COVID-19 may have lasting effect on heart

The symptoms associated with COVID-19 are well known, but the long-term effect of the virus on survivors remains a mystery.

Two recent studies raised concerns about the impact of COVID-19 on the heart. One study found that 78 out of 100 recovered patients had structural changes to their hearts, with 76 having evidence of a biomarker signaling cardiac injury and 60 showing signs of inflammation. In this study, the average age of participants was 49, and most had recovered from the infection at home.

Another study analyzed autopsy results from 39 people who died early in the pandemic, and high levels of the virus were found in the hearts of 24 patients. The average age of patients in this study was 85.

Both studies were done in Germany.

While there has been evidence of a percentage of COVID-19 survivors showing signs of myocarditis, an inflammation of the heart muscle caused by a viral infection, Geisinger Drs. Martin Matsumura and Robert Mangano believe more time and research is needed before determining if this is a pattern.

“Some of the alarm that’s been raised in the last several weeks both in the medical literature and some of the sports leagues, clearly we need to follow this illness closely to learn more about cardiac complications, but perhaps the alarm was a little bit premature,” said Matsumura, chief of cardiology at Geisinger Wyoming Valley Medical Center for the Geisinger Heart Institute and cardiology lead for Geisinger’s northeast region. “It’s really too early to know what kind of patterns we’re going to see, risk factors for longterm complications related to COVID-19 and the rate of heart involvement in acute COVID-19 infections.”

Mangano, a pediatric cardiologist who specializes in pediatric heart disease and adults with congenital heart disease, agrees with Matsumura.

“It was pretty scary,” he said of the studies. “It’s very early in the experience with this virus, and we’re learning along the way. Anything we’re saying now or any of the guidelines, they could change in the future as we learn more and refine this.”

COVID-19 and the heart

Myocarditis is a known complication of a vast variety of viral infections such as the seasonal flu or common cold syndromes. This condition is caused by the virus getting into the heart cells and causing inflammation.

“In general we see upticks in heart attacks every year when the influenza virus picks up,” Matsumura said. “Probably because these people are acutely sick, they have a lot of inflammation going on in their body, they may have changes in their blood pressure which leads to (heart attacks).”

Heart complications may not be due to an infection directly but can be caused by the body’s response to an infection. The immune system’s response to an infection causes a lot of substances to circulate in the bloodstream to fight the infection. These substances can also cause inflammation.

“Any severe infection can cause stress to the heart muscle and heart tissue to cause it to not work very well for a while,” Mangano said. “Fortunately the prognosis for that one is pretty good. Usually if you get over the illness, the heart’s going to be all right.”

Matsumura has seen a subgroup of acute COVID-19 patients have evidence of myocarditis. He has also had patients come in for what appears to be a common heart attack, only for the patients to then find out they also have an acute case of COVID-19.

“The unanswered question is if that is going to have a long-term effect for that patient,” Matsumura said. “Another question is, is that directly related to COVID-19 or is that some other underlying heart problem that was exacerbated by the COVID-19 infection.”

It will take time and more research to determine if COVID-19 causes myocarditis indirectly and what the effects will be for survivors long term.

Unlike Matsumura, Mangano does not see many children with possible COVID-19 related myocarditis. Children are still at risk even though many have been asymptomatic or experience mild systems with COVID-19.

“There is some evidence that kids can be affected by (COVID-19 myocarditis) as well,” Mangano said. “Especially if they have the multisystem inflammatory syndrome (in children). Those kids can have evidence of myocardial injury.”

Multisystem inflammatory syndrome in children is an illness affecting children. It appears a few weeks after a peak in COVID-19 in a community.

“There’s evidence there that this is an immune reaction,” he said. “It’s a reaction to having been exposed to the virus, and the body does something with its immune system and causes the release of the substances, and inflammatory cells and white cells do the damage after the exposure of COVID-19.”

Impact on athletes

The study that showed 78 of the recovered COVID-19 patients having structural changes to their heart caused some concern among the athletic community and what it would mean for athletes ready to take the field again.

“Part of that is will they just spread it around more and keep the pandemic going, cause a resurgence,” Mangano said. “The other concern is if it is safe for them to play because maybe if they’ve had COVID-19 their heart’s injured or weak or sick enough that if they do exertion in sports, will they die on the field.”

Geisinger has adopted a screening process for COVID-19 recovered athletes who feel ready to get back on the field.

“We want to find patients who might be in danger and perhaps keep them out of sports for a while or just delay their reentry.”

If the athlete has no symptoms associated with heart complications and feels fine, then no further testing would be required, though they may still have a wait time of two to four weeks before rejoining their team.

But if the athlete is experiencing shortness of breath, feeling faint, get winded more easily, having swelling in the legs or other symptoms of heart complications, then further testing would be needed before allowing them to begin playing again. In this case, athletes may be sidelined for three to six months as a cardiologist conducts further testing to make sure they are well enough to play.

“If a young person has been exposed to the coronavirus or has been positive for the coronavirus, the first step before they resume sports is to see their doctor,” Mangano said. “The goal is to detect heart troubles that could cause a problem when they are playing. We want to keep them safe.”