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September 3, 2020

Studies Raise Concerns About Potential Increases in Heart Failure in Recovered COVID-19 Patients

September 3, 2020—The American Heart Association (AHA) reported that recent studies suggest many COVID-19 survivors experience some type of heart damage, even if they did not have underlying heart disease and were not sick enough to be hospitalized. AHA noted that the findings from two studies, published online July 27 in Journal of American Medical Association (JAMA): Cardiology, have health care experts concerned about a potential increase in heart failure.

One study is an analysis of autopsies of 39 COVID-19 patients. The study identified infection in the hearts of patients who had not been diagnosed with cardiovascular issues while they were ill. Diana Lindner, PhD, et al published the findings as a brief report in JAMA Cardiology.

A second study, published as an original investigation by Valentina O. Puntmann, MD, et al in JAMA Cardiology, used cardiac MRIs on 100 patients who had recovered from COVID-19 within the past 2 to 3 months. The investigators found abnormalities in the hearts of 78% recovered patients and “ongoing myocardial inflammation” in 60% of recovered patients. Additionally, the investigators found high levels of troponin in 76% of patients tested, although heart function appeared to be generally preserved. Most patients in the study had not required hospitalization.

In the AHA news report, Gregg Fonarow, MD, and Mina Chung, MD, discussed the implications of these findings. With Clyde Yancy, MD, Dr. Fonarow coauthored an editorial that accompanies the JAMA Cardiology studies. Dr. Fonarow is Chief of the Division of Cardiology at the University of California, Los Angeles, in Los Angeles, California. Dr. Chung is a cardiologist and Professor of Medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Cleveland, Ohio. Dr. Chung is leading the coordination of more than a dozen ongoing COVID-19 research studies funded by the AHA.

“Very early into the pandemic, it was clear that many patients who were hospitalized were showing evidence of cardiac injury,” stated Dr. Fonarow. “More recently, there is recognition that even some of those COVID-19 patients not hospitalized are experiencing cardiac injury. This raises concerns that there may be individuals who get through the initial infection but are left with cardiovascular damage and complications.” Dr. Fonarow advised that these complications, such as myocarditis, could lead to an increase in heart failure.

Also, he was concerned about people with pre-existing heart disease who do not have COVID-19 but who avoid coming into the hospital with heart problems out of fear of being exposed to the virus. Dr. Fonarow commented, “The late consequences of that could be an increase in heart failure. It is much safer if having symptoms that could represent heart attack or stroke to come into the emergency department than to try to ride it out at home.”

The AHA report noted that approximately one-fourth of patients hospitalized with COVID-19 have been diagnosed with cardiovascular complications, which have been shown to contribute to approximately 40% of all COVID-19-related deaths.

Dr. Chung commented, “There’s a group of people who seem to be more affected from the cardiac point of view.” But, she said, it can be difficult to identify who is at risk or for those recovering from the virus to know if they are having heart problems.” She explained, “A lot of people end up feeling exhausted for a while. They can’t get up to the exertion level they were at before. But it’s difficult to tease out whether or not it’s the lungs taking a little more time to heal or whether it’s a cardiac issue. If things continue to get better with time, that’s a good sign. It’s not unexpected that if you have not been active for a while, you get deconditioned and may have shortness of breath if you push yourself.”

According to the AHA report, it is unclear whether screenings to detect cardiovascular damage should become a routine part of follow-up care for COVID-19 patients. Dr. Fonarow said, “The bottom line is, we don’t know. Before any recommendations are made for routine cardiac imaging, we need additional studies that help identify the frequency of this occurring and what the risk factors are.”

Dr. Fonarow and Dr. Chung advised that patients recovering from COVID-19 should watch for symptoms and consult their physician or a cardiologist if they experience them. Symptoms include increasing or extreme shortness of breath with exertion, chest pain, swelling of the ankles, heart palpitations, an irregular heartbeat, not being able to lie flat without shortness of breath, waking up at night short of breath, lightheadedness, or dizzy spells.

Dr. Fonarow cautioned, “But for someone who has had COVID-19 and recovered with no symptoms of heart trouble, it’s unknown whether there is a reason to have additional screenings. If there are concerns, they should discuss this with their physicians.”

He said it is also possible that some of the cardiovascular damage investigators are seeing could heal itself. “We've seen with other viruses where there is inflammation of the heart, there are individuals for whom there is spontaneous recovery. And in some people, we can treat this effectively with medication. The question becomes specifically with COVID-19, what is that frequency and does it differ from other viruses that infect the heart,” concluded Dr. Fonarow in the AHA report.

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