How and why COVID-19 is leading to more cases of serious heart disease

At the young age of 40, Raman Kumar, an executive with an airline firm in India, lost his life to heart failure days after he recovered from severe symptoms of COVID-19. Around the same time, in the month of April, at the age of 79, days after receiving the second dose of COVID-19 vaccine, music composer Vijay Patil, also known as Raam Laxman, suffered a heart attack and passed away at his home in Nagpur.

As per experts, while patients with pre-existing cardiovascular disease and risk factors are more likely to experience adverse outcomes associated with the novel coronavirus disease (COVID-19), those with no cardiovascular history are also showing signs of developing cardiac complications as a result of the COVID infection. Various research papers express that patients with co-existing cardiovascular diseases (CVDs) are more frequently hospitalised, more likely to be treated in an intensive care unit (ICU) and have poorer prognoses. Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19, primarily involves the respiratory system with viral pneumonia as a predominant manifestation, it also has various cardiovascular manifestations, which increase morbidity and mortality in COVID-19.

“Although SARS-CoV-2 infects people of all age groups, elderly people with underlying cardiovascular diseases and those with conventional cardiovascular risk factors including male sex, diabetes, obesity and hypertension are particularly vulnerable with high morbidity and mortality,” wrote Dr Ankur Gupta, from the department of cardiology at Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, in the March 2021 issue of Indian journal of Medical Research. He says that patients may have varied cardiovascular manifestations either upfront or after the resolution of symptoms of upper respiratory tract infection and these may include acute coronary syndrome (ACS), myocarditis, cardiac arrhythmias and out-of-hospital cardiac arrest in patients with COVID-19.

"We've seen at least a thousand patients with underlying heart disease during COVID," says Dr Upendra Bhalerao, a practising cardiovascular and thoracic surgeon at Mumbai's Wockhardt Hospital in Mira Road. "300 to 400 patients have come to us in the last six months from January to May this year, with complaints related to inflammation of the heart, heart attacks, heart failures, arrhythmias and stress-induced cardiomyopathy that have occurred after they contracted the SARS-CoV-2 virus. The heart issues have either been complicated by COVID or the latter has caused them," adds Dr. Bhalerao. Doctors across India concur that the age group of people who came to them with heart issues in the second wave of the pandemic fell in the young age group of 20 years to 50 years.

According to a paper published in The New England Journal of Medicine, COVID-19 may disproportionately affect people with cardiovascular disease. “Our study confirmed previous observations suggesting that underlying cardiovascular disease is associated with an increased risk of in-hospital death among patients hospitalised with COVID-19,” the paper stated. Using an observational database from 169 hospitals in Asia, Europe and North America, the researchers evaluated the relationship of cardiovascular disease and drug therapy with in-hospital death among hospitalised patients with COVID-19 who were admitted between December 20, 2019, and March 15, 2020. “Several studies of case series have noted cardiac arrhythmias (in which heartbeat turns irregular), cardiomyopathy and cardiac arrest as terminal events in patients with COVID-19,” the paper stated.

Additionally, there has also been a concern that medical treatment for cardiovascular disease might specifically contribute to the severity of illness in patients with COVID-19. Some studies suggest that close to 50 per cent people hospitalised with severe COVID-19 have shown evidence of heart damage months after recovering from the disease.

Back in 2020, when consistent reports of cardiac injury and de-novo cardiac complications—including possible myocarditis, arrhythmia and heart failure in patients without prior cardiovascular disease or significant risk factors—were emerging, researchers in a paper titled, Management of cardiovascular disease during Covid-19, pointed out that it could possibly be due to an “accentuated host immune response and cytokine release syndrome”. In the first wave of the pandemic, experts admitted that information about cardiovascular manifestations was 'very limited' as compared with the more aggressive and savage second wave that has led to a large number of CVD patients reporting of COVID-related complications now.

Manish Bansal, from Medanta's clinical and preventive cardiology unit, had written in June of last year that "acute cardiac injury is the most reported cardiovascular abnormality in COVID-19, with average incidence 8-12 per cent”. "Underlying CVD and/or development of acute cardiac injury are associated with significantly worse outcome in these patients. Many patients with coronavirus disease 2019 (COVID-19) have underlying cardiovascular (CV) disease or develop acute cardiac injury during the course of the illness," writes Bansal. This, say doctors, is because COVID-19 infection triggers inflammation in the body that may lead to the weakening of the heart muscle and formation of blots in blood vessels.

Dr Bhalerao says that those with existing heart diseases who had a weak heart before or a chronic heart failure, an angioplasty or bypass done, are likely to suffer more from COVID-19 because the impact of the disease in them will be more severe. These patients have more propensity to develop arrhythmia, that is abnormal beating of the heart, because their toxin saturation goes down and there occurs a deficiency in the amount of oxygen that reaches the tissues. So in order to keep them from developing severity of heart disease, these patients must be diagnosed in time. "In those with no history of heart disease, COVID is known to cause an inflammation or a cytokine storm, which affects the heart, along with other body organs. This inflammation/swelling of the heart or myocarditis is seen in two of every ten patients I have been treating," says Dr Bhalerao, in an interview with THE WEEK.

"At time it becomes so severe that it leads to an abnormal heart rate, at times, to acute heart failure too. COVID can also cause blockages in small blood vessels because of the inflammation. These blood vessels or pulmonary arteries, which begin at the heart and go to the lungs, develop blockages called as pulmonary thromboembolism. This can increase the severity of COVID and those patients who develop it have bad prognosis. They take time to recover, stay in the ICU and on ventilator for a longer duration," he explained.

The most dangerous aspect of developing risks for CVDs during COVID exists in the form of blood clots or thrombus in the coronary arteries or the arteries of the heart, thereby leading to heart attacks, explains Dr Narender Bansal, consultant cardiologist with H.N. Reliance Foundation Hospital. When the same clot gets deposited in the lung arteries, it is called pulmonary embolism, when it gets deposited in the veins of the leg, it is called deep vein thrombosis and when it deposits itself inside a nerve in the brain, it leads to paralysis or stroke.

"Therefore, as a routine practice when we treat COVID patients, we ask for a test called the D-Dimer test, which is a blood test that can be used to help rule out the presence of a serious blood clot in the body. If the marker is elevated, we prescribe anti-coagulants for one to two weeks, which block the clotting mechanism, whether the patient has symptoms or not. In case, the patient already has clots, we will either do an angioplasty to suck out the clot with a specialised instrument or dissolve the clot in the arteries using thrombolytic agents that are clot busters. This problem of the tendency towards formation of clots is commonly seen in both COVID and well as post-COVID period," explains Dr Bansal.

So, how exactly does the novel coronavirus create havoc with one's heart upon entering the body? It is important to understand the interplay between COVID-19 and cardiovascular diseases because although COVID-19 is primarily a respiratory illness, its involvement with the body's cardiovascular system can occur through several mechanisms.

The angiotensin-converting enzyme 2 (ACE2) is the receptor for both SARS-CoV-1 and SARS-Cov-2. As per medical literature, the virus enters into the cell with the help of viral surface protein S (spike), which facilitates the first step in the virus replication cycle into the target cells. The S protein has two subunits: S1 and S2. The S1 subunit engages with membrane-bound cellular receptor carboxypeptidase ACE2 present over the cell membrane of pulmonary cells and the S2 subunit mediates fusion to the infected cell. This way the internalisation of the virus takes place. After internalisation inside the cell, SARS-CoV-2 duplicates, proliferates and downregulates ACE2, which actually acts like a gatekeeper of our body's system. This way the virus causes inflammation, myocardial injury and thrombosis in the body.

Doctors say that while in most cases, patients complain of chest pain and can be rescued, in some instances, the heart function goes down to 10-15 per cent so quickly, that the chances of revival become almost minimal.

Mortality:

Cardiovascular diseases increase mortality risk from coronavirus infection (COVID-19), say experts. A 2021 meta-analysis of 198 research papers from across the world revealed a high burden of CVDs—including acute cardiac injury, hypertension, heart failure, arrhythmia, coronary artery disease and cardiovascular disease were significantly associated with mortality—among COVID-19 patients, which was significantly associated with mortality and ICU admissions. As per the Cardiological Society of India, COVID-19 patients with pre-existing CVD have increased case fatality rates compared with others.

Case fatality rates reported are 6 per cent for hypertensives, 7.3 per cent for diabetics and 10.5 per cent among those with CVD, while the overall case-fatality was only 2.3 per cent. Experts suggest proper management of CVD patients with COVID-19 and monitoring them for acute cardiac conditions to prevent mortality and critical situations. Exercise regularly for good immunity, get involved in de-stressing techniques daily and follow healthy nutrition by consuming at least 30-40 grams of protein every day, say doctors. Yoga and breathing exercises also help. Warning signs that patients with pre-existing heart ailments must look out for include heaviness or shortness of breath and oxygen saturation problems.