The management of patients hospitalized for novel coronavirus disease 2019 (COVID-19) who develop an Acute COVID-19 Cardiovascular Syndrome (ACovCS) should include surveillance and diagnostic strategies that balance potential patient risks and healthcare staff exposure with improvement in clinical outcomes, according to an article published in Circulation.
COVID-19, in addition to systemic and respiratory complications, can manifest with an acute cardiovascular syndrome. In this review, researchers examined a myocarditis-like syndrome involving acute myocardial injury often connected with reduced left ventricular ejection fraction in the absence of obstructive coronary artery disease. Further complications of this syndrome include cardiac arrhythmias and/or clinical heart failure with or without associated hemodynamic instability including shock. These complications can occur at any time during hospitalization.
Acute myocardial injury is observed in a considerable minority of hospitalized patients with COVID-19, particularly patients that require intensive care. In an analysis of a Chinese retrospective report of 416 patients hospitalized with COVID-19, approximately 20% of patients had an acute myocardial injury (ie, cardiac troponin I >0.04 μg/L), which was associated with higher mortality. The etiology of this injury is uncertain, but is thought to be related to myocarditis, microvascular injury, systemic cytokine-mediated injury or stress-related cardiomyopathy.
The myocardial cellular targets for SARS-CoV-2 may include pericytes, cardiomyocytes, fibroblasts, and immune cells such as resident macrophages. The S1 subunit of spike proteins expressed at the surface of SARS-CoV-2 is known to bind to angiotensin-converting enzyme 2 (ACE2) on target cells. Once the virus is bound to ACE2, the TMPRSS2 protease facilitates viral entry into the host cell. These mechanisms of SARS-CoV-2 highlight 3 potential therapeutic targets: antibodies against S1, as well as ACE2, and TMPRSS2. Prior studies on Severe Acute Respiratory Syndrome Coronavirus-1 have helped expedite the evaluation of several promising therapies that include anti-viral agents, interleukin-6 inhibitors, and convalescent serum.
COVID-19 has the potential to infect cardiomyocytes, pericytes and fibroblasts leading to direct myocardial injury, but that pathophysiological sequence remains unclear. Another possible explanation for COVID-19-related myocardial injury centers on cytokine excess and/or antibody-mediated mechanisms. Further examination via autopsy and endomyocardial biopsy tissue will be required to clarify which of these is the predominate mechanism of injury in ACovCS.
“Management of ACovCS should involve a multidisciplinary team including intensive care specialists, infectious disease specialists and cardiologists,” concluded the article authors.
Hendren NS, Drazner MH, Bozkurt B, Cooper LT Jr. Description and proposed management of the Acute COVID-19 Cardiovascular Syndrome. Circulation. doi:10.1161/CIRCULATIONAHA.120.047349