Houston—Outcomes of coronavirus infection appear to be worsened by pre-existing cardiovascular disease, while the infection itself can trigger cardiac events. That could have longer term implications in patients who survive, according to a new review.

The article in JAMA Cardiology notes that, based on what has occurred in previous coronavirus and influenza epidemics, viral infections can trigger acute coronary syndromes and arrhythmias and exacerbate heart failure. The cause is usually significant systemic inflammatory response in combination with localized vascular inflammation at the arterial plaque level, according to the review.

University of Texas Health Science Center researchers warn pharmacists and other healthcare professionals that coronavirus disease 2019 is likely to induce new cardiac pathologies and/or exacerbate underlying cardiovascular diseases.

“The severity, extent, and short-term vs. long-term cardiovascular effects of COVID-19, along with the effect of specific treatments are not yet known, and are subject to close scrutiny and investigation,” the authors point out.

Researchers emphasize, however, that during most influenza epidemics, more patients die of cardiovascular causes than pneumonia-influenza causes, adding, “Given the high inflammatory burden of COVID-19, and based on early clinical reports, significant cardiovascular complications with COVID-19 infection are expected. The prevalence of CVD in ambulatory, non-hospitalized cases, and milder cases of COVID-19 is likely lower.”

The article notes that, as of now, being age 60 years or older, male, and having comorbidities are known to be the major risk factors for COVID-19 mortality with cardiac injury, defined by elevated troponin levels, myocarditis, and acute respiratory distress syndrome being other strong and independent factors associated with mortality.

“Most available reports are primarily from China, where the smoking rate in the adult male population is very high (more than 50% in men and less than 3% in women), and it is not known whether the observed sex differences are primarily owing to disproportionate rate of smoking between genders or is associated with different immune responses or other factors,” the authors write.

While reports from China suggest that most, more than 80%, of cases are mild, the 14% severe and 5% critical cases are expected to have more severe effects on the cardiovascular system because of the inflammatory response.

With current treatment of COVID-19 primarily based on supportive care and treatment of complications, “Treatment of cardiovascular complications should be based on optimal and judicious use of guideline-based therapies. As with other triggers for acute CVD events, the use of antiplatelet agents, beta-blockers, ACE inhibitors, and statins are recommended per practice guidelines. Hypothetically, statins can curb systemic inflammation, help further stabilize the plaques, and prevent a viral-induced plaque destabilization, which can lead to acute coronary syndromes,” the article states.

The authors add that the cytokine storm associated with COVID-19 is the likely culprit in the development of ARDS and fulminant myocarditis, adding, “using immunomodulators to curtail this hyperinflammatory response might be beneficial in reducing mortality.”

They also advise, “As the disease spreads and new evidence emerges, it would be prudent to identify the risk factors for the development of cardiac complications in patients with COVID-19. A prospective registry of patients with COVID-19 with a systematic recording of clinical variables and cardiovascular complications will be beneficial to identify the pattern of cardiovascular complications, to develop a risk model for cardiac complications, and to identify and/or predict response to various treatment modalities.”

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