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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 85-88

Cardiovascular Complications in Coronavirus Disease-2019: The Understanding Continues to Evolve

1 Department of Cardiology, Medanta- The Medicity, Gurgaon, Haryana, India
2 JROP Institute of Echocardiography, Ultrasound and Vascular Doppler, Delhi, India

Date of Submission27-Jul-2021
Date of Acceptance28-Jul-2021
Date of Web Publication19-Aug-2021

Correspondence Address:
Manish Bansal
Department of Cardiology, Medanta- The Medicity, Sector 38, Gurgaon, Haryana - 122 001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_42_21

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How to cite this article:
Bansal M, Gupta R. Cardiovascular Complications in Coronavirus Disease-2019: The Understanding Continues to Evolve. J Indian Acad Echocardiogr Cardiovasc Imaging 2021;5:85-8

How to cite this URL:
Bansal M, Gupta R. Cardiovascular Complications in Coronavirus Disease-2019: The Understanding Continues to Evolve. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2021 [cited 2021 Nov 29];5:85-8. Available from: https://www.jiaecho.org/text.asp?2021/5/2/85/324098

Since the emergence of coronavirus disease 2019 (COVID-2019) in December 2019 in China[1] and its subsequent evolution into a pandemic, there have been widespread concerns about the potential cardiovascular impact of the illness.[2],[3] It was projected that COVID-19 would result in a surge of acute myocardial injury and myocardial infarctions. However, as the pandemic unfolded, it became apparent that acute coronary events had not increased much and myocardial injury,[4] though common in patients with severe COVID-19, was largely subclinical. Instead, thromboembolic events emerged as the single most common vascular complication of COVID-19, contributing to the disease pathogenesis as well as to morbidity and mortality.[5],[6] Accordingly, prevention of thromboembolism became an integral component of treatment of COVID-19. More recently, myocardial injury in COVID-19 has gained renewed attention due to various post-COVID, non-respiratory complications for which persisting myocardial involvement appears to be an important causative factor.[7] Three articles in this issue of the journal highlight these various facets of COVID-19 in Indian patients.[8],[9],[10]

Thromboembolism is a common complication in COVID-19, especially in patients with severe illness.[11],[12] Venous thromboembolism (VTE) is the main manifestation, but arterial thrombotic events have also been reported frequently. A pooled analysis of 66 studies enrolling 28173 hospitalized patients with COVID-19 reported the overall prevalence of VTE to be 22.7% in intensive care unit (ICU) patients and 7.9% in non-ICU patients.[11] The prevalence of VTE was much higher (45.6% in ICU patients, 23.0% in non-ICU patients) in studies that had actively screened for deep vein thrombosis (DVT). Notably, this meta-analysis did not include studies that had actively screened for pulmonary embolism (PE); otherwise, the prevalence would have been even higher.

The thromboembolism in COVID-19 is unique and quite distinct from what is commonly observed in patients admitted to medical ICUs for sepsis and other clinical conditions. Unlike sepsis, thromboembolism in COVID-19 is not a form of disseminated intravascular coagulation but occurs due to intense vascular inflammation and vascular injury.[6],[13] This distinct pathogenesis is reflected in the laboratory profile of the patients developing VTE secondary to COVID-19. In these patients, fibrinogen level is increased whereas platelet count, prothrombin time (PT), and activated partial thromboplastin time (aPTT) are not much affected, at least during the initial phase of the illness. These findings contrast with those observed in disseminated intravascular coagulation, which is characterized by reduced fibrinogen level and platelet count, and prolonged PT and aPTT.[13]

The distinct pathophysiology of thromboembolism in COVID-19 is also reflected in the clinical presentation of these patients. In situ pulmonary thrombosis is quite common, PE is more often peripheral and underlying DVT is much less common (only ~ 42% of the patients with so-called PE in a large, pooled analysis).[12] Vascular inflammation mediated thrombosis is also the reason for thrombosis in unusual locations (left ventricle, ascending aorta, other systemic arteries) that are frequently encountered in COVID-19 [Figure 1].
Figure 1: Left - A left ventricular thrombus (arrow) in a 37-years old lady who had no previous cardiovascular risk factor or cardiac illness and had presented with coronavirus disease-2019. Right - The patient also had thrombotic occlusion (arrow) of proximal left anterior descending coronary artery

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Echocardiography is the most valuable diagnostic modality for detecting various cardiovascular complications of COVID-19. Even for PE, echocardiography has been the main diagnostic tool because performing computed tomography (CT) pulmonary angiography has been difficult in these sick patients with strict isolation requirements. Unfortunately, even the echocardiography has been challenging due to the risk of exposure to the personnel, contamination of the equipment and cross-infection to other patients. To minimize this, all the hospitals and major societies all over the world have published guidelines for safe usage of echocardiography in COVID-19.[14] The Cardiological Society of India and the Indian Academy of Echocardiography have also published similar guidelines to help clinicians manage echocardiography services in the Indian scenario, where healthcare infrastructure is vastly different from the western countries.[15],[16]

The challenges inherent to performing echocardiography in COVID-19 patients have impeded our understanding of cardiac abnormalities in these patients. Another challenge has been that baseline echocardiography details are not available for most of the patients presenting with COVID-19 and therefore, it has been difficult to determine what proportion of the abnormalities (esp. left ventricular dysfunction) were pre-existing. Moreover, comparing COVID-19 patients with non-COVID patients admitted in medical ICUs has also been difficult which has compromised our ability to determine the true incremental role of COVID-19 in causing various cardiac abnormalities. Despite these challenges, several studies have now been published from different countries, describing echocardiography findings in COVID-19 patients.[17],[18],[19] Unfortunately, no such study has been available from India. Dutta et al. in this issue of the journal, for the first time, describe the spectrum of echocardiography findings in Indian patients with COVID-19.[8]

The study by Dutta et al. included 234 patients with COVID-19 who were admitted to ICU or high-dependency unit.[8] Right ventricular (RV) dilatation and/or dysfunction was the commonest finding, seen in 37% patients. Left ventricular (LV) systolic dysfunction was also common (27.7% patients), but it was mostly pre-existing. Although the study had several limitations (which have been there with most of the previous studies as well), several important messages can be gleaned. First, the high prevalence of RV dilatation/dysfunction once again points to pulmonary thromboembolism being an important pathogenetic mechanism in COVID-19. Most of the studies from the other parts of the world have also reported similarly high prevalence of RV abnormalities in COVID-19.[17],[18] Second, high proportion of pre-existing LV systolic dysfunction among those in whom LV systolic dysfunction was diagnosed serves a reminder as to how difficult it has been to ascertain true impact of COVID-19 on cardiac structure and function.

As the COVID-19 second wave subsides in India, a large number of patients are now presenting with a variety of post-COVID symptoms. The most commonly reported symptoms are- palpitations, persistently fast heart rate at rest, rapid rise in heart rate on minimal exertion, breathing difficulty, and extreme fatigue. Of these, resting sinus tachycardia and exaggerated heart rate response to exertion have been particularly intriguing. There is no evidence of hypoxemia in most of these patients, no significant residual lung injury and no appreciable abnormality on echocardiography. In view of this, physical deconditioning and autonomic dysfunction have been postulated to be the likely mechanisms responsible for these symptoms. In this regard, recent studies employing cardiac magnetic resonance imaging (MRI) in patients recently recovered from COVID-19 have provided important new insights.[7],[20],[21]

While cardiac MRI is not feasible during the acute phase of COVID-19, it appears to be an excellent modality for evaluation of cardiovascular involvement in patients recovering from COVID-19. Cardiac MRI not only permits a comprehensive evaluation of cardiac structure and function, it has the unique ability to permit tissue characterization. As a result, myocardial edema, fibrosis, and scarring can all be easily detected and quantified.

One of the earliest studies with cardiac MRI involved 100 patients with recent COVID-19 (median time interval between COVID-19 diagnosis and cardiac MRI being 71 days).[7] More than three-fourths of all patients had one or more MRI abnormalities indicative of myocardial or pericardial involvement. This was despite the fact that most of the patients had suffered mild illness only, had recovered at home and only one-third had required hospitalization. Quite understandably, this observation led to a considerable distress because of its potential long-term implications, including the risk of sudden death with resumption of intensive physical activities. Although the subsequent studies showed a much lower prevalence of myocardial abnormalities in post-COVID patients, the numbers were still quite high.[20],[21]

The study by Chudgar et al., in this issue of the journal is the first report from India describing cardiac MRI findings in patients with recent COVID-19.[10] Cardiac MRI was performed for one or more symptoms or investigation findings suggestive of underlying cardiac involvement. The evidence of LV myocardial involvement on cardiac MRI was found in more than half of these symptomatic patients. Interestingly, most of these patients had less extensive pulmonary involvement on CT during the acute phase of their illness and many of these patients also had unremarkable echocardiography study. These findings once again demonstrate that even though myocardial involvement secondary to COVID-19 may remain subclinical during the acute phase of the illness, it may persist for long-time and may be responsible for some of the post-COVID symptoms. It also reinforces the need to remain vigilant in post-COVID patients and not disregard their symptoms as being non-organic in origin, even if echocardiography and other investigations are normal. The long-term implications of these findings are however, yet to be understood.

Undoubtedly, COVID-19 has been a disease like none other and fathoming this disease has been a humbling experience for scientists, pathologists, microbiologists and clinicians alike. Despite more than 190 million documented cases of COVID-19 worldwide, several questions related to the disease remain unanswered. Factors determining the nature and severity of the illness in different individuals remain unclear, no effective antiviral therapy exists for this disease and even though vaccination has emerged as a powerful protective measure, numerous uncertainties exist regarding appropriate regimens and long-term safety and efficacy of the vaccines. The issue of cardiac complications in COVID-19 has been no different. Normally, imaging plays a pivotal role in delineating cardiac pathologies but unfortunately, cardiac imaging in COVID-19 has been greatly limited because of the contagious nature of the illness. Nonetheless, with sustained efforts and adaptation to the prevailing circumstances, experience with cardiac imaging in COVID-19 has gradually evolved. However, it is a long road, and the journey continues!

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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