A clinical case report published on March 27 in the Journal of the American Medical Association (JAMA) by Riccardo M. Inciardi and his colleagues demonstrated such a finding. The report presents a case of a 53-year-old woman admitted to hospital due to fatigue and hypotension (low blood pressure) with no fever. Subsequent electrocardiography suggested a myocardial injury along with increased heart enzymes, the chemical substance produced by heart cells. Those findings are typical of a heart attack (myocardial infarction). 

However, there was no further evidence of heart blood vessel blockage or narrowing as is the case with a heart attack. A swab test was carried out for COVID-19 due to the patient`s history of a dry cough and fever one week earlier, which was found to be positive. 

The above finding indicates that heart injury could become a late manifestation of COVID-19. Another study also found that some COVID-19 patients were also initially diagnosed with acute myocardial injury or arrhythmia (heart rhythm disorder). Therefore, the inability to recognize this condition may lead to pitfalls in patient treatment. Moreover, delays in diagnosing may lead to the patients spreading the virus unknowingly to those around them, including to health workers treating them and other patients.

Another study by Tao Guo and his colleagues at Seventh Hospital of Wuhan city in Hubei, China, which was also published in JAMA, indicated that COVID-19 may still contain surprises. The study involved 187 patients who had tested positive for COVID-19 of which 144 were discharged, while 43 others reportedly died. Among all the participants, 66 patients (35.3 percent) had a history of underlying cardiovascular disease including hypertension, coronary heart disease and cardiomyopathy (abnormality of the heart muscle).

The findings show that patients with a history of underlying cardiovascular disease have a higher probability of experiencing myocardial (heart muscle cells) injury and face a higher fatality rate. This is similar to heart attacks. Moreover, 16 patients (13.2 percent) with no history of any cardiovascular disease also experienced myocardial injury. Myocardial injury was proven by increased Troponin T, an enzyme released by the heart muscle during an episode of injury, which is also typically found in heart attacks or heart inflammation.

As the researchers found reason to believe that COVID-19 may manifest as a heart abnormality and that people with preexisting cardiovascular diseases are at higher risk of myocardial injury and death, one important question remains: How could this be since COVID-19 mainly affects the respiratory tract?

Based on the American College of Cardiology clinical bulletin in February, among all the coronavirus patients with preexisting medical conditions, cardiovascular and cerebrovascular (brain and its blood circulation) diseases were found in up to 80 percent of cases. The fatality rate among hypertensive patients’ may increase up to 6 percent, while that of patients with diabetes and significant heart disease could approach 7.3 percent and 10.5 percent, respectively.  

Generally, the metabolic demand or energy needed to maintain optimum metabolism will increase during the viral infection period, including in COVID-19 cases. The heart would then bear a heavier or even an excessive workload resulting in exhaustion, shortness of breath, chest pain or loss of consciousness. Hence, the disease would worsen, particularly among those with preexisting heart conditions. Furthermore, individuals with relatively stable and well-controlled chronic heart diseases will likely experience acute worsening of their preexisting heart conditions because of a sudden increase in metabolic demand, which may be fatal in most cases. 

Meanwhile, recent studies suggest several potential pathways through which SARS-Cov-2 virus infection, which causes COVID-19, could present cardiovascular symptoms. It could be through direct damage to the heart or through systemic inflammatory response. 

In cases of infection with SARS-CoV (the virus responsible for the Severe Acute Respiratory Symptom outbreak in 2002), evidence suggests that the virus gene was detected in the heart. Therefore, SARS-CoV-2 could directly damage the heart as both viruses are genetically identical.

COVID-19 could also lead to a “cytokine storm”, a condition in which our body responds excessively to an infection by releasing molecules that severely disrupt immunity. This process originally aims to overcome viral infection, yet results in self-tissue damage, including to heart muscle cells.

Systemic inflammation response during the infection period is also responsible for disease deterioration in those with coronary heart disease. Viral infection and its inflammation response will  destabilize coronary plaques on the inner artery wall, which can worsen the disease or lead to another heart attack. The risk is higher for those with hypertension, diabetes, obesity, chronic kidney disease and chronic lung disease, such as chronic obstructive pulmonary disease (chronic bronchitis). 

In conclusion, as COVID-19 could manifest as a heart and blood vessel abnormality in some patients, it is better to consider COVID-19 examination and cautious evaluation for such patients to prevent incorrect treatment and also to prevent further worsening of their conditions due to a failure to recognize unusual manifestations of the SARS-CoV-2 virus in the early stages.

No experts have conclusive knowledge so far surrounding the SARS-CoV-2 virus. However, persons with a history of cardiovascular disease should be advised to be more aware, disciplined and cautious in taking preventive measures, including conducting physical distancing.

***

Physician at RSUD Lakipadada Tana Toraja public hospital. The views are personal

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