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ER doctors highlight under-appreciated cardiovascular risks of COVID-19

A study from University of Virginia Health System's Dr William Brady, and colleagues aims to serve as a guide for emergency-medicine doctors treating patients who may have or are known to have COVID-19. The authors note that much attention has been paid to the pulmonary (breathing) complications of COVID-19, but less has been said about the cardiovascular complications that can lead to death or lasting impairment.

"In writing this article, we hope to increase emergency physicians' knowledge and awareness of this new pathogen and its impact on the cardiovascular system," said Brady, of UVA's department of emergency medicine. "As we encounter more and more patients with COVID-19-related illness, we are increasing our understanding of its impact on the body in general and the cardiovascular system in particular. The rate of learning on this area is amazingly rapid. Information continues to change weekly, if not daily."

Heart failure is a particular concern in patients with COVID-19. One study, the article authors note, found that almost a quarter of COVID-19 patients – 24% – were suffering acute heart failure when they were first diagnosed with the coronavirus. (This doesn't mean that 24% of all COVID-19 patients will suffer heart failure. The authors state that it remains unclear if the heart failure was the result of COVID-19 specifically or if the virus was worsening undiagnosed heart failure.) Of the patients with heart failure, nearly half were not known to have high blood pressure or cardiovascular disease.

The paper also notes that COVID-19, and other diseases that cause severe inflammation throughout the body, increase the risk that fatty plaque built up in the blood vessels will rupture, leading to heart attacks and stroke. Influenza and certain other viruses have been associated with increased risk of plaque ruptures within the first week after the disease was diagnosed, the authors state in their review of the available COVID-19 medical literature.

Finally, the authors describe potential drug interactions in COVID-19 patients. For example, the highly publicized malaria drug hydroxychloroquine can interact with medications designed to regulate heart rhythm, in addition to causing heart damage and worsening cardiomyopathy.

Remdesivir, an antiviral that is the only COVID-19 treatment authorised by the US Food and Drug Administration, can cause low blood pressure and abnormal heart rhythm. It's important for doctors to bear these interactions in mind when treating patients with COVID-19, the authors note. "As we gain more experience with this new pathogen, we realise that its adverse impact extends beyond the respiratory system," Brady said. "We will continue to learn more about COVID-19 and the most optimal means of managing its many presentations."

In addition to Brady, the article was written by Dr Brit Long, of Brooke Army Medical Centre; Dr Alex Koyfman, of the University of Texas Southwestern Medical Centre; and Dr Michael Gottlieb, of Rush University Medical Centre.

Abstract
Background: The coronavirus disease of 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While systemic inflammation and pulmonary complications can result in significant morbidity and mortality, cardiovascular complications may also occur.
Objective: This brief report evaluates cardiovascular complications in the setting of COVID-19 infection.

Discussion: The current COVID-19 pandemic has resulted in over one million infected worldwide and thousands of deaths. The virus binds and enters through angiotensin-converting enzyme 2 (ACE2). COVID-19 can result in systemic inflammation, multiorgan dysfunction, and critical illness. The cardiovascular system is also affected, with complications including myocardial injury, myocarditis, acute myocardial infarction, heart failure, dysrhythmias, and venous thromboembolic events. Current therapies for COVID-19 may interact with cardiovascular medications.
Conclusions: Emergency clinicians should be aware of these cardiovascular complications when evaluating and managing the patient with COVID-19.

Authors
Brit Long, William J Brady, Alex Koyfman, Michael Gottlieb

[link url="https://newsroom.uvahealth.com/2020/05/15/cardiovascular-covid-19/"]University of Virginia Health System material[/link]

[link url="https://www.ajemjournal.com/article/S0735-6757(20)30277-1/pdf"]The American Journal of Emergency Medicine abstract[/link]

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