COVID-19 Chest Pain

The most severe complications of the SARS-CoV-2 virus affect more than just the lungs.

Of those admitted to hospital with acute Covid-19 doctors are seeing:

  • Acute coronary syndrome: unstable angina and myocardial infarction due to a sudden reduction in blood flow to the heart.

  • Cardiac arrest: an abrupt loss of heart function so that it is unable to pump blood around the body, this can lead to arrhythmias and loss of consciousness.

  • Cardiogenic shock: a serious condition that occurs when the heart cannot pump enough blood and oxygen to the brain, kidneys, and other vital organs. It is normally due to a heart attack.

  • Arrhythmias: abnormal heart rhythms - bradycardia (too slow), tachycardia (too fast) and atrial fibrillation.

  • Left-sided heart failure: occurs when the left ventricle doesn't pump efficiently. This prevents the body from getting enough oxygen. The blood backs up into the lungs instead which causes shortness of breath due to a buildup of fluid - oedema.

  • Right-sided heart failure: the muscle of the right ventricle is not pumping as efficiently and less blood is delivered to the lungs. It is a normally a result of pulmonary emboli in Covid -19 and symptoms again are shortness of breath and oedema.

  • Pericarditis and pericardial effusion: is the swelling and irritation of the thin, saclike tissue surrounding the heart (pericardium). A pericardial effusion is the buildup of extra fluid in the space around the heart. If too much fluid builds up, it can put pressure on the heart. This can prevent it from pumping normally.

  • Cardiomyopathy: is a disease in which the heart muscle weakens, after becoming rigid or stiff, and has difficulty pumping blood around the body.

  • Myocarditis: an inflammation of the heart muscle (myocardium).

Those with myocardial injury have poorer outcomes, they were at greatest risk of requiring mechanical ventilation and therefore the greatest risk of dying.

Throughout the pandemic there has been a shift in the thinking that the damage to the heart is direct from the virus and more to it being ongoing inflammation.

Covid-19 can affect the lining of the blood vessels called the endothelium. This layer of cells allows or blocks certain substances through depending on conditions in the body.

A healthy, well-functioning endothelium helps to keep our blood vessels relaxed and open to the flow of blood. It also releases substances that help to prevent harmful blood clots and inflammation. But if the endothelium is damaged, these processes may not work effectively, known as endothelial dysfunction.

By damaging the endothelium, coronavirus infection has the potential to cause abnormal blood clotting, leaky blood vessels and a reduced blood flow. The "stickiness" of the blood also increases. These endothelial effects can have consequences literally from head to toe. There are strokes, confusion, heart attacks, pulmonary emboli and Covid toes.

It may also explain why people with certain heart and circulatory conditions seem to be at a higher risk of developing severe complications of Covid-19. If another condition, such as diabetes or high blood pressure, has already damaged the endothelium, the virus’s impact is magnified.

Long term vascular affects

In a cohort study of 100 patients who had recently recovered from COVID-19, randomly identified from a COVID-19 test centre, cardiac magnetic resonance imaging (cMRI) revealed cardiac involvement in 78 patients (78%) and ongoing myocardial inflammation in 60 patients (60%), which was independent of preexisting conditions, severity and overall course of the acute illness, and the time from the original diagnosis.

At UCSF they were finding that asymptomatic patients (those who had a positive PCR test for COVID but no symptoms) could also have myocarditis.

This impression of cardiac damage affecting ANYONE who had a Covid-19 infection is backed up by Coverscan UK. They MRI scanned multiple volunteers (500 in number) in the Summer 2020. The mean age of participants was 44 years with a medium time after onset of symptoms of 140 days (about 4 months). They were considered low risk individuals ie they were not admitted to hospital and had no major pre-existing conditions They found, amongst other organ damage, that 32 % of the volunteers had heart damage. Added to this - the patients symptoms nor their blood test results were indicative of organ impairment.

Dr Alexander Lyons, a cardiologist at the Royal Brompton Hospital In London, has anecdotally noticed long term cardiovascular complications in people who weren’t admitted to hospital.

He found the following in the Long Covid patients they were seeing at The Brompton:

  • Myocarditis 43%

  • Inappropriate sinus tachycardia 29%

  • Pericarditis 19%

  • Microvascular angina 2%

  • Pulmonary emboli 2 %

Out of the 40 Long Covid patients seen 31 have improved. So 88% of patients post Covid cardiac issues improved with treatment and/or time. He feels therefore that the long term prognosis is good.

Just to note - In a hot of the press research study "Cardiovascular sequelae in uncomplicated COVID-19 survivors" by Zhou et al They performed a systematic cardiac screening for 97 consecutive COVID-19 survivors including electrocardiogram (ECG), echocardiography, serum troponin and NT-proBNP assay 1-4 weeks after hospital discharge. Treadmill exercise test and cardiac magnetic resonance imaging (CMR) were performed according to initial screening results.

They found:

  • The mean age was 46.5 ± 18.6 years

  • 53.6% were men 46.4% women

  • All were classified with non-severe disease without overt cardiac manifestations and did not require intensive care

  • Median hospitalization stay was 17 days

  • Median duration from discharge to screening was 11 days.

  • Cardiac abnormalities were detected in 42.3% including sinus bradycardia (29.9%), newly detected T-wave abnormality (8.2%), elevated troponin level (6.2%), newly detected atrial fibrillation (1.0%), and newly detected left ventricular systolic dysfunction with elevated NT-proBNP level (1.0%). Significant sinus bradycardia with heart rate below 50 bpm was detected in 7.2% COVID-19 survivors, which appeared to be self-limiting and recovered over time. For COVID-19 survivors with persistent elevation of troponin level after discharge or newly detected T wave abnormality, echocardiography and CMR did not reveal any evidence of infarct, myocarditis, or left ventricular systolic dysfunction.

They concluded that "cardiac abnormality is common amongst COVID-survivors with mild disease, which is mostly self-limiting. Nonetheless, cardiac surveillance in form of ECG and/or serum biomarkers may be advisable to detect more severe cardiac involvement including atrial fibrillation and left ventricular dysfunction".

These are very different results to the COVERSCAN UK research, anecdotal evidence form a leading London hospital and researchers in the States. It maybe that it was too small a study size, inferior imaging techniques, different definitions of diseases or a whole host of other reasons. But be prepared that some cardiologists will favour this report if they are still of the opinion that SARS-CoV-2 is a respiratory illness.

In future blogs I shall be discussing myocarditis and inappropriate sinus tachycardia the two most common post Covid cardiac sequelae.

However if you have ongoing breathlessness, chest pain, palpitations or extreme fatigue please discuss this with your medical practitioner.


Covid-19 rapid guideline - Diagnosing acute myocardial injury in patients with suspected /confirmed COVID- 19

40 patients seen 31 have improved (88%)

Long term prognosis is good.

But need long term follow up as cardiomyopathy can occur.

Covid-19 rapid guideline - Diagnosing acute myocardial injury in patients with suspected /confirmed COVID- 19

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