With yesterday being Valentine’s Day, the WISE Indiana team decided it was fitting to discuss the COVID-19 pandemic effects on the heart; both clinically and socially.

COVID-19 Infection Risk with Cardiovascular Complications

In this publication, the authors explored cardiovascular complications during COVID-19 infection. A meta-analysis of 1,527 patients with COVID-19 found that the prevalence of hypertension was 17.1% and cardiac disease was 16.4%, and that these patients were more likely to require critical care. Another study of 44,672 patients with COVID-19 found that a history of cardiovascular disease (CVD) was associated with a nearly five-fold increase in the case fatality rate when compared with patients without CVD (10.5% vs. 2.3%). The figure to the right displays risk factors that may lead to more severe outcomes, as well as cardiac complications of COVID-19 infection.”

They also reviewed some of the medications utilized to treat COVID-19 that also have potential cardiac complications or interactions with other cardiovascular drugs, including antihypertensives, antiarrhythmics, anticoagulants, antiplatelets, and statins. Current medications under study include antivirals, antimalarials, azithromycin, corticosteroids, and biologics.

In this article, the authors review the possible mechanisms by which SARS-CoV-2 may cause heart damage.

1. First, is direct cardiac infection. The spike protein of SARS-CoV-2 has a similar structure to SARS-CoV, both having a high affinity with ACE2. SARS-CoV binds to ACE2 in the lungs, but ACE2 is also expressed in the heart, leading researchers to believe that SARS-CoV-2 is likely to attack myocardial cells.
2. The second pathway is that SARS-CoV-2 downregulates ACE2. It has been shown that ACE2 is necessary for cardiac function and that a downregulation of ACE2 in myocardial tissue may lead inflammatory effects and elevated levels of angiotensin II, accelerating the occurrence and development of CVD.
3. The third pathway is cytokine storms leading to excessive inflammatory response. Many severe patients among the first confirmed SARS-CoV-2 patients developed cytokine storms. Minimally invasive autopsy of a SARS-CoV-2 patient showed markedly elevated pro-inflammatory cells, leading to cardiac inflammation.
4. Other mechanisms to be considered are hypoxemia caused by viral infection, the side effects of antiviral drugs, and stress/anxiety-induced catecholamine release.

Long-term Cardiovascular Health

Much is still to be learned about the long-term effects of COVID-19, including effects on heart health. This article outlines two populations observed post-recovery from COVID-19 infection. In a German study of 100 patients who recently recovered from COVID-19, 78% had cardiac involvement and 60% had ongoing myocardial inflammation (median, 71 days after diagnosis). Among 26 college athletes who received a diagnosis of COVID-19 (none required hospitalization and the majority without symptoms), 46% had evidence of myocarditis or prior myocardial injury by cardiac magnetic resonance imaging (range, 12-53 days later). Though much more follow-up and longitudinal studies are needed, there is concern that COVID-19 infection may have a lasting impact on all populations, not just those with comorbidities.

Quarantine Relationships

This article examines how the pandemic has influenced married couples with young children.  Married US couples are reporting that COVID-19 has led to increased disharmony. Using the Pandemic Parenting Study looking at Indiana mothers, the authors found that a substantial portion of the mothers they studied reported being more frustrated with their partners than they were pre-pandemic.  Mothers are reporting that their partners are not providing adequate parenting support, leading to them leaving the workforce, increasing or beginning use of anti-depressant medications, or ignoring their own COVID-19 concerns.

Domestic Violence

Another article highlights the impact that COVID-19 has had on victims of domestic and intimate partner violence.  Policies that work to reduce the spread of COVID-19, including self-isolation, social distancing, and lockdown have had an impact on the increase of intimate partner violence since the start of the pandemic.  Increased time with the violent partner and isolation from other people outside of the household, already tools that abusers may use to control their victims, are exacerbated by COVID-19 lockdown policies.  These, along with economic and other disruptions in a household can contribute to stresses that may increase the risk for intimate partner violence episodes.  Victims are further affected by the lack of access to specialized services for victims due to pandemic caused disruptions.

Closeness

All is not bad news however.  This article looks at the role that online based interventions can have to improve closeness between couples.  In the study, couples were randomized into a control group, which watched a movie together, or into an intervention group, which participated in a two hour online group therapy session based on the Awareness, Courage, and Love (ACL) model in order to encourage and promote closeness between these couples.  Researchers found that those couples who participated in the intervention scored 23% higher on an instrument that assessed their relationship than those couples who only watched a movie.  A week later, the group who participated in the therapy session scored significantly higher on the measure than the group who watched a movie.

WISE Indiana Staff Contributors: Dr. Amber E. Osterholt & Aaron J. Zych, MPH