Dr. Charles Mild recalls a very unusual patient that he saw not long before the coronavirus outbreak became a full-blown pandemic.
“He was a young guy, and he had acute coronary syndrome,” said Mild, a cardiologist based in Harlingen, Texas.
Mild said that the patient had some risk factors for heart disease in that he was obese and had a sedentary lifestyle, although he was not diabetic. What was unusual, given his age, is that he had three blockages in arteries close to his heart.
“I’ve never seen that before,” Mild said.
After some treatment, the patient recovered. But Mild wonders if he was an early case of COVID-19.
“This was before we were routinely looking for COVID by testing for it,” said Mild. “I can’t be sure, but it is very suspicious.”
The reason Mild suspects COVID-19 is that it can create a hypercoagulable state, a condition in which there is an abnormally high tendency for the body to create blood clots. Studies from China, France, Italy, the Netherlands, and the United States have found blood clots in both the veins and arteries of COVID-19 patients.
In the last year, the medical profession has begun to get a grasp on the more immediate cardiovascular effects of COVID-19. But an understanding of the long-term effects may be years away.
“COVID-19 can increase the risk of blood clots, and if these clots form in the arteries to the heart, this can result in acute coronary syndromes,” said Dr. Gregg Fonarow, co-chief of the division of cardiology at the University of California at Los Angeles. “In addition, the increase in inflammation during COVID-19 can increase the vulnerability of preexisting plaques in the coronary arteries to rupture, which can also lead to [heart attack].”
Inflammation of the heart, known as myocarditis, is another disease that may be caused by COVID-19. Myocarditis is usually caused by a virus and can reduce the heart’s ability to pump blood, possibly causing heart attacks, strokes, or arrhythmias.
The prevalence of myocarditis in COVID-19 patients is a matter of considerable debate. A German study found ongoing myocardial inflammation in 60% of 100 patients who had recovered from the virus. But a more recent study by Louisiana State University and Johns Hopkins University researchers of 277 autopsies of people who had COVID-19 found evidence of myocarditis in just over 7%. In only about 1.4% was it likely to have been a serious problem.
But even a rate as low as 1.4% could be serious given how widespread COVID-19 has been. There are over 27 million confirmed cases in the U.S. and over 107 million around the world.
“More recent studies have shown a very small percentage of individuals with evidence of myocardial inflammation or myocarditis,” said Fonarow, who is also director of the Ahmanson-UCLA Cardiomyopathy Center and co-director of the UCLA Preventive Cardiology Program. “However, with millions of men and women having been infected with COVID-19, even if this represents less than 1% of individuals, that would still be a high number in absolute terms.”
An as-yet-unpublished study has found that heart cells infected with the coronavirus were often severely fragmented. Many of the cells lacked nuclear DNA. While potentially ominous, the study was conducted on heart cells created in a laboratory, and thus, it is not known to what degree this could happen in patients with COVID-19.
At this point, Mild said, the medical community’s understanding of the long-term cardiovascular effects of COVID-19 are, at best, preliminary.
“I think the safest statement right now is, ‘We just don’t know,’” said Mild. “We’re learning every day, and the literature on this changes every day.”
Fonarow worries that COVID-19 will cause long-term problems not only in patients who were infected with the virus, but also in those whose lives were affected by the pandemic.
“The greatest concern is that because of the COVID-19 pandemic, individuals have not been able to as closely follow heart-healthy lifestyles, keep close monitoring of their blood pressure, cholesterol levels, and other cardiovascular risk factors, and being less adherent to prescribed therapy,” said Fonarow. “As a result, there could be a significant increase in cardiovascular events and heart failure over the next few years.”
