While the focus of the COVID-19 pandemic is on breathing problems and securing adequate ventilators, frontline doctors are grappling with new medical mysteries.
In addition to lung damage, many COVID-19 patients also experience heart problems – and die of heart attacks.
As more data comes from China and Italy, as well as the states of Washington and New York, more cardiologists believe that the COVID-19 virus can infect the heart muscle. An initial study found heart damage in as many as 1 in 5 patients, which caused heart failure and death even among those who showed no signs of respiratory distress.
That can change the way doctors and hospitals need to think about patients, especially in the early stages of the disease. This could also open a second front in the battle against the COVID-19 pandemic, with the need for new preventative measures in people with pre-existing heart problems, new requests for equipment and, ultimately, new treatment plans for damaged hearts among those who survive.
“It’s important to answer the question: Are their hearts affected by the virus and can we do something about it?” said Dr. Ulrich Jorde, head of heart failure, heart transplant and mechanical circulation support for the Montefiore Health System in New York City. “This might save many lives in the end.”
Virus or disease?
The question of whether the heart problem that arises is caused by the virus itself or is a by-product of the body’s reaction to it has become one of the unknown critical problems faced by doctors when they race to understand this new disease. Determining how the virus affects the heart is difficult, in part, because severe illness alone can affect heart health.
“Someone who dies of bad pneumonia will eventually die because their heart stops,” Dr. Robert Bonow, a cardiology professor at Northwestern University’s Feinberg School of Medicine and editor of the medical journal JAMA Cardiology. “You can’t get enough oxygen into your system and things fall apart.”
But Bonow and many other heart specialists believe COVID-19 infection can cause heart damage in four or five ways. Some patients, they say, may be affected by more than one path at a time.
Doctors have long known that any serious medical event, even something immediate like hip surgery, can create enough stress to damage the heart. In addition, conditions such as pneumonia can cause extensive inflammation in the body. That, in turn, can cause plaque in the arteries to become unstable, causing a heart attack. Inflammation can also cause a condition known as myocarditis, which can cause weakening of the heart muscle and, ultimately, heart failure.
But Bonow said the damage observed in COVID-19 patients could be caused by a virus that directly infects the heart muscle. Early research shows coronavirus attaches to certain receptors in the lungs, and the same receptors are found in the heart muscle too.
Preliminary Data from China
In March, doctors from China published two studies that gave a first look at how heart problems were prevalent among patients with COVID-19 disease. The larger of the two studies looked at 416 patients who were hospitalized. Researchers found that 19% show signs of heart damage. And those who did it were significantly more likely to die: 51% of those who experienced heart damage died compared to 4.5% who didn’t have it.
Patients who have heart disease before their coronavirus infection are far more likely to show heart damage afterwards. But some patients without previous heart disease also show signs of heart damage. In fact, patients without pre-existing heart conditions who experience heart damage during their infection are more likely to die than patients with previous heart disease but no COVID-19-induced heart damage.
It is not clear why some patients experience more heart effects than others. Bonow said it could be due to genetic predisposition or it could be because they were exposed to a higher viral load.
These uncertainties underline the need for closer monitoring of heart markers in COVID-19 patients, Jorde said. If doctors in New York, Washington state and other hot spots can begin to find out how the virus affects the heart, they might be able to provide risk scores or other guidelines to help doctors manage COVID-19 patients in other parts of the country.
“We have to assume, perhaps, that the virus directly affects the heart,” Jorde said. “But it’s important to find out.”
Collecting data to do it in a crisis, can be difficult. Ideally, the doctor will take a heart biopsy to determine whether the heart muscle is infected with a virus.
But COVID-19 patients are often so ill that it is difficult for them to undergo invasive procedures. And more testing can expose additional health care workers to the virus. Many hospitals do not use electrocardiograms in patients in isolation to avoid bringing additional staff into the room and using limited masks or other protective equipment.
Still, Dr. Sahil Parikh, an interventional cardiologist at Columbia University’s Irving Medical Center in New York City, said the hospital made a concerted effort to order the tests needed and put the findings in medical records so they could sort out what happened with the heart.
“We all recognize that because we are on the cutting edge, good or bad, we need to try to gather information and use it to help advance this field,” he said.
Indeed, despite improvements in patients, doctors continue to collect data, compile trends and publish their findings in the near future. Parikh and several of his colleagues recently wrote a compilation from what is known about COVID-19 heart complications, make the article available online immediately and add new findings before the article is printed.
Cardiologists in New York, New Jersey and Connecticut share the latest COVID-19 information through the WhatsApp group which has at least 150 members. And even when New York hospitals operate in crisis conditions, doctors are testing new drugs and treatments in clinical trials to ensure that what they have learned about the corona virus can be shared elsewhere with scientific validity.
The work has resulted in changes in the way hospitals deal with cardiac implications of COVID-19. Doctors have found that infection can mimic a heart attack. They have taken the patient to the heart catheterization lab to clear any suspected blockage, only to find the patient did not really have a heart attack but had COVID-19.
Over the years, hospitals have taken patients suspected of having a heart attack directly to the catheterization lab, bypassing the emergency room, in an effort to shorten the time from when patients enter the door when doctors can clear blockages with balloons. The time from the door to the balloon has become an important measure of how well hospitals treat heart attacks.
“We take a step back from that now and think about bringing patients to the emergency department so they can be briefly evaluated, so we can determine: Is this person really at high risk for COVID-19?” Parikh said. “And are these manifestations that we call heart attacks really heart attacks?”
The new protocol now includes bringing a cardiologist and getting an EKG or ultrasound to confirm the blockage.
“We do that to protect patients from procedures that should not need to be done,” Parikh said, “But also to help us decide what level of personal protective equipment we will use in the laboratory.”
Sorting out how the virus affects the heart must help the doctor determine which therapy should be taken to keep the patient alive.
Jorde said that after COVID-19 patients recovered, they could have long-term effects from the heart damage. But, he said, treatments exist for various forms of heart damage that must be effective after the viral infection has healed.
However, that could require a wave of widespread demand for health care after the pandemic has subsided.
Kaiser Health News (KHN) is a non-profit news service that addresses health issues. This is an independent editorial program from the Kaiser Family Foundation that is not affiliated with the Kaiser Permanente.
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