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I heard that NYC hospitals are seeing an increased cases of myocardial infarction with higher mortality than normal during this COVID-19 pandemic. What the connection is between COVID-19 and cardiovascular disease?

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Cardiovascular disease is known to worsen during infections such as influenza through two proposed mechanisms:

  • cytokines from the resulting inflammation cause weaken atherosclerotic plaques and cause plaque rupture/thrombosis
  • stress from illness can precipitate decompensated heart failure in predisposed patients

Two studies from Wuhan have looked into this so far. One cohort study of 416 patients found that 19.7% of COVID-19 patients developed myocardial infarction during their hospitalization and had higher rates of mortality (51.2% MI vs 4.5% no MI)[2]. Another cohort study of 187 patients found that 27.8% of their patients developed MI with a similar mortality rate (59.6% MI vs 8.9% no MI). Patients from both studies who developed MIs seem to be older and have preexisting hypertension, diabetes and coronary artery disease.

From these studies, the current data support the idea that getting COVID-19 increases the risk of having an MI, especially in those with risk factors.

Update: The CDC states that patients with COVID-19 can also develop a hypercoagulable state, leading to thrombotic complications such as an MI. Unfortunately, the pathogenesis of COVID-19-related hypercoagulability is unknown.

Source:

  1. JAMA Cardiology: Association of Coronavirus Disease 2019 (COVID-19) With Myocardial Injury and Mortality

  2. JAMA Cardiology: Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China

  3. JAMA Cardiology: Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19)

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    The first mechanism seems to be a "lite" version of the "cytokine storm". ("Lite" only in the sense that's not so generalized, the outcome can be just as deadly.) N.B. similar paper: "Suspected myocardial injury in patients with COVID-19: Evidence from front-line clinical observation in Wuhan, China" Int J Cardiol. 2020 Apr 8 – Fizz Apr 11 at 11:21
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    It would be unusual for a viral infection to accelerate atherosclerosis on such a fast time scale. Atherosclerotic disease occurs on the order of years, so while the putative mechanism might involve inflammation as from viral illness, unless coronavirus infection is specifically leading to plaque instability or other acute coronary events, if people with existing coronary disease are getting myocardial infarction, there is likely overwhelming demand ischemia due to viral sepsis-like syndrome itself... not an acceleration of atherosclerotic plaque development itself. – Henry Wei Apr 12 at 19:54
  • Good point @HenryWei! I have edited my answer to say that cardiovascular disease in general, not the development of new atherosclerotic disease, is worsen by viral illness. – D.Tan Apr 13 at 5:11
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A case series in Seattle published in JAMA on March 17, 2020 describes a potential cardiomyopathy associated with coronavirus in critically-ill patients. Current thinking includes a potential direct cardiac effect of the COVID-19 viral infection, rather than atherosclerotic or ischemic disease per se.

The authors noted:

It is unclear whether the high rate of cardiomyopathy in this case series reflects a direct cardiac complication of SARS-CoV-2 infection or resulted from overwhelming critical illness. Others have described cardiomyopathy in COVID-19, and further research may better characterize this risk

They go on to cite two other reports on potential COVID-19 related cardiomyopathy and cardiac impacts.

Mullen  B. COVID-19 clinical guidance for the cardiovascular care team. Published online March 6, 2020. Accessed March 16, 2020. https://www.acc.org/~/media/665AFA1E710B4B3293138D14BE8D1213.pdf

Zheng  YY, Ma  YT, Zhang  JY, Xie  X.  COVID-19 and the cardiovascular system.  Nat Rev Cardiol. 2020. doi:10.1038/s41569-020-0360-5PubMedGoogle Scholar

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