Cardiovascular sequalae in uncomplicated COVID-19 survivors

Persistent increase of cardiovascular and cerebrovascular events in COVID-19 patients: a 3-year population-based analysis

AIMS

We evaluated the incidence and relative risk of major post-acute cardiovascular consequences of SARS-CoV-2 infection in a large real-world population from a primary care database in a region at moderate cardiovascular risk followed up in the period 2020-22.

METHODS AND RESULTS

This is a retrospective cohort analysis using data from a cooperative of general practitioners in Italy. Individuals aged >18 affected by COVID-19 starting from January 2020 have been followed up for 3 years. Anonymized data from 228 266 patients in the period 2020-22 were considered for statistical analysis and included 31 764 subjects with a diagnosis of COVID-19. An equal group of subjects recorded in the same database in the period 2017-19 was used as propensity score-matched comparison as an unquestionable COVID-19-free population. Out of the 228 266 individuals included in the COMEGEN database during 2020-22, 31 764 (13.9%) were ascertained positive with SARS-CoV-2 infection by a molecular test reported to general practitioners. The proportion of individuals with a new diagnosis of major adverse cardiovascular and cerebrovascular events was higher in the 2020-22 COVID-19 group than in the 2017-19 COMEGEN propensity score-matched comparator, with an odds ratio of 1.73 (95% confidence interval: 1.53-1.94; P < 0.001). All major adverse cardiovascular and cerebrovascular events considered showed a significantly higher risk in COVID-19 individuals. Incidence calculated for each 6-month period after the diagnosis of COVID-19 in our population was the highest in the first year (1.39% and 1.45%, respectively), although it remained significantly higher than in the COVID-19-free patients throughout the 3 years.

CONCLUSION

The increase of cardiovascular risk associated with COVID-19 might be extended for years and not limited to the acute phase of the infection. This should promote the planning of longer follow-up for COVID-19 patients to prevent and promptly manage the potential occurrence of major adverse cardiovascular and cerebrovascular events.

The Burden of Cardiovascular Disease in the Post-COVID Era

In 2019, before the COVID-19 pandemic, cardiovascular disease (CVD) was the leading cause of death. Since 2020, the pandemic has had far-reaching effects on the landscape of health care including CVD prevention and management. Recent decreases in life expectancy in the United States could potentially be explained by issues related to disruptions in CVD prevention and control of CVD risk factors from the COVID-19 pandemic. This article reviews the effects of the SARS-CoV-2 virus and the accompanying pandemic on CVD risk factor prevention and management in the United States. Potential solutions are also proposed for these patients.

Thirty-Day Mortality and Complication Rates in Total Joint Arthroplasty After a Recent COVID-19 Diagnosis: A Retrospective Cohort in the National COVID Cohort Collaborative (N3C)

BACKGROUND

The risk of postoperative complications in patients who had a positive COVID-19 test prior to a total joint arthroplasty (TJA) is unknown. The purpose of this investigation was to study the complications and mortality associated with a recent COVID-19 diagnosis prior to TJA.

METHODS

Patients undergoing primary and revision total hip arthroplasties (THAs) or total knee arthroplasties (TKAs) were identified using the National COVID Cohort Collaborative (N3C) Data Enclave. Patients were divided into a COVID-19-positive group (positive polymerase chain reaction [PCR] test, clinical diagnosis, or positive antibody test) and a COVID-19-negative group, and the time from diagnosis was noted. There was no differentiation between severity or acuity of illness available. The postoperative complications reviewed included venous thromboembolism, pneumonia, acute myocardial infarction, readmission rates, and 30-day mortality rates.

RESULTS

A total of 85,047 patients who underwent elective TJA were included in this study, and 3,516 patients (4.13%) had had a recent positive COVID-19 diagnosis. Patients diagnosed with COVID-19 at 2 weeks prior to TJA were at increased risk of pneumonia (odds ratio [OR], 2.46), acute myocardial infarction (OR, 2.90), sepsis within 90 days (OR, 2.63), and 30-day mortality (OR, 10.61).

CONCLUSIONS

Patients with a recent COVID-19 diagnosis prior to TJA are at greater risk of postoperative complications including 30-day mortality. Our analysis presents critical data that should be considered prior to TJA in patients recently diagnosed with COVID-19.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Long COVID in Uganda: Electrographic findings among patients at risk

Background

COVID-19 has a significant cardiovascular involvement. Electrocardiographic (ECG) abnormalities among people at a risk of Long COVID in Uganda was investigated.

Methods

A cross-sectional study was conducted from February to June 2022 at the post COVID - 19 clinic in Mulago National Specialized Hospital, Kampala. A standard resting ECG was performed on individuals at least 2 months following acute COVID-19, with a negative SARS-CoV-2 reverse-transcription polymerase chain reaction. Sociodemographic and clinical characteristics as well as vital signs were recorded for all study participants.

Results

Of the 244 study participants, 117 (47.9%) were female. The median age of all the participants was 33.0 (interquartile range: 26.0 - 43.5) years. Twenty-five (10.2%) participants had a history of smoking while 117 (48%) had a history of alcohol intake. In total, 46 (18.9%) had abnormal ECG findings (95% Confidence Interval (CI): 14.39 - 24.29) and non-specific T-wave inversion (n = 16, 34%) was the most frequent ECG abnormality. The proportion of participants with ECG abnormalities was 48% lower among females (adjusted prevalence ratio (aPR): 0.52, 95% CI: 0.28 - 0.96, p value < 0.05) and 2-fold greater for those with a history of smoking (aPR: 2.03, 95% CI:1.096 - 3.776, p value < 0.05).

Conclusion

One in five Ugandans who were checked at the clinic at a risk of Long COVID showed ECG abnormalities. ECG screening is suggested to be integrated into the follow-up care of those at a risk of Long COVID.

Beyond Acute COVID-19: A Review of Long-term Cardiovascular Outcomes

Statistics Canada estimated that approximately 1.4 million Canadians suffer from long COVID. Although cardiovascular changes during acute SARS-CoV-2 infection are well documented, long-term cardiovascular sequelae are less understood. In this review, we sought to characterize adult cardiovascular outcomes in the months after acute COVID-19 illness. In our search we identified reports of outcomes including cardiac dysautonomia, myocarditis, ischemic injuries, and ventricular dysfunction. Even in patients without overt cardiac outcomes, subclinical changes have been observed. Cardiovascular sequelae after SARS-CoV-2 infection can stem from exacerbation of preexisting conditions, ongoing inflammation, or as a result of damage that occurred during acute infection. For example, myocardial fibrosis has been reported months after hospital admission for COVID-19 illness, and might be a consequence of myocarditis and myocardial injury during acute disease. In turn, myocardial fibrosis can contribute to further outcomes including dysrhythmias and heart failure. Severity of acute infection might be a risk factor for long-term cardiovascular consequences, however, cardiovascular changes have also been reported in young, healthy individuals who had asymptomatic or mild acute disease. Although evolving evidence suggests that previous SARS-CoV-2 infection might be a risk factor for cardiovascular disease, there is heterogeneity in existing evidence, and some studies are marred by measured and unmeasured confounders. Many investigations have also been limited by relatively short follow-up. Future studies should focus on longer term outcomes (beyond 1 year) and identifying the prevalence of outcomes in different populations on the basis of acute and long COVID disease severity.

Prophylactic rivaroxaban in the early post-discharge period reduces the rates of hospitalization for atrial fibrillation and incidence of sudden cardiac death during long-term follow-up in hospitalized COVID-19 survivors

Introduction: While acute Coronavirus disease 2019 (COVID-19) affects the cardiovascular (CV) system according to recent data, an increased CV risk has been reported also during long-term follow-up (FU). In addition to other CV pathologies in COVID-19 survivors, an enhanced risk for arrhythmic events and sudden cardiac death (SCD) has been observed. While recommendations on post-discharge thromboprophylaxis are conflicting in this population, prophylactic short-term rivaroxaban therapy after hospital discharge showed promising results. However, the impact of this regimen on the incidence of cardiac arrhythmias has not been evaluated to date. Methods: To investigate the efficacy of this therapy, we conducted a single center, retrospective analysis of 1804 consecutive, hospitalized COVID-19 survivors between April and December 2020. Patients received either a 30-day post-discharge thromboprophylaxis treatment regimen using rivaroxaban 10 mg every day (QD) (Rivaroxaban group (Riva); n = 996) or no thromboprophylaxis (Control group (Ctrl); n = 808). Hospitalization for new atrial fibrillation (AF), new higher-degree Atrioventricular-block (AVB) as well as incidence of SCD were investigated in 12-month FU [FU: 347 (310/449) days]. Results: No differences in baseline characteristics (Ctrl vs Riva: age: 59.0 (48.9/66.8) vs 57 (46.5/64.9) years, p = n.s.; male: 41.5% vs 43.7%, p = n.s.) and in the history of relevant CV-disease were observed between the two groups. While hospitalizations for AVB were not reported in either group, relevant rates of hospitalizations for new AF (0.99%, n = 8/808) as well as a high rate of SCD events (2.35%, n = 19/808) were seen in the Ctrl. These cardiac events were attenuated by early post-discharge prophylactic rivaroxaban therapy (AF: n = 2/996, 0.20%, p = 0.026 and SCD: n = 3/996, 0.30%, p < 0.001) which was also observed after applying a logistic regression model for propensity score matching (AF: χ ²-statistics = 6.45, p = 0.013 and SCD: χ ²-statistics = 9.33, p = 0.002). Of note, no major bleeding complications were observed in either group. Conclusion: Atrial arrhythmic and SCD events are present during the first 12 months after hospitalization for COVID-19. Extended prophylactic Rivaroxaban therapy after hospital discharge could reduce new onset of AF and SCD in hospitalized COVID-19 survivors.

Multimodality Cardiac Imaging in COVID

Infection with SARS-CoV-2, the virus that causes COVID, is associated with numerous potential secondary complications. Global efforts have been dedicated to understanding the myriad potential cardiovascular sequelae which may occur during acute infection, convalescence, or recovery. Because patients often present with nonspecific symptoms and laboratory findings, cardiac imaging has emerged as an important tool for the discrimination of pulmonary and cardiovascular complications of this disease. The clinician investigating a potential COVID-related complication must account not only for the relative utility of various cardiac imaging modalities but also for the risk of infectious exposure to staff and other patients. Extraordinary clinical and scholarly efforts have brought the international medical community closer to a consensus on the appropriate indications for diagnostic cardiac imaging during this protracted pandemic. In this review, we summarize the existing literature and reference major societal guidelines to provide an overview of the indications and utility of echocardiography, nuclear imaging, cardiac computed tomography, and cardiac magnetic resonance imaging for the diagnosis of cardiovascular complications of COVID.

Association of Lung Fibrotic Changes and Cardiological Dysfunction with Comorbidities in Long COVID-19 Cohort

Background. Long COVID-19 symptoms appeared in many COVID-19 survivors. However, the prevalence and symptoms associated with long COVID-19 and its comorbidities have not been established. Methods. In total, 312 patients with long COVID-19 from 21 primary care centers were included in the study. At the six-month follow-up, their lung function was assessed by computerized tomography (CT) and spirometry, whereas cardiac function was assessed by elec-trocardiogram (ECG), Holter ECG, echocardiography, 24 h blood pressure monitoring, and a six-minute walk test (6MWT). Results. Of the 312 persons investigated, significantly higher sys-tolic and diastolic blood pressure, left ventricular hypertrophy, and elevated NT-proBNP were revealed in participants with hypertension or type 2 diabetes. Left ventricular diastolic dysfunc-tion was more frequently present in patients with hypertension. The most common registered CT abnormalities were fibrotic changes (83, 36.6%) and mediastinal lymphadenopathy (23, 10.1%). Among the tested biochemical parameters, three associations were found in long COVID-19 patients with hypertension but not diabetes: increased hemoglobin, fibrinogen, and ferritin. Nine patients had persisting IgM antibodies to SARS-CoV-2. Conclusions. We demon-strated a strong association between signs of cardiac dysfunction and lung fibrotic changes with comorbidities in a cohort of long COVID-19 subjects.

A systematic review and meta-analysis of long term physical and mental sequelae of COVID-19 pandemic: call for research priority and action

The long-term physical and mental sequelae of COVID-19 are a growing public health concern, yet there is considerable uncertainty about their prevalence, persistence and predictors. We conducted a comprehensive, up-to-date meta-analysis of survivors' health consequences and sequelae for COVID-19. PubMed, Embase and the Cochrane Library were searched through Sep 30th, 2021. Observational studies that reported the prevalence of sequelae of COVID-19 were included. Two reviewers independently undertook the data extraction and quality assessment. Of the 36,625 records identified, a total of 151 studies were included involving 1,285,407 participants from thirty-two countries. At least one sequelae symptom occurred in 50.1% (95% CI 45.4-54.8) of COVID-19 survivors for up to 12 months after infection. The most common investigation findings included abnormalities on lung CT (56.9%, 95% CI 46.2-67.3) and abnormal pulmonary function tests (45.6%, 95% CI 36.3-55.0), followed by generalized symptoms, such as fatigue (28.7%, 95% CI 21.0-37.0), psychiatric symptoms (19.7%, 95% CI 16.1-23.6) mainly depression (18.3%, 95% CI 13.3-23.8) and PTSD (17.9%, 95% CI 11.6-25.3), and neurological symptoms (18.7%, 95% CI 16.2-21.4), such as cognitive deficits (19.7%, 95% CI 8.8-33.4) and memory impairment (17.5%, 95% CI 8.1-29.6). Subgroup analysis showed that participants with a higher risk of long-term sequelae were older, mostly male, living in a high-income country, with more severe status at acute infection. Individuals with severe infection suffered more from PTSD, sleep disturbance, cognitive deficits, concentration impairment, and gustatory dysfunction. Survivors with mild infection had high burden of anxiety and memory impairment after recovery. Our findings suggest that after recovery from acute COVID-19, half of survivors still have a high burden of either physical or mental sequelae up to at least 12 months. It is important to provide urgent and appropriate prevention and intervention management to preclude persistent or emerging long-term sequelae and to promote the physical and psychiatric wellbeing of COVID-19 survivors.

Cardiac Phenotyping of SARS-CoV-2 in British Columbia: A Prospective Echo Study With Strain Imaging

BACKGROUND

There is limited data on the residual echocardiographic findings including strain analysis among post-coronavirus disease (COVID) patients. The aim of our study is to prospectively phenotype post-COVID patients.

METHODS

All patients discharged following acute COVID infection were systematically followed in the post-COVID-19 Recovery Clinic at Vancouver General Hospital and St. Paul's Hospital. At 4-18 weeks post diagnosis, patients underwent comprehensive echocardiographic assessment. Left ventricular ejection fraction (LVEF) was assessed by 3D, 2D Biplane Simpson's, or visual estimate. LV global longitudinal strain (GLS) was measured using a vendor-independent 2D speckle-tracking software (TomTec).

RESULTS

A total of 127 patients (53% female, mean age 58 years) were included in our analyses. At baseline, cardiac conditions were present in 58% of the patients (15% coronary artery disease, 4% heart failure, 44% hypertension, 10% atrial fibrillation) while the remainder were free of cardiac conditions. COVID-19 serious complications were present in 79% of the patients (76% pneumonia, 37% intensive care unit admission, 21% intubation, 1% myocarditis). Normal LVEF was seen in 96% of the cohort and 97% had normal right ventricular systolic function. A high proportion (53%) had abnormal LV GLS defined as < 18%. Average LV GLS of septal and inferior segments were lower compared to that of other segments. Among patients without pre-existing cardiac conditions, LVEF was abnormal in only 1.9%, but LV GLS was abnormal in 46% of the patients.

CONCLUSIONS

Most post-COVID patients had normal LVEF at 4-18 weeks post diagnosis, but over half had abnormal LV GLS.

Cardiac Manifestations of Post-Acute COVID-19 Infection

PURPOSE OF REVIEW

There is emerging evidence that the post-acute and chronic phases of COVID-19 infection are associated with various significant cardiovascular sequelae.

RECENT FINDINGS

Long COVID has been shown to be associated with multiple cardiovascular sequelae including direct myocardial injury, arrhythmias, and cardiomyopathies. Hypotheses on the mechanism of myocardial injury include direct viral infiltration and autoimmune dysregulation. Long COVID is associated with persistent cardiac ischemia in patients with no previous history of coronary disease, atrial and ventricular arrhythmias, and the development of new-onset heart failure in previously healthy patients. Onset of long COVID may be related to severity of the initial SARS-CoV2 infection. Cardiac MRI is a valuable tool in assessing myocarditis and the development of cardiomyopathies in the setting of long COVID. Both patients with and without pre-existing cardiovascular disease are at risk of developing myocardial injury in the setting of long COVID. Future studies will elucidate both cardiovascular mortality and cardiac rehabilitation in the post-acute and chronic phases of COVID-19.

Cardiovascular complications of COVID-19 severe acute respiratory syndrome

603,711,760 confirmed cases of COVID-19 have been reported throughout the world and 6,484,136 individuals have died from complications of COVID-19 as of September 7, 2022. Significantly, the Omicron variant has produced the largest number of COVID-19 associated hospitalizations since the beginning of the pandemic. Cardiac injury occurs in ≥20% of the hospitalized patients with COVID-19 and is associated with cardiac dysrhythmias in 17 to 44%, cardiac injury with increases in blood troponin in 22 to 40%, myocarditis in 2 to 7%, heart failure in 4 to 21%, and thromboembolic events in 15 to 39%. Risk factors for cardiac complications include age >70 years, male sex, BMI ≥30 kg/m², diabetes, pre-existing cardiovascular disease, and moderate to severe pneumonia at hospital presentation. Patients with prior cardiovascular disease who contract COVID-19 and experience a significant increase in their blood troponin concentration are at risk for mortality rates as high as 69%. This review focuses on the prevalence, the pathophysiologic mechanisms of CoV-2 injury to the cardiovascular system and the current recommended treatments in hospitalized patients with COVID-19 in order that medical personnel can decrease the morbidity and mortality of patients with COVID-19 and effectively treat patients with Covid and post Covid syndrome.

Post-acute cardiac complications following SARS-CoV-2 infection in partial lipodystrophy due to LMNA gene p.R349W mutation

PURPOSE

SARS-CoV-2 infection may cause varying degrees of cardiac injury and the presence of underlying cardiovascular morbidities contributes to the frequency and severity of occurrence of this complication. Lipodystrophy syndromes are frequently characterized by severe metabolic derangements that represent relevant cardiovascular risk factors. Besides causing lipodystrophy, mutations in the lamin A/C (LMNA) gene can lead to a wide spectrum of tissue-specific disorders including cardiac involvement.

METHODS AND RESULTS

We herein examine the case of two patients affected by atypical progeroid syndrome and partial lipodystrophy due to a heterozygous missense LMNA mutation c.1045 C > T (p.R349W) who presented initially with mild COVID-19 and developed severe cardiovascular complications within few weeks of SARS-CoV-2 infection. Before being infected with SARS-CoV-2, our patients had cardiovascular morbidities (mild mitral regurgitation in one patient, ischemic heart disease with bifascicular block in the other patient) in adjunct to cardiovascular risk factors, but the SARS-CoV-2 infection contributed to quickly and significantly decompensate their balance.

CONCLUSION

These findings warn that patients affected by LMNA p.R349W mutation and likely other LMNA mutations associated with cardiovascular morbidity should be considered at extremely elevated risk of post-acute cardiological manifestations and should therefore undergo a vigilant follow-up after SARS-CoV-2 infection. Both patients developed COVID-19 before the specific vaccination was available to them and this unfortunate situation should remark the importance of vaccination coverage against SARS-CoV-2 infection for all patients affected by lipodystrophy, especially those with underlying comorbidities.

Bebtelovimab-Induced Bradycardia Leading to Cardiac Arrest

Bebtelovimab is a monoclonal antibody used to prevent progression of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Complications of SARS-CoV-2 infection can include cardiac effects including sinus bradycardia.

COVID-19 and cardiovascular disease: manifestations, pathophysiology, vaccination, and long-term implication

The coronavirus disease 2019 (COVID-19) pandemic is caused by a new coronavirus family member, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is linked with many disease manifestations in multiple organ systems on top of pulmonary manifestations. COVID-19 is also accompanied by several cardiovascular pathologies including myocarditis, acute myocardial infarction, stress cardiomyopathy, arterial and venous thromboembolism, pericarditis, and arrhythmias. The pathophysiological mechanisms explaining these clinical symptoms are multifactorial including systemic inflammation (cytokine storm), coagulopathy, direct viral invasion through angiotensin-converting enzyme 2, hypoxemia, electrolyte imbalance, and fever. Several case reports have shown the development of an unusual cardiovascular event after receiving SARS-CoV-2 vaccines. The current article aimed to review cardiovascular involvement in the COVID-19 pandemic with respect to clinical features, pathogenesis, long-term effects, and the adverse effects of treatments and vaccines based on the latest evidence.

Occurrence of Relative Bradycardia and Relative Tachycardia in Individuals Diagnosed With COVID-19

The COVID-19 disease caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has become one of the worst global pandemics of the century. Wearable devices are well suited for continuously measuring heart rate. Here we show that the Resting Heart Rate is modified for several weeks following a COVID-19 infection. The Resting Heart Rate shows 3 phases: 1) elevated during symptom onset, with average peak increases relative to the baseline of 1.8% (3.4%) for females (males), 2) decrease thereafter, reaching a minimum on average ≈13 days after symptom onset, and 3) subsequent increase, reaching a second peak on average ≈28 days from symptom onset, before falling back to the baseline ≈112 days from symptom onset. All estimates vary with disease severity¹.

Cardiovascular manifestations secondary to COVID-19: A narrative review

The coronavirus disease 2019 (COVID-19) pandemic has spread rapidly, becoming a major threat to global health. In addition to having required the adaptation of healthcare workers for almost 2 years, it has been much talked about, both in the media and among the scientific community. Beyond lung damage and respiratory symptoms, the involvement of the cardiovascular system largely explains COVID-19 morbimortality. In this review, we emphasize that cardiovascular involvement is common and is associated with a worse prognosis, and that earlier detection by physicians should lead to better management. First, direct cardiac involvement will be discussed, in the form of COVID-19 myocarditis, then secondary cardiac involvement, such as myocardial injury, myocardial infarction and arrhythmias, will be considered. Finally, worsening of previous cardiovascular disease as a result of COVID-19 will be examined, as well as long-term COVID-19 effects and cardiovascular complications of COVID-19 vaccines.

Role of antibodies, inflammatory markers, and echocardiographic findings in post-acute cardiopulmonary symptoms after SARS-CoV-2 infection

Shortness of breath, chest pain, and palpitations occur as postacute sequelae of COVID-19, but whether symptoms are associated with echocardiographic abnormalities, cardiac biomarkers, or markers of systemic inflammation remains unknown. In a cross-sectional analysis, we assessed symptoms, performed echocardiograms, and measured biomarkers among adults more than 8 weeks after confirmed SARS-CoV-2 infection. We modeled associations between symptoms and baseline characteristics, echocardiographic findings, and biomarkers using logistic regression. We enrolled 102 participants at a median of 7.2 months following COVID-19 onset; 47 individuals reported dyspnea, chest pain, or palpitations. Median age was 52 years, and 41% of participants were women. Female sex, hospitalization, IgG antibody against SARS-CoV-2 receptor binding domain, and C-reactive protein were associated with symptoms. Regarding echocardiographic findings, 4 of 47 participants (9%) with symptoms had pericardial effusions compared with 0 of 55 participants without symptoms; those with effusions had a median of 4 symptoms compared with a median of 1 symptom in those without effusions. There was no strong evidence for a relationship between symptoms and echocardiographic functional parameters or other biomarkers. Among adults more than 8 weeks after SARS-CoV-2 infection, SARS-CoV-2 RBD antibodies, markers of inflammation, and, possibly, pericardial effusions are associated with cardiopulmonary symptoms. Investigation into inflammation as a mechanism underlying postacute sequelae of COVID-19 is warranted.

Attention-based 3D CNN with residual connections for efficient ECG-based COVID-19 detection

BACKGROUND

The world has been suffering from the COVID-19 pandemic since 2019. More than 5 million people have died. Pneumonia is caused by the COVID-19 virus, which can be diagnosed using chest X-ray and computed tomography (CT) scans. COVID-19 also causes clinical and subclinical cardiovascular injury that may be detected on electrocardiography (ECG), which is easily accessible.

METHOD

For ECG-based COVID-19 detection, we developed a novel attention-based 3D convolutional neural network (CNN) model with residual connections (RC). In this paper, the deep learning (DL) approach was developed using 12-lead ECG printouts obtained from 250 normal subjects, 250 patients with COVID-19 and 250 with abnormal heartbeat. For binary classification, the COVID-19 and normal classes were considered; and for multiclass classification, all classes. The ECGs were preprocessed into standard ECG lead segments that were channeled into 12-dimensional volumes as input to the network model. Our developed model comprised of 19 layers with three 3D convolutional, three batch normalization, three rectified linear unit, two dropouts, two additional (for residual connections), one attention, and one fully connected layer. The RC were used to improve gradient flow through the developed network, and attention layer, to connect the second residual connection to the fully connected layer through the batch normalization layer.

RESULTS

A publicly available dataset was used in this work. We obtained average accuracies of 99.0% and 92.0% for binary and multiclass classifications, respectively, using ten-fold cross-validation. Our proposed model is ready to be tested with a huge ECG database.

The Potential Impact of COVID-19 Virus on the Heart and the Circulatory System

Heart attacks, arrhythmias, and cardiomyopathy are all linked to the 2019 coronavirus disease (COVID-19), which has been identified as a risk factor for cardiovascular disease. Nothing can be held accountable in the current state of affairs. Undiagnosed chronic systolic heart failure (CSHF) develops when the heart’s second half of the cardiac cycle does not function properly. As a result, the heart’s blood pumping function is interrupted. Stress-induced cardiomyopathy may be caused by a variety of factors inside the body (SICM). Cytokine storm and microvascular dysfunction are among the issues. There is inflammation in the heart muscle, which may lead to stress-induced cardiomyopathy. A major part of our study is going to be devoted to understanding the effects of coronavirus on the cardiovascular system and blood vessels. A lot of time and effort has been put into figuring out the health effects of radiation exposure. The heart and circulatory system are shown to be affected by the coronavirus in this research. COVID-19 is shown to influence persons with heart disease, heart failure, arrhythmias, microvascular angiopathy, and cardiac damage in this study.

Long COVID: post-acute sequelae of COVID-19 with a cardiovascular focus

Emerging as a new epidemic, long COVID or post-acute sequelae of coronavirus disease 2019 (COVID-19), a condition characterized by the persistence of COVID-19 symptoms beyond 3 months, is anticipated to substantially alter the lives of millions of people globally. Cardiopulmonary symptoms including chest pain, shortness of breath, fatigue, and autonomic manifestations such as postural orthostatic tachycardia are common and associated with significant disability, heightened anxiety, and public awareness. A range of cardiovascular (CV) abnormalities has been reported among patients beyond the acute phase and include myocardial inflammation, myocardial infarction, right ventricular dysfunction, and arrhythmias. Pathophysiological mechanisms for delayed complications are still poorly understood, with a dissociation seen between ongoing symptoms and objective measures of cardiopulmonary health. COVID-19 is anticipated to alter the long-term trajectory of many chronic cardiac diseases which are abundant in those at risk of severe disease. In this review, we discuss the definition of long COVID and its epidemiology, with an emphasis on cardiopulmonary symptoms. We further review the pathophysiological mechanisms underlying acute and chronic CV injury, the range of post-acute CV sequelae, and impact of COVID-19 on multiorgan health. We propose a possible model for referral of post-COVID-19 patients to cardiac services and discuss future directions including research priorities and clinical trials that are currently underway to evaluate the efficacy of treatment strategies for long COVID and associated CV sequelae.

Cardiac biomarkers alterations in patients with SARS-CoV-2 infection

Reliable biomarkers are necessary for the risk stratification of patients infected with SARS-CoV-2. This novel coronavirus is now established to affect several organs in addition to the lungs, most prominently the heart. This is achieved through direct damage to the myocardium and indirect immune-associated effects during the cytokine storm. We performed a literature review aiming to identify the prognostic value of alterations of cardiac biomarkers in SARS-CoV-2 infection. Cardiac biomarkers are significantly elevated in patients with severe COVID-19 and are independent predictors of mortality. High-sensitivity troponin I and T are correlated with multiple inflammatory indexes and poor outcomes. Although cut-off values have been established for most of cardiac biomarkers, lower limits for troponins may have better prognostic values and longitudinal monitoring of cardiac biomarkers can help the clinician assess the patient's course. Additional measurements of NT-proBNP, can detect the subgroup of patients with poor prognosis.

Emerging Role of Platelet-Endothelium Interactions in the Pathogenesis of Severe SARS-CoV-2 Infection-Associated Myocardial Injury

Cardiovascular dysfunction and disease are common and frequently fatal complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Indeed, from early on during the SARS-CoV-2 virus pandemic it was recognized that cardiac complications may occur, even in patients with no underlying cardiac disorders, as part of the acute infection, and that these were associated with more severe disease and increased morbidity and mortality. The most common cardiac complication is acute cardiac injury, defined by significant elevation of cardiac troponins. The potential mechanisms of cardiovascular complications include direct viral myocardial injury, systemic inflammation induced by the virus, sepsis, arrhythmia, myocardial oxygen supply-demand mismatch, electrolyte abnormalities, and hypercoagulability. This review is focused on the prevalence, risk factors and clinical course of COVID-19-related myocardial injury, as well as on current data with regard to disease pathogenesis, specifically the interaction of platelets with the vascular endothelium. The latter section includes consideration of the role of SARS-CoV-2 proteins in triggering development of a generalized endotheliitis that, in turn, drives intense activation of platelets. Most prominently, SARS-CoV-2–induced endotheliitis involves interaction of the viral spike protein with endothelial angiotensin-converting enzyme 2 (ACE2) together with alternative mechanisms that involve the nucleocapsid and viroporin. In addition, the mechanisms by which activated platelets intensify endothelial activation and dysfunction, seemingly driven by release of the platelet-derived calcium-binding proteins, SA100A8 and SA100A9, are described. These events create a SARS-CoV-2–driven cycle of intravascular inflammation and coagulation, which contributes significantly to a poor clinical outcome in patients with severe disease.

Predictors of Prolonged Cardiopulmonary Exercise Impairment After COVID-19 Infection: A Prospective Observational Study

Objectives: Coronavirus disease 2019 (COVID-19) is a global pandemic affecting individuals to varying degrees. There is emerging evidence that even patients with mild symptoms will suffer from prolonged physical impairment. Methods: In this prospective observational study, lung function, and cardiopulmonary exercise testing have been performed in 100 patients for 3-6 months after COVID-19 diagnosis (post-CoVG). Depending on the severity of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection, patients were divided into asymptomatic, or mild to moderate (mild post-CoVG), and severe post-CoVG [hospitalization with or without intensive care unit/non-invasive ventilation (ICU/NIV)]. Results have been compared with age, sex, and body mass index (BMI) matched control group (CG, N = 50). Results: Both lung function (resting) and exercise capacity (peak workload, Wpeak and peak oxygen uptake, VO₂ peak - % predicted) were considerably affected in patients with severe post-CoV (81.7 ± 27.6 and 86.1 ± 20.6%), compared to the mild post-CoVG (104.8 ± 24.0%, p = 0.001 and 100.4 ± 24.8; p = 0.003). In addition, also the submaximal exercise performance was significantly reduced in the severe post-CoVG (predicted VT1/VO₂ peak; p = 0.013 and VT2/VO₂ peak; p = 0.001). Multiple linear regression analyses revealed that 74 % (adjusted R ²) of the variance in relative VO₂ peak of patients who had CoV could be explained by the following variables: lower age, male sex, lower BMI, higher DLCO, higher predicted heart rate (HR) peak, lower breathing reserve (BR), and lower SaO₂ peak, which were related to higher relative VO₂ peak values. Higher NT-proBNP and lower creatinine kinase (CK) values were seen in severe cases compared to patients who experienced mild CoV. Discussion: Maximal and submaximal exercise performance in patients recovering from severe COVID-19 remain negatively affected for 3-6 months after COVID-19 diagnosis. The presented findings reveal that impaired pulmonary, cardiac, and skeletal muscle function contributed to the limitation of VO₂ peak in those patients, which may have important implications on rehabilitation programs.

Care management and 90-day post discharge mortality in patients hospitalized for myocardial infarction and COVID-19: A French nationwide observational study

BACKGROUND

Concomitant or cured coronavirus disease 2019 (COVID-19) in patients with myocardial infarction (MI) may lead to difficulties in acute care management and impair prognosis.

AIMS

To describe and compare the characteristics, care management and 90-day post discharge outcomes of patients hospitalized for MI who did not have COVID-19 with those of patients with concomitant or previous hospital-diagnosed COVID-19.

METHODS

This population-based French study included all patients hospitalized for MI in France (30 December 2019 to 04 October 2020) from the French National Health Data System. Outcomes were described for each COVID-19 group and compared using adjusted logistic regression analysis.

RESULTS

Among 55,524 patients hospitalized for MI, 135 had previous hospital-diagnosed COVID-19 and 329 had concomitant COVID-19. Patients with previous hospital-diagnosed COVID-19 had more personal history of cardiovascular diseases than those without concomitant/previous confirmed COVID-19. In-hospital and 90-day post discharge mortality rates of patients with previous COVID-19 were 8.1% and 4.0%, respectively, compared with 3.5% and 3.0% in patients without concomitant/previous confirmed COVID-19 (odds ratio [OR]_{adjin-hospital} 1.83, 95% confidence interval [CI] 0.97-3.46; OR_{adjpostdischarge} 0.77, 95% CI 0.28-2.13). Patients with concomitant COVID-19 had more personal history of cardiovascular diseases, but also a poorer prognosis than their no concomitant/no previous confirmed COVID-19 counterparts; they presented excess cardiac complications during hospitalization (OR_adj 1.62, 95% CI 1.29-2.04), in-hospital mortality (OR_adj 3.31, 95% CI 2.32-4.72) and 90-day post discharge mortality (OR_adj 2.09, 95% CI 1.24-3.51).

CONCLUSIONS

In-hospital and 90-day post discharge mortality of patients hospitalized for MI who had previous hospital-diagnosed COVID-19 did not seem to differ from those hospitalized for MI alone. Conversely, concomitant COVID-19 and MI carried a poorer prognosis extending beyond the hospital stay. Special attention should be given to patients with simultaneous COVID-19 and MI, in terms of acute care and secondary prevention.

Sex-Related Factors in Cardiovascular Complications Associated to COVID-19

Coronavirus disease 2019 (COVID-19), the pandemic infection caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), presents with an extremely heterogeneous spectrum of symptoms and signs. The clinical manifestations seem to be correlated with disease severity. COVID-19 susceptibility and mortality show a significant sex imbalance, with men being more prone to infection and showing a higher rate of hospitalization and mortality compared to women. Such variability can be ascribed to both sex-related biological factors and gender-related behavioral cues. This review will discuss the potential mechanisms accounting for sex/gender influence in vulnerability to COVID-19. Cardiovascular diseases play a central role in determining COVID-19 outcome, whether they are pre-existent or arose upon infection. We will pay particular attention to the impact of sex and gender on cardiovascular manifestations related to COVID-19. Finally, we will discuss the sex-dependent variability in some biomarkers for the evaluation of COVID-19 infection and prognosis. The aim of this work is to highlight the significance of gendered medicine in setting up personalized programs for COVID-19 prevention, clinical evaluation and treatment.

Normalized Cardiac Structure and Function in COVID-19 Survivors Late After Recovery

Background: Coronavirus disease 2019 can result in myocardial injury in the acute phase. However, information on the late cardiac consequences of coronavirus disease 2019 (COVID-19) is limited. Methods: We conducted a prospective observational cohort study to investigate the late cardiac consequences of COVID-19. Standard echocardiography and myocardial strain assessment were performed, and cardiac blood biomarkers were tested in 86 COVID-19 survivors 327 days (IQR 318-337 days) after recovery. Comparisons were made with 28 age-matched and sex-matched healthy controls and 30 risk factor-matched patients. Results: There were no significant differences in all echocardiographic structural and functional parameters, including left ventricular (LV) global longitudinal strain, right ventricular (RV) longitudinal strain, LV end-diastolic volume, RV dimension, and the ratio of peak early velocity in mitral inflow to peak early diastolic velocity in the septal mitral annulus (E/e') among COVID-19 survivors, healthy controls and risk factor-matched controls. Even 26 patients with myocardial injury at admission did not have any echocardiographic structural and functional abnormalities. There were no significant differences among the three groups with respect to serum concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin I (cTnI). Conclusion: This study showed that COVID-19 survivors, including those with myocardial injury at admission and those with severe and critical types of illness, do not have any echocardiographic evidence of cardiac structural and functional abnormalities 327 days after diagnosis.

Implementation of a practice plan for the outpatient cardiac evaluation of children after acute SARS-CoV-2 infection and a report of outcomes

SARS-CoV-2 infection has been associated with cardiovascular disease in children, but which children need cardiac evaluation is unclear. We describe our experience evaluating 206 children for cardiac disease following SARS-CoV-2 infection (one of whom had ventricular ectopy) and propose a new guideline for management of these children. Routine cardiac screening after SARS-CoV-2 infection in children without any cardiac signs or symptoms does not appear to be high yield.

Prevalence of abnormal cardiovascular magnetic resonance findings in recovered patients from COVID-19: a systematic review and meta-analysis

BACKGROUND

The prevalence of abnormal cardiovascular magnetic resonance (CMR) findings in recovered coronavirus disease 2019 (COVID-19) patients is unclear. This study aimed to investigate the prevalence of abnormal CMR findings in recovered COVID-19 patients.

METHODS

A systematic literature search was performed to identify studies that report the prevalence of abnormal CMR findings in recovered COVID-19 patients. The number of patients with abnormal CMR findings and diagnosis of myocarditis on CMR (based on the Lake Louise criteria) and each abnormal CMR parameter were extracted. Subgroup analyses were performed according to patient characteristics (athletes vs. non-athletes and normal vs. undetermined cardiac enzyme levels). The pooled prevalence and 95% confidence interval (CI) of each CMR finding were calculated. Study heterogeneity was assessed, and meta-regression analysis was performed to investigate factors associated with heterogeneity.

RESULTS

In total, 890 patients from 16 studies were included in the analysis. The pooled prevalence of one or more abnormal CMR findings in recovered COVID-19 patients was 46.4% (95% CI 43.2%-49.7%). The pooled prevalence of myocarditis and late gadolinium enhancement (LGE) was 14.0% (95% CI 11.6%-16.8%) and 20.5% (95% CI 17.7%-23.6%), respectively. Further, heterogeneity was observed (I2 > 50%, p < 0.1). In the subgroup analysis, the pooled prevalence of abnormal CMR findings and myocarditis was higher in non-athletes than in athletes (62.5% vs. 17.1% and 23.9% vs. 2.5%, respectively). Similarly, the pooled prevalence of abnormal CMR findings and LGE was higher in the undetermined than in the normal cardiac enzyme level subgroup (59.4% vs. 35.9% and 45.5% vs. 8.3%, respectively). Being an athlete was a significant independent factor related to heterogeneity in multivariate meta-regression analysis (p < 0.05).

CONCLUSIONS

Nearly half of recovered COVID-19 patients exhibited one or more abnormal CMR findings. Athletes and patients with normal cardiac enzyme levels showed a lower prevalence of abnormal CMR findings than non-athletes and patients with undetermined cardiac enzyme levels. Trial registration The study protocol was registered in the PROSPERO database (registration number: CRD42020225234).

Echocardiography, lung ultrasound, and cardiac magnetic resonance findings in COVID-19: A systematic review

BACKGROUND

The manifestations of COVID-19 as outlined by imaging modalities such as echocardiography, lung ultrasound (LUS), and cardiac magnetic resonance (CMR) imaging are not fully described.

METHODS

We conducted a systematic review of the current literature and included studies that described cardiovascular manifestations of COVID-19 using echocardiography, CMR, and pulmonary manifestations using LUS. We queried PubMed, EMBASE, and Web of Science for relevant articles. Original studies and case series were included.

RESULTS

This review describes the most common abnormalities encountered on echocardiography, LUS, and CMR in patients infected with COVID-19.

COVID-19 induced bradyarrhythmia and relative bradycardia: An overview

Novel coronavirus 2019 (COVID-19) has been the focus of the medical community since its emergence in December 2019 and has already infected more than 100 million patients globally. Primarily described to cause a respiratory illness, COVID-19 has been found to affect almost every organ system. Bradycardia is a newly recognized ramification of COVID-19 that still has unknown prognostic value. Studies have shown an increase in the incidence of arrhythmias, cardiomyopathies, myocarditis, acute coronary syndromes, and coagulopathies in infected patients as well as an increased risk of mortality in patients with preexisting cardiovascular disease. While the pathogenesis of bradycardia in COVID-19 may be multifactorial, clinicians should be aware of the mechanism by which COVID-19 affects the cardiovascular system and the medication side effects which are used in the treatment algorithm of this deadly virus. There has yet to be a comprehensive review analyzing bradyarrhythmia and relative bradycardia in COVID-19 infected patients. We aim to provide a literature review including the epidemiology, pathogenesis, and management of COVID-19 induced bradyarrhythmia.

Cardiac Magnetic Resonance Imaging Findings in 2954 COVID-19 Adult Survivors: A Comprehensive Systematic Review

Background

Recent studies have utilized MRI to determine the extent to which COVID‐19 survivors may experience cardiac sequels after recovery.

Purpose

To systematically review the main cardiac MRI findings in COVID‐19 adult survivors.

Study type

Systematic review.

Subjects

A total of 2954 COVID‐19 adult survivors from 16 studies.

Field Strength/sequence

Late gadolinium enhancement (LGE), parametric mapping (T1‐native, T2, T1‐post (extracellular volume fraction [ECV]), T2‐weighted sequences (myocardium/pericardium), at 1.5 T and 3  T.

Assessment

A systematic search was performed on PubMed, Embase, and Google scholar databases using Boolean operators and the relevant key terms covering COVID‐19, cardiac injury, CMR, and follow‐up. MRI data, including (if available) T1, T2, extra cellular volume, presence of myocardial or pericardial late gadolinium enhancement (LGE) and left and right ventricular ejection fraction were extracted.

Statistical Tests

The main results of the included studies are summarized. No additional statistical analysis was performed.

Results

Of 1601 articles retrieved from the initial search, 12 cohorts and 10 case series met our eligibility criteria. The rate of raised T1 in COVID‐19 adult survivors varied across studies from 0% to 73%. Raised T2 was detected in none of patients in 4 out of 15 studies, and in the remaining studies, its rate ranged from 2% to 60%. In most studies, LGE (myocardial or pericardial) was observed in COVID‐19 survivors, the rate ranging from 4% to 100%. Myocardial LGE mainly had nonischemic patterns. None of the cohort studies observed myocardial LGE in “healthy” controls. Most studies found that patients who recovered from COVID‐19 had a significantly greater T1 and T2 compared to participants in the corresponding control group.

Data Conclusion

Findings of MRI studies suggest the presence of myocardial and pericardial involvement in a notable number of patients recovered from COVID‐19.

Level of Evidence

3

Technical Efficacy Stage

3

Classification of COVID-19 electrocardiograms by using hexaxial feature mapping and deep learning

BACKGROUND

Coronavirus disease 2019 (COVID-19) has become a pandemic since its first appearance in late 2019. Deaths caused by COVID-19 are still increasing day by day and early diagnosis has become crucial. Since current diagnostic methods have many disadvantages, new investigations are needed to improve the performance of diagnosis.

METHODS

A novel method is proposed to automatically diagnose COVID-19 by using Electrocardiogram (ECG) data with deep learning for the first time. Moreover, a new and effective method called hexaxial feature mapping is proposed to represent 12-lead ECG to 2D colorful images. Gray-Level Co-Occurrence Matrix (GLCM) method is used to extract features and generate hexaxial mapping images. These generated images are then fed into a new Convolutional Neural Network (CNN) architecture to diagnose COVID-19.

RESULTS

Two different classification scenarios are conducted on a publicly available paper-based ECG image dataset to reveal the diagnostic capability and performance of the proposed approach. In the first scenario, ECG data labeled as COVID-19 and No-Findings (normal) are classified to evaluate COVID-19 classification ability. According to results, the proposed approach provides encouraging COVID-19 detection performance with an accuracy of 96.20% and F1-Score of 96.30%. In the second scenario, ECG data labeled as Negative (normal, abnormal, and myocardial infarction) and Positive (COVID-19) are classified to evaluate COVID-19 diagnostic ability. The experimental results demonstrated that the proposed approach provides satisfactory COVID-19 prediction performance with an accuracy of 93.00% and F1-Score of 93.20%. Furthermore, different experimental studies are conducted to evaluate the robustness of the proposed approach.

CONCLUSION

Automatic detection of cardiovascular changes caused by COVID-19 can be possible with a deep learning framework through ECG data. This not only proves the presence of cardiovascular changes caused by COVID-19 but also reveals that ECG can potentially be used in the diagnosis of COVID-19. We believe the proposed study may provide a crucial decision-making system for healthcare professionals.

SOURCE CODE

All source codes are made publicly available at: https://github.com/mkfzdmr/COVID-19-ECG-Classification.

Return to High Altitude After Recovery from Coronavirus Disease 2019

Luks, Andrew M. and Colin K. Grissom. Return to high altitude after recovery from coronavirus disease 2019. High Alt Med Biol. 22: 119-127, 2021.-With the increasing availability of coronavirus disease 2019 (COVID-19) vaccines and the eventual decline in the burden of the disease, it is anticipated that all forms of tourism, including travel to high altitude, will rebound in the near future. Given the physiologic challenges posed by hypobaric hypoxia at high altitude, it is useful to consider whether high-altitude travel will pose risks to those previously infected with severe acute respiratory syndrome coronavirus 2, particularly those with persistent symptoms after resolution of their infection. Although no studies have specifically examined this question as of yet, available data on the cardiopulmonary sequelae of COVID-19 provide some sense of the problems people may face at high altitude and who warrants evaluation before such endeavors. On average, most individuals who have recovered from COVID-19 have normal or near normal gas exchange, pulmonary function testing, cardiovascular function, and exercise capacity, although a subset of individuals have persistent functional deficits in some or all of these domains when examined up to 5 months after infection. Evaluation is warranted before planned high-altitude travel in individuals with persistent symptoms at least 2 weeks after a positive test or hospital discharge as well as in those who required care in an intensive care unit or suffered from myocarditis or arterial or venous thromboembolism. Depending on the results of this testing, planned high-altitude travel may need to be modified or even deferred pending resolution of the identified abnormalities. As more people travel to high altitude after the pandemic and further studies are conducted, additional data should become available to provide further guidance on these issues.