Editorial: Post-COVID-19 cardiovascular sequelae

"When," "Where," and "How" of SARS-CoV-2 Infection Affects the Human Cardiovascular System: A Narrative Review

Coronavirus disease 2019 (COVID-19) is caused by the novel severe acute respiratory coronavirus-2 (SARS-CoV-2). Several explanations for the development of cardiovascular complications during and after acute COVID-19 infection have been hypothesized. The COVID-19 pandemic, caused by SARS-CoV-2, has emerged as one of the deadliest pandemics in modern history. The myocardial injury in COVID-19 patients has been associated with coronary spasm, microthrombi formation, plaque rupture, hypoxic injury, or cytokine storm, which have the same pathophysiology as the three clinical variants of Kounis syndrome. The angiotensin-converting enzyme 2 (ACE2), reninaldosterone system (RAAS), and kinin-kallikrein system are the main proposed mechanisms contributing to cardiovascular complications with the COVID-19 infection. ACE receptors can be found in the heart, blood vessels, endothelium, lungs, intestines, testes, neurons, and other human body parts. SARS-CoV-2 directly invades the endothelial cells with ACE2 receptors and constitutes the main pathway through which the virus enters the endothelial cells. This causes angiotensin II accumulation downregulation of the ACE2 receptors, resulting in prothrombotic effects, such as hemostatic imbalance via activation of the coagulation cascade, impaired fibrinolysis, thrombin generation, vasoconstriction, endothelial and platelet activation, and pro-inflammatory cytokine release. The KKS system typically causes vasodilation and regulates tissue repair, inflammation, cell proliferation, and platelet aggregation, but SARS-CoV-2 infection impairs such counterbalancing effects. This cascade results in cardiac arrhythmias, cardiac arrest, cardiomyopathy, cytokine storm, heart failure, ischemic myocardial injuries, microvascular disease, Kounis syndrome, prolonged COVID, myocardial fibrosis, myocarditis, new-onset hypertension, pericarditis, postural orthostatic tachycardia syndrome, pulmonary hypertension, stroke, Takotsubo syndrome, venous thromboembolism, and thrombocytopenia. In this narrative review, we describe and elucidate when, where, and how COVID-19 affects the human cardiovascular system in various parts of the human body that are vulnerable in every patient category, including children and athletes.

Prevalence and impact of myocardial injury among patients hospitalized with COVID-19

Background

Myocardial injury is a prevalent complication observed in patients hospitalized with COVID-19 and is strongly associated with severe illness and in-hospital mortality. However, the long-term consequences of myocardial injury on clinical outcomes remain poorly understood. This study aimed to assess the impact of myocardial injury on both acute-phase and long-term prognosis in COVID-19 patients.

Methods

A retrospective, observational study was conducted on all patients who received treatment at the Intensive Care Center for COVID-19 patient, University Medical Center Ho Chi Minh City (UCICC), from August 3rd, 2021, to October 28th, 2021.

Results

A total of 582 patients were enrolled in the study, of which 55.3% were female. The mean age of participants was 63.3 ± 16.2. Out of these patients, 330 cases (56.8%) showed myocardial injury. Compared to patients without myocardial injury, those with myocardial injury were older and had a higher incidence of chronic diseases including hypertension, ischemic heart disease, atrial fibrillation, heart failure, diabetes mellitus, chronic kidney disease. They also presented with more severe respiratory failure upon admission and showed a more pronounced abnormality in inflammation and kidney function tests. Furthermore, the in-hospital mortality rate was significantly higher in the group with myocardial injury (49.7% vs 14.3%, p < 0.001). After adjusting for age, gender, comorbidities, renal function, and disease severity at admission, myocardial injury emerged as an independent risk factor for in-hospital mortality (OR = 3.758, 95% CI 1.854-7.678, p < 0.001). Among successfully discharged COVID-19 patients, the all-cause mortality rate after a median follow-up of 18.4 months was 7.9%. Patients with myocardial injury had a significantly higher long-term mortality rate compared to those without myocardial injury (14.0% vs. 3.2%, p < 0.001). However, multivariable Cox regression analysis did not find myocardial injury to be a significant predictor of long-term mortality (HR = 2.128, 95% CI 0.792-5.712, p = 0.134).

Conclusions

Myocardial injury is a common and serious complication in hospitalized COVID-19 patients, associated with increased in-hospital mortality. However, it does not significantly impact long-term mortality in successfully discharged COVID-19 patients.