In the early days of the global COVID-19 pandemic, much concern was raised over the potential for deadly cardiac complications after infection — even among patients with healthy hearts.1 The heart is a target for COVID-19 because the attacking spike protein is tuned for ACE2 proteins, which are bountifully expressed on heart cell membranes.2 Patients were found to have worryingly elevated heart enzymes and abnormal ECG shapes and rhythms. At the time, we didn't — and couldn't — know if these patients' hearts were being directly injured by COVID-19, or if their hearts were just overworked by the excessive demands of their bodies struggling to survive. Reassuringly, through large international registries such as CAPACITY-COVID, we now know that the incidence of acute cardiac complications is relatively low. Even patients with known pre-existing heart disease, which significantly increases their risk for severe COVID-19 illness, appear to have a low incidence of direct heart damage.3
The initial cardiovascular health panic over COVID-19 has now given way to a simmering worry about potential long-term cardiac consequences. We have known that patients who survived other viral illnesses, including influenza4, SARS-CoV, and MERS5, were at increased risk of heart disease and strokes months to years afterwards. Children, who are at low risk of severe COVID-19 disease, can develop multisystem inflammatory syndrome (MIS-C).6 Because MIS-C is very similar to Kawasaki Disease, these children have a theoretical risk for coronary artery damage and future heart disease. The strongest evidence of delayed heart disease is from MRI studies demonstrating silent heart damage 2-3 months after COVID-19.1 However, because we are still in the midst of the pandemic, our fears of potential cardiac sequelae of COVID-19 are stoked by speculation from analogous disease models, limited datasets, and sporadic case reports.
Consequently, there is no consensus on how to monitor for post-COVID-19 cardiac syndromes. We are on high alert for heart remodeling (cardiomyopathy) leading to less efficiency (heart failure), tissue scarring causing irregular rhythms such as premature and disorganized heart beats (atrial fibrillation and premature complexes), and inflammation (myocarditis) leading to coronary syndromes (heart attacks) and sudden heart death (cardiac arrest). As of the time of this writing, we don't know what risk factors warrant monitoring, what diagnostics should be used to monitor, and how frequently to monitor. As of February 2021, leading heart societies published a joint statement recommending that patients who survive COVID-19 should be monitored, without a clear set of practice guidelines on how to do so.7
One thing is clear, though: we cannot indefinitely monitor every single COVID-19 survivor using gold standard diagnostics. A cardiac MRI, echocardiogram, or even a 12-lead ECG for every single COVID-19 survivor would surely bankrupt healthcare systems worldwide. This is where today's digital health technology revolution can make a meaningful impact in our post-pandemic future.7 Innovations in sensor technology and machine learning have already demonstrated significant outcomes improvements when applied to chronic disease management. These innovations have even discovered early signs of acute COVID-19.8,9 There is reason to believe that technologies such as digital stethoscopes, hand held ECGs, and point-of-care cardiac imaging — all enhanced by machine learning — could provide cost-effective ways to monitor for serious post-COVID-19 cardiac syndromes.
References
1. Puntmann VO, Carerj ML, Wieters I, Fahim M, Arendt C, Hoffmann J, Shchendrygina A, Escher F, Vasa-Nicotera M, Zeiher AM, Vehreschild M, Nagel E. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020 Nov 1;5(11):1265-1273. doi: 10.1001/jamacardio.2020.3557. Erratum in: JAMA Cardiol. 2020 Nov 1;5(11):1308. PMID: 32730619; PMCID: PMC7385689.
2. Samidurai A, Das A. Cardiovascular Complications Associated with COVID-19 and Potential Therapeutic~Strategies. Int J Mol Sci. 2020;21(18):6790. Published 2020 Sep 16. doi:10.3390/ijms21186790
3. Linschoten M, Peters S, van Smeden M, Jewbali LS, Schaap J, Siebelink HM, Smits PC, Tieleman RG, van der Harst P, van Gilst WH, Asselbergs FW; CAPACITY-COVID collaborative consortium. Cardiac complications in patients hospitalised with COVID-19. Eur Heart J Acute Cardiovasc Care. 2020 Dec;9(8):817-823. doi: 10.1177/2048872620974605. Epub 2020 Nov 21. PMID: 33222494; PMCID: PMC7734244.
4. Kwong JC, Schwartz KL, Campitelli MA. Acute Myocardial Infarction after Laboratory-Confirmed Influenza Infection. N Engl J Med. 2018 Jun 28;378(26):2540-2541. doi: 10.1056/NEJMc1805679. PMID: 29949484.
5. Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O. Potential Effects of Coronaviruses on the Cardiovascular System: A Review. JAMA Cardiol. 2020 Jul 1;5(7):831-840. doi: 10.1001/jamacardio.2020.1286. PMID: 32219363.
6. Nakra NA, Blumberg DA, Herrera-Guerra A, Lakshminrusimha S. Multi-System Inflammatory Syndrome in Children (MIS-C) Following SARS-CoV-2 Infection: Review of Clinical Presentation, Hypothetical Pathogenesis, and Proposed Management. Children (Basel). 2020 Jul 1;7(7):69. doi: 10.3390/children7070069. PMID: 32630212; PMCID: PMC7401880.
7. Varma N, Marrouche NF, Aguinaga L, Albert CM, Arbelo E, Choi JI, Chung MK, Conte G, Dagher L, Epstein LM, Ghanbari H, Han JK, Heidbuchel H, Huang H, Lakkireddy DR, Ngarmukos T, Russo AM, Saad EB, Saenz Morales LC, Sandau KE, Sridhar ARM, Stecker EC, Varosy PD. HRS/EHRA/APHRS/LAHRS/ACC/AHA worldwide practice update for telehealth and arrhythmia monitoring during and after a pandemic. Europace. 2021 Feb 5;23(2):313. doi: 10.1093/europace/euaa187. PMID: 32526011; PMCID: PMC7313983.
8. Smarr BL, Aschbacher K, Fisher SM, Chowdhary A, Dilchert S, Puldon K, Rao A, Hecht FM, Mason AE. Feasibility of continuous fever monitoring using wearable devices. Sci Rep. 2020 Dec 14;10(1):21640. doi: 10.1038/s41598-020-78355-6. PMID: 33318528; PMCID: PMC7736301.
9. Natarajan, A., Su, HW. & Heneghan, C. Assessment of physiological signs associated with COVID-19 measured using wearable devices. npj Digit. Med. 3, 156 (2020). https://doi.org/10.1038/s41746-020-00363-7
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