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Al-Kindi S, Zidar DA. COVID-lateral damage: cardiovascular manifestations of SARS-CoV-2 infection. Transl Res 2022; 241:25-40. [PMID: 34780967 PMCID: PMC8588575 DOI: 10.1016/j.trsl.2021.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 02/07/2023]
Abstract
Early in the pandemic, concern that cardiovascular effects would accompany COVID-19 was fueled by lessons from the first SARS epidemic, knowledge that the SARS-COV2 entry receptor (Angiotensin-converting enzyme 2, ACE2) is highly expressed in the heart, early reports of myocarditis, and first-hand accounts by physicians caring for those with severe COVID-19. Over 18 months, our understanding of the cardiovascular manifestations has expanded greatly, leaving more new questions than those conclusively answered. Cardiac involvement is common (∼20%) but not uniformly observed in those who require treatment in a hospitalized setting. Cardiac MRI studies raise the possibility of manifestations in those with minimal symptoms. Some appear to experience protracted cardiovascular symptoms as part of a larger syndrome of post-acute sequelae of COVID-19. Instances of vaccine induced thrombosis and myocarditis are exceedingly rare but illustrate the need to monitor the cardiovascular safety of interventions that induce inflammation. Here, we will summarize the current understanding of potential cardiovascular manifestations of SARS-COV2. To provide proper context, paradigms of cardiovascular injury due to other inflammatory processes will also be discussed. Ongoing research and a deeper understanding COVID-19 may ultimately reveal new insight into the mechanistic underpinnings of cardiovascular disease. Thus, in this time of unprecedented suffering and risk to global health, there exists the opportunity that well conducted translational research of SARS-COV2 may provide health dividends that outlast the current pandemic.
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Key Words
- ace2, angiotensin-converting enzyme 2
- pasc, post-acute sequelae of covid-19
- cvd, cardiovascular disease
- tnf, tumor necrosis factor
- pamp, pathogen associated molecular patterns
- damps, damage associated molecular patterns
- car-t, chimeric antigen receptor therapy
- dvt, deep venous thrombosis
- tf, tissue factor
- psgl, p-selectin glycoprotein ligand
- nets, neutrophil extracellular traps
- lv, left ventricular
- crp, c-reactive protein
- lge, late gadolinium enhancement
- cbv, coxsackie virus b
- b19v, parvovirus b12
- car, coxsackievirus and adenovirus receptor
- ns1, nonstructural protein 1
- ec, endothelial cells
- scrnaseq, single cell rna sequencing
- embx, endomyocardial biopsy
- tte, transthoracic echocardiograms
- rv, right ventricular
- gls, global longitudinal strain
- hscrp, high sensitivity c-reative protein
- vitt, vaccine-induced immune thrombotic thrombocytopenia
- dtap, diphtheria, tetanus, and polio
- vaers, vaccine adverse event reporting system
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Affiliation(s)
- Sadeer Al-Kindi
- Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio
| | - David A Zidar
- Department of Medicine, School of Medicine, Case Western Reserve University, Cleveland, Ohio; Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio; Louis Stokes VA Medical Center, Cleveland, Ohio.
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Melillo F, Napolano A, Loffi M, Regazzoni V, Boccellino A, Danzi GB, Cappelletti AM, Rovere-Querini P, Landoni G, Ingallina G, Stella S, Ancona F, Dagna L, Scarpellini P, Ripa M, Castagna A, Tresoldi M, Zangrillo A, Ciceri F, Agricola E. Myocardial injury in patients with SARS-CoV-2 pneumonia: Pivotal role of inflammation in COVID-19. Eur J Clin Invest 2022; 52:e13703. [PMID: 34706062 PMCID: PMC8646244 DOI: 10.1111/eci.13703] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/25/2021] [Accepted: 10/25/2021] [Indexed: 01/01/2023]
Abstract
AIMS Infection by SARS-CoV-2 may result in a systemic disease and a proportion of patients ranging 15%-44% experienced cardiac injury (CI) diagnosed by abnormal troponin levels. The aim of the present study was to analyse the clinical characteristics of a large series of hospitalized patients for COVID-19 in order to identify predisposing and/or protective factors of CI and the outcome. METHODS AND RESULTS This is an observational, retrospective study on patients hospitalized in two Italian centres (San Raffaele Hospital and Cremona Hospital) for COVID-19 and at least one high-sensitivity cardiac troponin (hs-cTnt) measurement during hospitalization. CI was defined if at least one hs-cTnt value was above the 99th percentile. The primary end-point was the occurrence of CI during hospitalization. We included 750 patients (median age 67, IQR 56-77 years; 69% males), of whom 46.9% had history of hypertension, 14.7% of chronic coronary disease and 22.3% of chronic kidney disease (CKD). Abnormal troponin levels (median troponin 74, IQR 34-147 ng/l) were detected in 390 patients (52%) during the hospitalization. At multivariable analysis age, CKD, cancer, C-reactive protein (CRP) levels were independently associated with CI. Independent predictors of very high troponin levels were chronic kidney disease and CRP levels. Patients with CI showed higher rate of all-cause mortality (40.0% vs. 9.1%, p = 0.001) compared to those without CI. CONCLUSION This large, multicentre Italian study confirmed the high prevalence of CI and its prognostic role in hospitalized patients with COVID-19, highlighting the leading role of systemic inflammation for the occurrence of CI.
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Affiliation(s)
- Francesco Melillo
- Cardiovascular Imaging Unit, Cardiothoracic Department, San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Napolano
- Cardiovascular Imaging Unit, Cardiothoracic Department, San Raffaele Scientific Institute, Milan, Italy
| | - Marco Loffi
- Division of Cardiology, Cremona Hospital, Cremona, Italy
| | | | - Antonio Boccellino
- Cardiovascular Imaging Unit, Cardiothoracic Department, San Raffaele Scientific Institute, Milan, Italy
| | | | | | - Patrizia Rovere-Querini
- Internal Medicine, Diabetes and Endocrinology Unit, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milan, Italy.,Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Ingallina
- Cardiovascular Imaging Unit, Cardiothoracic Department, San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Stella
- Cardiovascular Imaging Unit, Cardiothoracic Department, San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Ancona
- Cardiovascular Imaging Unit, Cardiothoracic Department, San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Dagna
- Vita-Salute San Raffaele University, Milan, Italy.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Scarpellini
- Department of Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Marco Ripa
- Department of Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Antonella Castagna
- Vita-Salute San Raffaele University, Milan, Italy.,Department of Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Moreno Tresoldi
- Department of Internal Medicine and Advanced Therapies, San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Vita-Salute San Raffaele University, Milan, Italy.,Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- Vita-Salute San Raffaele University, Milan, Italy.,Hematology and Bone Marrow Transplantation Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, Cardiothoracic Department, San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
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