Address for Correspondence: Cristiane da Cruz Lamas, Cardiovascular Research Unit, Instituto Nacional de Cardiologia,
Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Rio de Janeiro Universidade do Grande Rio
(UNIGRANRIO), Rio de Janeiro, Brazil Email: firstname.lastname@example.org
The COVID-19 pandemic is raging on, with impressive numbers of cases and deaths. As of 19 May 2020, there are 4,731,458 confirmed cases of COVID-19 in the world, of which 112,637 in the last 24 hours; number of deaths is 316,169 , of which 4 322 in the day before last (1) . Regions most affected are the Americas, with 2, 082,945 cases, or 44% of all cases in the world, and Europe, with 1,909,592 cases, or 40% of all reported cases. Mortality rates are, so far, 6% and 8.8%, in the Americas and Europe, respectively (1).
The new coronavirus, SARS-CoV-2, causes an acute upper respiratory tract infection in around 80% of patients; in 5 to 20% it may cause severe disease, especially involving the lungs, leading to hypoxemia and acute respiratory failure (2, 3). The disease COVID-19 manifested as a critical condition, leading to intensive care treatment, in 5% of Chinese patients, and in 14% of patients in New York, USA (2-3).
In this subset of critically ill patients, multiple organ failure was seen, including cardiac dysfunction and decreased vascular tone, leading to hypotension. Risk factors for development of complications of Covid-19 include older age (e.g., >65 years), prior cardiovascular disease, chronic lung disease, hypertension, diabetes, and obesity (2, 3).
The cardiovascular complications of COVID-19 deserve especial attention. Myocardial injury, usually defined as increased troponin levels, with or without additional electrocardiographic or echocardiographic data suggesting cardiac damage, has been associated with adverse outcomes (4-8). The etiology of troponin elevation remains unclear in most cases - it may be due to either coronary plaque destabilization and acute myocardial infarction, myocardial blood flow supply/demand imbalance, microvascular ischemia, sepsis-related troponin increases, or may occur as a result of myocarditis caused by inflammatory cytokines or by the virus itself (6). As SARS-CoV-2 contaminates the host cells by means of the transmembrane angiotensin-converting enzyme (ACE)-II receptor, which is expressed in endothelial cells, there is a substrate for a direct pathogenic effect of the virus, as described by Varga et al (9), who found evidence of direct viral infection of endothelial cells and diffuse endothelial inflammation.
Recently, thrombotic complications of COVID-19, including deep vein thrombosis, pulmonary thromboembolism, peripheral and central arterial occlusions (11, 12) became widely recognized, such that the disease has been considered a syndrome of hyperinflammation, hypercoagulability and immunothrombosis. Platelet hyper-reactivity, hypercoagulability, hypofibrinolysis, complement overactivation, likely lead to a state of COVID-induced coagulopathy (13). D-dimer and prothrombin time are prognostic markers of adverse outcomes in COVID-19. (14, 15). Elevated D-dimer values at hospital admission and during further disease progression may reflect COVID-19-induced pulmonary inflammation with activation of platelets and blood coagulation (15).
The understanding of the pathophysiology of cardiovascular complications in COVID-19 is a key to the implementation of therapeutic measures, which may offer additional benefits, mainly for patients with severe disease, such as anticoagulants. Continued research and data reporting, which have been performed with great effort, concomitantly to the fight against the disease, are fundamental in the progress of this knowledge.
1,2Andrea Rocha de Lorenzo
1,3,4Cristiane da Cruz Lamas
1Cardiovascular Research Unit, Instituto Nacional de Cardiologia, Rio de Janeiro, Brazil,
2Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
3Instituto Nacional de Infectologia Evandro Chagas, Fiocruz, Rio de Janeiro, Brazil
4Rio de Janeiro Universidade do Grande Rio (UNIGRANRIO), Rio de Janeiro, Brazil
Conflict of interest: None to declare
Authorship: A.R.L and C.C.L. equally contributed to preparation of editorial
Acknowledgement and funding: We acknowledge our research group colleagues from Instituto Nacional de Cardiologia who promote constant stimulating debates on COVID-19 and other matters.
1. WHO Situation report - 120. Coronavirus disease 2019 (COVID-19) .19 May 2020. Accessed 20 May 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports
2. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. N Engl J Med 2020 Feb 28. doi: 10.1056/NEJMoa2002032.https://doi.org/10.1056/NEJMoa2002032 PMid:32109013 PMCid:PMC7092819
3. Richardson S, Hirsch JS, Narasimhan M, Crawford JM, McGinn T, Davidson KW, et al. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA 2020 Apr 22. doi: 10.1001/jama.2020.6775.https://doi.org/10.1001/jama.2020.6775 PMid:32320003 PMCid:PMC7177629
4. Shi S, Qin M, Shen B, Cai y, Liu T, Yang F, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol 2020; e200950.https://doi.org/10.1001/jamacardio.2020.0950 PMid:32211816 PMCid:PMC7097841
5. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395:1054-62.https://doi.org/10.1016/S0140-6736(20)30566-3
6. Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, et al. Cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020; e201017.https://doi.org/10.1001/jamacardio.2020.1017 PMCid:PMC7101506
7. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med 2020; 8: 475-81.https://doi.org/10.1016/S2213-2600(20)30079-5
8. Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med 2020; 46: 846-8.https://doi.org/10.1007/s00134-020-05991-x PMid:32125452 PMCid:PMC7080116
9. Tavazzi G, Pellegrini C, Maurelli M, Belliato M, Sciutti F, Bottazzi A, et al. Myocardial localization of coronavirus in COVID-19 cardiogenic shock. Eur J Heart Fail; 2020 [Epub ahead of print]. PMID: 32275347https://doi.org/10.1002/ejhf.1828
10. Varga Z, Flammer AJ, Steiger P, Haberecker M, Andermatt R, Zinkernagel AS, et al. Endothelial cell infection and endotheliitis in COVID-19. Lancet 2020; 395: 1417-8. Doi: 10.1016/S0140-6736(20)30937-5https://doi.org/10.1016/S0140-6736(20)30937-5
11. Zhang Y, Cao W, Xiao M, Li YJ, Yang Y, Zhao J, et al. Clinical and coagulation characteristics of 7 patients with critical COVID-2019 pneumonia and acro-ischemia. Zhonghua Xue Ye Xue Za Zhi 2020; 41: E006. doi: 10.3760/cma.j.issn.0253-2727.2020.0006.
12. Valderrama EV, Humbert K, Lord A, Frontera J, Yaghi. Severe acute respiratory syndrome coronavirus 2 infection and ischemic stroke. Stroke 2020; 51: 00-00. DOI: 10.1161/STROKEAHA.120.030153https://doi.org/10.1161/STROKEAHA.120.030153 PMid:32396456
13. Henry BM, Vikse J, Benoit S, Favaloro EJ, Lippi G. Hyperinflammation and derangement of renin-angiotensin-aldosterone system in COVID-19: A novel hypothesis for clinically suspected hypercoagulopathy and microvascular immunothrombosis. Clini Chim Acta 2020; 507: 167-73.https://doi.org/10.1016/j.cca.2020.04.027 PMid:32348783 PMCid:PMC7195008
14. Lippi G, Favaloro EJ. D-dimer is associated with severity of coronavirus disease 2019: a pooled analysis, Thromb Haemost 2020; doi: 10.1055/s-0040-1709650https://doi.org/10.1055/s-0040-1709650 PMid:32246450
15. Henry BM, de Oliveira MHS, Benoit S, Plebani M, Lippi G. Hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (COVID-19): a meta-analysis. Clin Chem Lab Med (CCLM) 2020; doi: 10.1515/cclm-2020-0369.https://doi.org/10.1515/cclm-2020-0369 PMid:32286245