang’s study, nonsteroidal anti-inflammatory drugs (NSAIDs), antiviral drugs, and glucocorticoids being administered can exacerbate underlying heart issues and have fatal outcomes.

“Anti-inflammatories and antivirals impact the immune system and the heart muscle in many different ways, some of which could lead to lethal heart rhythms in the short term or worsen heart recovery in the long term,” Wolfson said.

NSAIDs can increase a person’s blood pressure, which can be risky for patients who have a history of hypertension, said Oen-Hsiao.

Additionally, glucocorticoids, which are used to reduce inflammation, are also known to raise blood sugar levels, which can trigger complications in people who have coronary artery disease.

And the antiviral drugs being experimentally used on patients with COVID-19 can potentially alter the channels in the heart cells and lead to arrhythmias and wearing of the heart muscle.

All that said, Oen-Hsiao explained that we need more evidence to confirm if and how these medications affect a person’s risk.

In the meantime, physicians should practice caution when using anti-inflammatory and antiviral drugs — especially on patients with underlying heart issues — as they could put wear and tear on a person’s heart.

Despite the fact that COVID-19 is considered an illness of the lungs, many patients who contract the new coronavirus experience cardiac issues. Recent research suggests there are a few mechanisms as to why COVID-19 damages the heart: the widespread inflammation the infection causes, the possibility that the virus directly infects and injures the cardiovascular system, and the overall stress the infection puts on preexisting heart conditions.

Still, more research is needed to confirm exactly how the coronavirus affects heart function, and which patients with COVID-19 are most at risk for running into heart troubles.