Collecting a comprehensive clinical health history is critical across care areas, including cardiology. Current intake questionnaires cover several risk factors, including comorbidities such as diabetes and behaviors such as smoking. But as researchers learn more about COVID-19 and the heart, many are asking: should there be a box on those questionnaires for past SARS-CoV-2 infection?
Dr. Nicola Cosentino of the Monzino Cardiology Center in Milan, Italy suggests there should be. Having cared for cardiac patients with COVID-19 since the pandemic began, Dr. Cosentino has seen an uptick in otherwise healthy people with no family history of cardiomyopathy presenting with low ejection fraction and chronic heart failure just three or four months after recovering from COVID-19. While he cautions not to deduce too much from these anecdotal associations—and emphasizes they are not necessarily causal—the circumstances do raise eyebrows.
Research Emerges on COVID-19 and Myocardial Infarction
Dr. Cosentino's observations align with a 2022 study published in Nature Medicine that examined more than 150,000 patients who had recovered from COVID-19 against millions of others—both before and during the pandemic—from the United States Department of Veterans Affairs healthcare system. Researchers found that those who had been infected with COVID-19 were 52% more likely to have a stroke and 72% more likely to have heart failure within a year of infection. Rates of myocardial infarction also went up, with a hazard ratio of 1.63. However, the study had limitations, including a lack of diversity among the veteran patients and the fact that those in the control group may have had undiscovered COVID-19.1,2 Still, with these insights, researchers seem to have arrived at a consensus similar to Dr. Cosentino's.
"It's probably still too early to say whether COVID-19 is definitively a cardiovascular risk factor, but it's a red flag for sure," he says. "Many long-haulers experience cardiac problems, so it's a relevant part of their history."
How long that might be the case remains undetermined. Reports of long-COVID have included cardiac symptoms such as shortness of breath, chest pain, and heart palpitations.3 Such symptoms could last much longer than cardiologists originally suspected, Dr. Cosentino says.
"As time passes, more reports emerge indicating that long-COVID is longer than we actually think," he says. "Last year, we thought it could last six months, but now there are a few records, especially from China, that it can last a year or more."
"The reality is that this virus is going to stay with us for a while. With so many people infected by now, the effects in cardiology could last for years."
Cardiologist, Monzino Cardiology Centre, Milan
Long-Term Cardiac Effects of COVID-19
Cardiovascular care shifted tremendously as cardiologists became aware of SARS-Cov-2's acute impacts on the heart. We now know that roughly 25% of COVID-19 patients experience cardiac complications, which factor into nearly 4 in 10 COVID-19 deaths.4 Many "direct" effects, caused by inflammation, contribute to short-term but largely resolvable problems. Those issues include arrhythmias and to some extent acute heart failure, Dr. Cosentino says.
But with emerging evidence that some complications linger long enough to become chronic concerns, the temporary cautions adopted by the cardiology community in 2020 could eventually become more permanent amid a potential long-term wave of heart patients. Dr. Cosentino also predicts that we could see a future wave of heart failure patients unrelated to COVID-19 history, simply because many patients delayed or skipped needed care during the pandemic out of fear of infection.
Reports of ongoing complications such as "post-COVID-19 heart syndrome" have increased clinicians' concern that the virus could leave lasting damage.5 Moreover, indirect effects of COVID-19 may trigger hypoxemia, hypotension, thrombosis, cytokine storms, or hypovolemia—all of which can lead to arrhythmias, acute heart failure, and acute coronary syndrome, Dr. Cosentino adds.
This amounts to a troubling cardiovascular picture for patients who have had COVID-19, whether they had preexisting cardiac concerns or not. Some studies have found a 10.5% mortality rate among COVID-19 patients with preexisting cardiovascular disease, and up to a 52% mortality rate for patients with both COVID-19 and heart failure.6 These compare to the 1.42% death rate of COVID-19 overall.7 Measuring elevations in troponin was among those early indications that alerted practitioners to the possible risk of heart failure. When troponin increased among patients without cardiovascular disease, as it has been known to do with COVID-19, the mortality rate multiplied by 4.9 times.6
Perhaps most alarmingly, the Nature Medicine study found that even mild cases of COVID-19—such as those that didn't require hospitalization—came with an elevated risk of certain cardiac problems. Similarly, young patients and those without other risk factors such as smoking were also at risk.8
Monitoring at-Risk Patients with ECG
When patients arrive for a routine visit and report having recovered from a prior COVID-19 infection, cardiologists should approach that health history similar to how they would address other risk factors—with open ears and, when warranted, diligent monitoring.
In particular, an ECG heart test can help to identify waveform abnormalities that could point to complications from COVID-19, such as sinus tachycardia, conduction defects, and arrhythmias. Laboratory testing for troponin and brain natriuretic peptides may also be useful to identify factors such as a potential risk for ischemic heart disease or heart failure. Diagnostic tools such as echocardiography and MRI are also key.
Additionally, patients' self-reported symptoms and concerns may factor into diagnostic decision-making. The Nature Medicine study observed risk elevations for angina, as well as known risks for rhythm abnormalities. New guidance from the American College of Cardiology is also available to support possible cardiac aftereffects such as myocarditis after COVID-19 infection, or even after mRNA vaccination. For patients whose cases involve at least a moderate level of suspicion around cardiac features, ECG is among the recommended testing tools, which also include lab work and advanced imaging.9
Lifelong Risk—or Not?
While researchers do not know whether COVID-19 infection will be a lifelong risk factor, insights so far suggest that its direct and indirect effects can raise red flags in a patient's chart, potentially for years. What is known, however, is that having tools such as ECG at the ready to evaluate those populations can help to assess risk for cardiac concerns quickly and inform interventions as needed.
1. Xie Y, Xu E, Bowe B, Al-Aly Z. Long-term cardiovascular outcomes of COVID-19. Nature Medicine. 2022;28(3):583-590. doi:10.1038/s41591-022-01689-3.
2. Sidik SM. Heart-disease risk soars after COVID — even with a mild case. Nature. 2022;602(7898):560-560. doi:10.1038/d41586-022-00403-0.
3. Berg S. 3 tips for doctors trying to manage long COVID's cardiac symptoms. American Medical Association. https://www.ama-assn.org/delivering-care/public-health/3-tips-doctors-trying-manage-long-covid-s-cardiac-symptoms. Accessed June 23, 2022.
4. What COVID-19 is doing to the heart, even after recovery. www.heart.org. https://www.heart.org/en/news/2020/09/03/what-covid-19-is-doing-to-the-heart-even-after-recovery. Accessed June 23, 2022.
5. Gasecka A, Pruc M, Kukula K, et al. Post-COVID-19 heart syndrome. Cardiology Journal. 2021;28(2):353-354. doi:10.5603/cj.a2021.0028.
6. Dan S, Pant M, Upadhyay SK. The case fatality rate in COVID-19 patients with cardiovascular disease: Global health challenge and paradigm in the current pandemic. Current Pharmacology Reports. Published online September 15, 2020. doi: 10.1007/s40495-020-00239-0.
7. Johns Hopkins University of Medicine. Johns Hopkins University of Medicine Coronavirus Resource Center. https://coronavirus.jhu.edu/. Accessed February 12, 2022.
8. Xie Y, Xu E, Bowe B, Al-Aly Z. Long-term cardiovascular outcomes of COVID-19. Nature Medicine. 2022;28(3):583-590. doi:10.1038/s41591-022-01689-3
9. 2022 ACC expert consensus decision pathway on cardiovascular sequelae of COVID-19 in adults: myocarditis and other myocardial involvement, post-acute sequelae of SARS-CoV-2 infection, and return to play: a report of the American College of Cardiology Solution Set Oversight Committee. Journal of the American College of Cardiology. Published 2022. https://www.jacc.org/doi/10.1016/j.jacc.2022.02.003. Accessed June 23, 2022.
The opinions, beliefs, and viewpoints expressed in this article are solely those of Dr Cosentino and do not necessarily reflect the opinions, beliefs, and viewpoints of GE Healthcare. Dr Cosentino is a paid consultant for GE Healthcare and was compensated his involvement in this article.
